8.42: Selective Mutism (313.23)

DSM-IV-TR criteria

• A. Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g. at school) despite speaking in other situations.
• B. The disturbance interferes with educational or occupational achievement or with social communication.
• C. The duration of the disturbance is at least one month (not limited to the first month of school).
• D. The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
• E. The disturbance is not better accounted for by a communication disorder (e.g. stuttering) and does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic disorders.

Associated features

• In unfamiliar settings or situations a child with Selective Mutism is often described as “excessively shy”. This can be misleading due to the fact that shy children can withhold from conversations for hours or days, but will eventually begin speaking. Shy children can function in social settings.
• Children with Selective Mutism suffer from fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling behavior, along with the excessive shyness that is seen in children that are shy.
• When confronted with a conversation, a child with this disorder will attempt to avoid it, using stiff body language, avoiding eye contact, maintaining a blank facial expression.
• These children are often very normal in the home and around the family members. They are also sometimes teased by their peers. There may also be an associated Communication Disorder or a general medical condition causing abnormalities of articulation.
• Children suffering from this can be over dependent on their parents.
• Mute children are not mute because they do not want to speak but because they are afraid to speak.

Child vs. adult presentation

Children are affected by Selective Mutism, which usually appears between the ages of 4-6. When children leave the home setting, usually for school or daycare, the symptoms begin to appear. Children do not outgrow this disorder, but it has usually been treated and overcome by adolescence.

Gender and cultural differences in presentation

• Children of immigrants are often more uncomfortable or unfamiliar with the new country’s language and this lack of communication should not be confused with or misdiagnosed as Selective Mutism.
• Females tend to present with Selective Mutism more frequently than males. According to the Developmental and Behavioral Pediatrics “A Handbook for Primary Care,” females with this disorder outnumber males 2:1.

Epidemiology

• 90% of children with Selective Mutism also have a social phobia. In many cases Selective Mutism lasts for only a few months, however, the symptoms may last up to several years.
• Selective Mutism is very rare, with rates of 0.1% to 0.7% in the general population and 1% in mental health institutes being reported. These extremely low rates are due, in part, to limited research.

Etiology

• There is a genetic predisposition to Selective Mutism, with most cases having a first degree family history; 70% being a Social Phobia or 30% being Selective Mutism. Since this condition is so rare, the etiology is poorly understood. There are many theories on etiological factors for this disorder, but three main ones have emerged, due to consistency in cases.
• The three main etiological factors for Selective Mutism are anxiety, developmental delays, and not being exposed to the local language. Many clinicians consider trauma as a factor for Selective Mutism,(before the age of 3) however, trauma tends to cause global mutism (refusal to speak to everyone) instead of a selective development.
• In one study, Kristensen linked Selected Mutism with many nonlinguistic developmental problems. Some of these problems included motor delays, elimination disorders, and pre- and perinatal problems. Selective Mutism is also highly found among immigrant children, although sometimes it may be misdiagnosed due to unfamiliarity or uncomfortableness with the host country’s language. When these children cannot speak the language, it may affect their confidence.
• Other children may also tease them about their inability to speak well, their accent, or minor grammatical errors. The child cannot participate in school due to the language barrier, which predisposes them to Selective Mutism, a disease only reinforced by the teasing.
• One study by BarHaim also suggested that a deficit may exist in the child’s auditory efferent system. This deficit prevents the child from desensitizing their own vocalizations if the child is anxious they will cope with this deficit by developing Selective Mutism.

Empirically supported treatments

• When treating Selective Mutism, the main goal is to treat the anxiety, not to force the child to speak. Treating Selective Mutism usually begins with therapy. Family members, teachers, and the therapist should work together to attempt to reduce the child’s anxiety, reduce the pressure they feel to speak, and increase their self esteem.
• Therapy also attempts to create a desensitized atmosphere so that the child is able to practice speaking. Cognitive Behavioral Therapy is used to help the child to work toward specific goals. Therapy can be difficult because the child refuses to speak and feels uncomfortable.
• In the most chronic cases, usually after all other options have been exhausted, medications have been used in combination with therapy. Selective serotonin reuptake inhibitors (SSRIs) have proven to be effective in some cases. SSRIs do not treat the Selective Mutism but the anxiety symptoms which is a main etiological factor. These medications are usually given for 9 to 12 months.

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