Selective Mutism

(Previously called elective mutism in the DSM-III)

Contributed by Lori Bini, Penn State College of Medicine

 

Selective Mutism (SM) –The name was changed to indicate that the children chose not to speak is select situations, rather than an oppositional behavior where the child refused to speak.

 

Diagnosis

1. A) Persistent failure to speak in certain situations when speaking is expected (often at school), while speaking fluently in other situations (often at home and in familiar places) (rare instances exist where the child is mute at home but talks in school)

 

1. B) Interferes with educational or occupational achievement or with social communication

 

1. C) Lasts at least 1 month (not limited to the first month of school)

 

1. D) Failure to speak is not due to a lack of knowledge of or comfort with the spoken language

 

1. E) Does not meet the criteria for a communication disorder such as stuttering, and mutism does not occur exclusively during the course of Pervasive Developmental Disorder, schizophrenia or other psychotic disorder

 

Note: The presence of symptoms of social anxiety and avoidance such as excessive shyness, social isolation, withdrawal and school refusal are no longer considered symptoms of both social phobia and selective mutism (as indicated by the DSM III). Although these symptoms are commonly found among children with selective mutism, their presence should indicate the presence of an additional social phobia

 

Epidemiology

• Uncommon, 3-8/10,000, (one or the reasons why much of the literature sites single case reports and small sample sizes. It is suspected that many cases do not seek medical     attention and resolve without treatment
• Slightly more common in girls
• Onset between the ages of 4 and 8 (most commonly at 5 or 6, when the child enters school)
• Associated with delayed onset of speech or speech abnormalities which may contribute to the development of the disorder
• Over 90% meet the diagnostic criteria for social phobia
• High incidence of anxiety, depression and dependence in the children’s mothers resulting in overprotection of the children
• 70% of children with SM have a first degree relative with a history of a social phobia and 30% have a first degree relative with a history of SM

 

Possible etiologies

ÞPathogenesis is poorly understood. It may be a symptom of social anxiety rather than a distinct diagnostic syndrome. It is probably multifactorial including:

• Psychological trauma or stressors (particularly during the time of speech development)(although most children with SM have not experienced a trauma)
• A particular mother profile and mother-child relationship (maternal anxiety, depression, dependence and a domineering and overprotective approach to the child)
• Minimal brain dysfunction
• History of developmental delays and speech and language disabilities
• neuropsychological social cue processing disorder
• Anxious temperment: shyness, worry, social avoidance,fearful, social withdrawl clinging, Negativism
• Deletion in the short arm of chromosome 18- One researcher demonstrated that two children diagnosed with persistent elective mutism both showed the same deletion. There have been other reports that selective mutism is more common in relatives of an affected individual than in the general population.

 

Note: Adults who suffered from SM as a child sometimes remember being afraid to speak because they thought they may say the wrong thing or that their voice sounded funny. Some even remember symptoms indicative of a panic attack such as SOB, palpitations, and dizziness)

 

Other clinical features

• Some cases are precipitated by an emotional or physical trauma (sometimes termed traumatic mutism)
• Some children communicate with eye contact or nonverbal gestures such as nodding their head or smiling
• Some children may even whisper monosyllables in a nonfluent manor
• The child may talk on the phone with people who they will not talk to in person or, they may talk to a particular person in one environment (such as in their home), but refuse to talk to that same person in a different situation (such as a public place).
• Children are usually shy, anxious and vulnerable to the development of depression
• Associated features include excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper tantrums, OCD, phobias, school refusal , depression, developmental delay (69%), elimination disorders (32%), oppositional behavior (10%- 90%)

Note: almost half (46%) of the children with SM meet the criteria for both an anxiety diagnosis and a developmental delay (vs. .9% of controls)

 

Differential Diagnosis

• Transient adaptional shyness in an adjustment disorder- eg. Muteness that occurs with the start of a new school and spontaneously improves
• Mental retardation
• Pervasive developmental disorders
• Expressive language disorders (phonological disorder, expressive language disorder, mixed receptive-epressive language disorder, stuttering): a comprehensive speech and language evaluation is necessary and may require the parents to bring in prerecorded audio tapes
• Mood disorders
• Hearing impairment: Auditory testing should be done
• CNS mass lesion or degenerative disease

Note: most of these other disorders are not specific to particular situations, they consistently demonstrate symptoms during all activities.

• Transient postepileptic aphasia (only last a few hours or a day)
• Infection
• Basilar migrane
• Posterior fossa syndrome (often a complication of surgery which is transient and has delayed onset-associated with dysphasia and emotional liability.)

 

Evaluation

• When did symptoms begin? History of abuse or trauma?
• Which environments is the child mute in? (become suspicious of another etiology if the child is mute around close family)
• Extent of interaction with others
• Does the child have symptoms suggestive of another disorder such as Asperger’s (impaired nonverbal communication, peer relationships, no interest in sharing joy with others, repetitive or stereotyped behaviors), PDD, psychosis, communication disorder such as stuttering.
• Adequate education?
• Unfamiliarity with the language?
• Degree of communicative inhibition (does the child whisper or use nonverbal communication?)
• Family history of SM, or anxiety disorders such as social phobia, panic disorder, OCD
• Medical history: Any neurologic injuries? Prenatal history? Developmental history? Ear infections? Hearing evaluation?
• Speech evaluation: often requires the parents to bring in an audio or videotape of the child talking. If the tape shows that the speech is normal than there is no need to do neuroimaging, EEG or other neurological tests. Rate the speech for fluency, pronunciation, rhythm, stress, inflection, pitch, volume, complexity

 

Treatment

• Difficult
• Multimodal treatment works best
• Individual, behavioral and family therapy

ÞBehavior therapy uses positive reinforcement for initially all forms of communication, including facial expressions and gestures and gradually applies only to whispers and normal verbalization. Mute behaviors are not punished, but they will cause reinforcement to be withheld. Develop a behavior plan for the parents

ÞPsychodynamic therapy uses art and play therapy to determine intrapsychic             conflicts- has not proven to be very suscessful

ÞFamily therapy is used to discuss a treatment plan and to identify any psychosocial stressors which could inhibit progress

ÞSpeech therapy may provide practice for children and allow them to gain confidence in their speech, even if they do not have another speech disability

ÞTeachers may assist in encouraging children to speak and can use suggestive language such as “I wonder when Michael will start to speak?”, “I wonder who he will talk to first?” These type of phrases let the child know that you expect he will speak again. The teacher can also help by placing the child next to supportive children and separating the class into small groups. (See article on assessment and treatment of SM)

 

ÞSelf modeling with the use of audio or video feedforward techniques may prove to be very effective. This technique involves video/audiotaping a trusted person asking the child questions to which one anticipates more than a one-word answer to. The tapes are then edited to combine questioning, from another tape of someone who the child does not talk to, with the answers provided on the other tape. The child is than asked to watch/listen to this edited tape twice a day for at least a week. After this trial period, the person whom which the child is normally mute with asks the child the same questions from the tape and a few additional questions. There have been several reports that the child will speak to this person on the first trial and that behavior will generalize to other situations in which the child was previously mute. (See study included in your packet)

 

ÞA study by Dummit showed that Fluoxetine (SSRI) can significantly improve speech and decrease anxiety in up to 76% of children. The study included 21 children between the ages of 5-14 with SM but had no control group. The children were treated for 9 weeks with varying doses of Fluoxetine. The starting dose was 10 mg qd, but it was titrated up until the child began speaking. The final mean dose was 21 mg qd and the maximum dose was 60 mg qd. (None of the children met the criteria for depression so the success cannot be due to anti-depressive effects. The major side effect was behavioral disinhibition (in 19% of children); sleep problems, jitteriness, and headaches were all reported in 10% of the children.Abdominal pain, decreased appetite, difficulty arousing, drowsiness, irritability and agitation were found in 5% of patients. Complete cessation of mutism often took longer than 9 weeks.

 

ÞPhenelzine (MAOI) also appears to be beneficial in treating SM. It’s most common side effect was weight gain and showed no hypertensive crises at a dose of 30-60 mg qd for 24-60 weeks. The food and drug interactions make this a second line drug after Fluoxetine has failed.

 

ÞBenzodiazepines like lorazepam and oxazepam may be used to relieve psychomotor agitation.

 

ÞThere has been a case report of combining the above treatments with an electronic communication device in order to expedite the disappearance of SM. The device had 4 panels containing phrases spoken by the child when only their mother was in the room. The child used the device to respond to questions asked by those who he would not speak with. Systematic desensitization occurred within one month by allowing the child to become so comfortable with hearing his voice around others that he actually felt comfortable enough to verbalize a response.

 

Course and prognosis

• Onset is often insidious, before the age of 5, but not noticed until the initiation of school
• Often resolves without treatment in a few weeks or months
• Children who remain symptomatic for longer than 6 months should receive treatment
• Often causes failure in school
• Fluoxetine may assist recovery
• Children who do not improve by 10 years of age have a worse prognosis
• Early identification and treatment confers a better prognosis
• One study showed that more that ½ of patients treated still retained symptoms
• up to 1/3 will develop other psychiatric disorders such as anxiety of depression, regardless of treatment

 

 

References:

1.Black B. Uhde TW. Psychiatric characteristics of children with selective mutism: a pilot study. [see comments]. Journal of the American Academy of Child & Adolescent Psychiatry. 34(7):847-56, 1995 Jul

2. Blum NJ. Kell RS. Starr HL. Lender WL. Bradley-Klug KL. Osborne ML. Dowrick PW. Case study: audio feedforward treatment of selective mutism. Journal of the American Academy of Child & Adolescent Psychiatry. 37(1):40-3, 1998

3.Dow SP. Sonies BC. Scheib D. Moss SE. Leonard HL. Practical guidelines for the assessment and treatment of selective mutism. [Review] [65 refs] Journal of the American Academy of Child & Adolescent Psychiatry. 34(7):836-46, 1995 Jul

4.Dummit ES 3rd. Klein RG. Tancer NK. Asche B. Martin J. Fluoxetine treatment of children with selective mutism: an open trial. Journal of the American Academy of Child & Adolescent Psychiatry. 35(5):615-21, 1996 May.

5.Dummit ES 3rd. Klein RG. Tancer NK. Asche B. Martin J. Fairbanks JA. Systematic assessment of 50 children with selective mutism. Journal of the American Academy of Child & Adolescent Psychiatry. 36(5):653-60, 1997 May.

6.Gordon N. Mutism: elective or selective, and acquired. [Review] [42 refs] Brain & Development. 23(2):83-7, 2001 Mar.

7.Grosso S. Cioni M. Pucci L. Morgese G. Balestri P. Selective mutism, speech delay, dysmorphisms, and deletion of the short arm of chromosome 18: a distinct entity?. Journal of Neurology, Neurosurgery & Psychiatry. 67(6):830-1, 1999 Dec.

8.Joseph PR. Selective mutism–the child who doesn’t speak at school. Pediatrics. 104(2 Pt 1):308-9, 1999 Aug.

9.Kee CH. Fung DS. Ang LK. An electronic communication device for selective mutism. Journal of the American Academy of Child & Adolescent Psychiatry. 40(4):389, 2001 Apr.

10.Kristensen H. Selective mutism and comorbidity with developmental disorder/delay, anxiety disorder, and elimination disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 39(2):249-56, 2000 Feb

11.Lafferty JE. Constantino JN. Fluvoxamine in selective mutism. Journal of the American Academy of Child & Adolescent Psychiatry. 37(1):12-3, 1998 Jan.

12.Stein MT. Rapin I. Yapko D. Selective mutism. Journal of Developmental & Behavioral

13.Szabo CP. Selective mutism and social anxiety. [letter; comment]. Journal of the American Academy of Child & Adolescent Psychiatry. 35(5):555, 1996 May.

14.Wright HH. Cuccaro ML. Leonhardt TV. Kendall DF. Anderson JH. Case study: fluoxetine in the multimodal treatment of a preschool child with selective mutism. Journal of the American Academy of Child & Adolescent Psychiatry. 34(7):857-62, 1995 Jul.

15.Yanof J. Language, communication, and transference in child analysis. I. Selective mutism: the medium is the message. Journal of the American Psychoanalytic Association. 44(1):79-100, 1996