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'''For patient information click [[Selective mutism (patient information)|here]]'''
{{DiseaseDisorder infobox |
{{DiseaseDisorder infobox |
   Name        = Selective mutism |
   Name        = Selective mutism |
Line 4: Line 7:
   ICD9        = {{ICD9|309.83}} {{ICD9|313.23}} |
   ICD9        = {{ICD9|309.83}} {{ICD9|313.23}} |
}}
}}
{{SI}}
{{CMG}}; {{AE}} {{KS}}


==Overview==
==Overview==
'''Selective mutism''' is a [[social anxiety]] disorder in which a person who is normally capable of [[Speech communication|speech]] is unable to speak in given situations.  
Selective mutism is a [[social anxiety]] disorder in which a person who is normally capable of [[Speech communication|speech]] is unable to speak in given situations.  


==Description==
==Causes==
In the [[Diagnostic and Statistical Manual of Mental Disorders]] selective mutism is described as a rare [[psychology|psychological]] disorder in children. Children (and adults) with the disorder are fully capable of speech and understanding language, but fail to speak in certain social situations when it is expected of them. They function normally in other areas of behavior and learning, though appear severely withdrawn and some are unable to participate in group activities due to their extreme anxiety. It is like an extreme form of [[shyness]], but the intensity and duration distinguish it. As an example, a child may be completely silent at school, for years at a time, but speak quite freely or even excessively at home.  
No single cause has been established, but there is some evidence that there is a hereditary component.  


Particularly in young children, selective mutism can sometimes be confused with an [[Autistic spectrum|autism spectrum disorder]], especially if the child acts particularly withdrawn around his or her diagnostician. Unfortunately, this can lead to incorrect treatment.
==Differential Diagnosis==
*[[Autism spectrum disorder]]
*Communication disorders
:*[[Language disorder]]
:*[[Speech sound disorder]] (previously phonological disorder)
:*[[Childhood-onset fluency disorder]] ([[stuttering]])
:*Pragmatic (social) communication disorder
*[[Intellectual disability]]
*Neuro-developmental disorders
*[[Psychotic disorder]]s
*[[Schizophrenia]]
*[[Social anxiety disorder]] ([[social phobia]])<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>


Selective mutism is usually characterised by the following:
==Epidemiology and Demographics==
*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.
===Prevalence===
*The disturbance interferes with educational or occupational achievement or with social communication.
The prevalence of selective mutism is 30-1,000 per 100,000 (0.03%-1%) of the overall population.<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*The duration of the disturbance is at least 1 month (not limited to the first month of school).
*The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
*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 Disorder.  


The former name '''elective mutism''' indicates a widespread ''misconception'' even among psychologists that selective mute people choose to be silent in certain situations, while the truth is that they are forced by their extreme anxiety to remain silent; despite their will to speak, they just cannot make any voice. To reflect the involuntary nature of this disorder, its name had been changed to ''selective mutism'' in [[1994]]. However, misconceptions still prevail; for instance, the [[ABC News]] erroneously attributed the cause of selective mutism to trauma and described it as willful in a report dated [[May 26]], [[2005]].<ref>http://abcnews.go.com/Primetime/Health/story?id=794677&page=1</ref>
==Risk Factors==
*Behavioral inhibition
*Genetic predisposition
*Negative affectivity (neuroticism) 
*Parental history of shyness
*[[Social anxiety]]
*Social isolation<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>


The [[incidence (epidemiology)|incidence]] of selective mutism is not certain. Due to the poor understanding of the general public on this condition, many cases are undiagnosed. Based on the number of reported cases, the figure is commonly estimated to be 1 in 1000. However, in a 2002 study in ''The Journal of the American Academy of Child and Adolescent Psychiatry'', the figure has increased to 7 in 1000.
==Natural History, Complications, and Prognosis==
Children (and adults) with the disorder are fully capable of speech and understanding language, but fail to speak in certain social situations when it is expected of them. They function normally in other areas of behavior and learning, though appear severely withdrawn and some are unable to participate in group activities due to their extreme anxiety. It is like an extreme form of [[shyness]], but the intensity and duration distinguish it. As an example, a child may be completely silent at school, for years at a time, but speak quite freely or even excessively at home.  


No single cause has been established, but there is some evidence that there is a hereditary component. Typical sufferers have some of the following traits when anxious, some of which are often perceived as rudeness: {{Fact|date=April 2007}}
==Diagnostic Criteria==
===DSM-V Diagnostic Criteria for Selective Mutism<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===
{{cquote|


*They find it difficult to maintain eye contact.
*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.
*Often don't smile and have blank expressions.
*They move stiffly and awkwardly.
*They find situations where talk is normally expected particularly hard to handle. (answering school registers, saying hello, goodbye, thank-you, etc.)
*They tend to worry about things more than others
*They can be very sensitive to noise and crowds
*Find it difficult to talk about themselves or express their feelings


==Treatment==
'''''AND'''''


Contrary to popular belief, people suffering from selective mutism don't necessarily improve with age, or just ''grow out of it''. Consequently, treatment at an early age is important. If not addressed, selective mutism tends to be self-reinforcing; those around such a person may eventually expect him or her not to speak, and stop attempting to initiate verbal contact, making the prospect of talking seem even more difficult or foreign. Sometimes in this situation, a change of environment (such as changing schools) to a place where the condition is not proven make the difference, but in some cases; with psychological help the sufferer's condition can improve.
*B. The disturbance interferes with educational or occupational achievement or with social communication.


Occasionally, treatment in teenage years becomes more difficult, though not necessarily.
'''''AND'''''


Forceful attempts to make the child talk are not productive, usually resulting in higher anxiety levels and so reinforcing the condition. The behaviour is often viewed externally as willful, or controlling, as the child usually shuts down all communication and body language in such situations, which is perceived as rudeness.
*C. The duration of the disturbance is at least 1 month (not limited to the first month of school).


The exact treatment depends a lot on the subject, their age and other factors. Typically, stimulus fading is used with younger children.
'''''AND'''''


Some in the psychiatric community believe that anxiety medication may be effective in extremely low dosages and that higher doses may just make the problem worse. Others in the field believe that the side-effects of psychiatric medications- in any dose and on any child- are so dangerous as to negate any temporary benefit, preferring behavioral and psychological interventions.  
*D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.


===Stimulus Fading===
'''''AND'''''
In this technique the sufferer is brought into a controlled environment with someone who they are at ease with and can communicate. Gradually another person is introduced into the situation involving a number of small steps.


These steps are often done in separate stages in which case it is called the ''sliding-in'' technique, where a new person is slid into the talking group.
*E. The disturbance is not better explained by a communication disorder (e.g., [[childhood onset fluency disorder]]) and does not occur exclusively during the course of autism spectrum disorder, [[schizophrenia]], or another psychotic disorder.
This can take a relatively long time for the first one or two faded in people.
}}


===Desensitization===
===Symptoms===
The subject is allowed to communicate via non-direct means to prepare them mentally for the next step. This might include email, phone, taped recordings, webchat, until they are in a position to try more direct communication.
Selective mutism is usually characterised by the following:
*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.
*Interference with educational or occupational achievement or with social communication.
*Disturbance lasting at least 1 month (not limited to the first month of school).
*Failure to speak not due to a lack of knowledge of, or comfort with, the spoken language required by the social situation.
*Lack of better cause explained by a Communication Disorder (e.g. stuttering) and disturbance lasting longer than a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder.


===Drug treatments===
Some practitioners believe that there is evidence indicating that antidepressants such as [[fluoxetine]] (prozac) may be effective in treating children with selective mutism. Though many in the medical community believe that psychiatric medications decrease the anxiety levels enough to allow communication to take place in cases of selective mutism, other practitioners and activists (see articles on [[Peter Breggin]] and [[David Healy (psychiatrist)]]) stringently decry any use of psychiatric medications on children and note the lack of medical proof of genetic links to behavioral disorders. The denunciation of psychotropic intervention on children with behavioral anxiety disorders has intensified particularly since lawsuits against several drug companies—current to 2005—have exposed previously unseen internal research documents linking fluoxetine and other SSRI antidepressants with increased risk of suicide, psychosis and—ironically enough—damage to areas of the brain which could affect language production and normal social development.


==Cultural references==
Typical sufferers have some of the following traits when anxious, some of which are often perceived as rudeness:
*Find it difficult to maintain eye contact.
*Often don't smile and have blank expressions.
*Move stiffly and awkwardly.
*Find situations where talking is normally expected particularly hard to handle (answering school registers, saying hello, goodbye, thank you, etc.).
*Tend to worry about things more than others.
*Can be very sensitive to noise and crowds.
*Find it difficult to talk about themselves or express their feelings.


* (1948) ''[[The Makioka Sisters (novel)|The Makioka Sisters]]'', a novel by [[Jun'ichirō Tanizaki]], is published in Japan, its characters modeled upon real members of the author's third wife's family. The distinctively 'shy' character of Yukiko, who challenges her family with a stubborn refusal to marry, is based on a sister who may have had selective mutism.
==Treatment==


* (c. 1985)  In the cartoon ''[[Care Bears]]'', Secret Bear appears to be selectively mute and verbally communicates only with Friend Bear by whispering in her ear.  He mimes his words to all other characters.
Contrary to popular belief, people suffering from selective mutism don't necessarily improve with age, or ''grow out of it''. Consequently, treatment at an early age is important. If it is not addressed, selective mutism tends to be self-reinforcing: the expectation that one suffering from selective mutism will not speak causes those around them to stop trying to initiate verbal contact, thus making the prospect of talking seem increasingly difficult or foreign. In such a situation, a change of environment (such as changing schools) can decrease the severity of one's selective mutism by eliminating such expectations.  


* (1987) In ''[[A Nightmare on Elm Street 3: Dream Warriors]]'' the character Joey Crusel is selectively mute; his scream kills Freddy. In the sequel, he appears to be over it.
Psychological treatment has also been shown to help the counteract this condition, though treatment in teenage years is sometimes more difficult. Specific courses of treatment differ based on the subject, and must take factors such as age into account.  


* (1993) In the film ''[[The Piano]]'', the main character, Ada McGrath, is a selective mute.
Attempts to force a child to talk are typically ineffective and often result in higher anxiety levels, consequently worsening the condition.


* (1994) In the film ''[[Corrina, Corrina]]'', the main character, Molly Singer (played by [[Tina Majorino]]) has selective mutism.
Some in the psychiatric community believe that anti-anxiety medications may be effective in extremely low dosages while higher doses may worsen the condition. Others in the field advocate that the side-effects of psychiatric medications- in any dose and on any child- are so dangerous that they negate any temporary benefits, preferring behavioral and psychological interventions.


* (2000) The title character of [[Dori Jones Yang]]'s novel [[The Secret Voice of Gina Zhang]] has selective mutism.
===Stimulus Fading===
Stimulus fading is a common treatment for younger children suffering from selective mutism. This ''sliding-in'' technique consists of the subject being brought into a controlled environment with someone who they are at ease with and can communicate with. Gradually, another person is introduced into the situation, often in several distinct stages. This process can be relatively long as the first few people are slid (or faded) into the environment and the conversation.


* (c. 2001) In the Disney Channel original series ''[[Lizzie McGuire]]'' the character Lenny Onassis, a friend of Matt McGuire, is selectively mute and only communicates to Matt.
===Desensitization===
 
The subject is prompted to communicate via indirect means in order to prepare them mentally for direct communication. Methods of indirect communication include email, phone, voice recordings, and conversations on the internet.
* (2001) The song "She's Given Up Talking" by [[Paul McCartney]] (from the album ''[[Driving Rain]]'') conforms almost perfectly to a clinical description of selective mutism in childhood, describing a young girl who is mute at school yet normally talkative at home ("When she comes home it's a yap yap yap/ words start to flow like water from a tap").
 
* (August 20, 2007) The Wall Street Journal reports that [[Seung-Hui Cho]], the perpetrator of the [[Virginia Tech massacre]] on April 16, 2007, was diagnosed with selective mutism in high school. With his family, Cho moved from South Korea to the United States when he was eight years old and performed well academically despite difficulties with communication. In his sophomore year of high school, Cho was "placed in special education under the 'emotional disturbance' classification" and was excused from participation in class discussions. In addition, he was given 50 minutes a month of speech and language therapy.<ref name=”SelMutism”>{{cite news|title=From Disturbed High Schooler to College Killer|url=http://online.wsj.com/public/article/SB118756463647202374-Ov_1NZv4xxHzWuURpyNEJzRhdYw_20070918.html|publisher=Wall Street Journal|author=Daniel Golden|date=[[2007-08-20]]|accessdate=2007-08-20}}</ref>


* In [[Brecht]]'s play, [[Mother Courage and Her Children]], the title character's daughter, Katrin, has seletive mutism after being raped by a soldier as a child.
===Medical Therapy===
Some practitioners advocate the use of antidepressants such as [[fluoxetine]] (prozac) as treatment for children with selective mutism. While many in the medical community believe that psychiatric medications can decrease anxiety levels enough to allow patients with selective mutism to communicate, others (see articles on [[Peter Breggin]] and [[David Healy (psychiatrist)]]) stringently decry the use of psychiatric medications on children. These practitioners and activists note the lack of medical evidence that behavioral disorders have genetic bases. The denunciation of psychotropic intervention on children with behavioral anxiety disorders intensified as lawsuits against several drug companies exposed previously unseen internal research documents linking fluoxetine and other SSRI antidepressants with increased risk of suicide, psychosis and damage to areas of the brain which could affect language production and normal social development.


==References==
==References==
{{reflist|2}}
{{reflist|2}}


==See also==
* [[June and Jennifer Gibbons]]
* [[Shyness]]
* [[Social anxiety]]
* [[Torey Hayden]]
==Other Organisations==
* SMIRA (Selective Mutism Information and Research Association) (UK)
* SMG-CAN (Selective Mutism Group Childhood Anxiety Network) www.selectivemutism.org
{{Mental and behavioural disorders}}
{{Mental and behavioural disorders}}


[[Category:Psychiatry]]
[[Category:Psychiatry]]
[[Category:Childhood psychiatric disorders]]
[[Category:Pediatrics]]


[[br:Mudelezh diuzel]]
[[de:Elektiver Mutismus]]
[[es:Mutismo selectivo]]
[[nl:Selectief mutisme]]
[[ja:場面緘黙症]]
[[sv:Selektiv mutism]]
[[zh:选择性缄默症]]
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Latest revision as of 12:48, 24 June 2015

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Overview

Selective mutism is a social anxiety disorder in which a person who is normally capable of speech is unable to speak in given situations.

Causes

No single cause has been established, but there is some evidence that there is a hereditary component.

Differential Diagnosis

Epidemiology and Demographics

Prevalence

The prevalence of selective mutism is 30-1,000 per 100,000 (0.03%-1%) of the overall population.[1]

Risk Factors

  • Behavioral inhibition
  • Genetic predisposition
  • Negative affectivity (neuroticism)
  • Parental history of shyness
  • Social anxiety
  • Social isolation[1]

Natural History, Complications, and Prognosis

Children (and adults) with the disorder are fully capable of speech and understanding language, but fail to speak in certain social situations when it is expected of them. They function normally in other areas of behavior and learning, though appear severely withdrawn and some are unable to participate in group activities due to their extreme anxiety. It is like an extreme form of shyness, but the intensity and duration distinguish it. As an example, a child may be completely silent at school, for years at a time, but speak quite freely or even excessively at home.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Selective Mutism[1]

“
  • 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.

AND

  • B. The disturbance interferes with educational or occupational achievement or with social communication.

AND

  • C. The duration of the disturbance is at least 1 month (not limited to the first month of school).

AND

  • D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

AND

  • E. The disturbance is not better explained by a communication disorder (e.g., childhood onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.
 ”

Symptoms

Selective mutism is usually characterised by the following:

  • 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.
  • Interference with educational or occupational achievement or with social communication.
  • Disturbance lasting at least 1 month (not limited to the first month of school).
  • Failure to speak not due to a lack of knowledge of, or comfort with, the spoken language required by the social situation.
  • Lack of better cause explained by a Communication Disorder (e.g. stuttering) and disturbance lasting longer than a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder.


Typical sufferers have some of the following traits when anxious, some of which are often perceived as rudeness:

  • Find it difficult to maintain eye contact.
  • Often don't smile and have blank expressions.
  • Move stiffly and awkwardly.
  • Find situations where talking is normally expected particularly hard to handle (answering school registers, saying hello, goodbye, thank you, etc.).
  • Tend to worry about things more than others.
  • Can be very sensitive to noise and crowds.
  • Find it difficult to talk about themselves or express their feelings.

Treatment

Contrary to popular belief, people suffering from selective mutism don't necessarily improve with age, or grow out of it. Consequently, treatment at an early age is important. If it is not addressed, selective mutism tends to be self-reinforcing: the expectation that one suffering from selective mutism will not speak causes those around them to stop trying to initiate verbal contact, thus making the prospect of talking seem increasingly difficult or foreign. In such a situation, a change of environment (such as changing schools) can decrease the severity of one's selective mutism by eliminating such expectations.

Psychological treatment has also been shown to help the counteract this condition, though treatment in teenage years is sometimes more difficult. Specific courses of treatment differ based on the subject, and must take factors such as age into account.

Attempts to force a child to talk are typically ineffective and often result in higher anxiety levels, consequently worsening the condition.

Some in the psychiatric community believe that anti-anxiety medications may be effective in extremely low dosages while higher doses may worsen the condition. Others in the field advocate that the side-effects of psychiatric medications- in any dose and on any child- are so dangerous that they negate any temporary benefits, preferring behavioral and psychological interventions.

Stimulus Fading

Stimulus fading is a common treatment for younger children suffering from selective mutism. This sliding-in technique consists of the subject being brought into a controlled environment with someone who they are at ease with and can communicate with. Gradually, another person is introduced into the situation, often in several distinct stages. This process can be relatively long as the first few people are slid (or faded) into the environment and the conversation.

Desensitization

The subject is prompted to communicate via indirect means in order to prepare them mentally for direct communication. Methods of indirect communication include email, phone, voice recordings, and conversations on the internet.

Medical Therapy

Some practitioners advocate the use of antidepressants such as fluoxetine (prozac) as treatment for children with selective mutism. While many in the medical community believe that psychiatric medications can decrease anxiety levels enough to allow patients with selective mutism to communicate, others (see articles on Peter Breggin and David Healy (psychiatrist)) stringently decry the use of psychiatric medications on children. These practitioners and activists note the lack of medical evidence that behavioral disorders have genetic bases. The denunciation of psychotropic intervention on children with behavioral anxiety disorders intensified as lawsuits against several drug companies exposed previously unseen internal research documents linking fluoxetine and other SSRI antidepressants with increased risk of suicide, psychosis and damage to areas of the brain which could affect language production and normal social development.

References

  1. ↑ 1.0 1.1 1.2 1.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.

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