Selective mutism

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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.

Description

In the Diagnostic and Statistical Manual of Mental Disorders selective mutism is described as a rare 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 They function normally in other areas of behavior and learning, though appear severely withdrawn and some are unable to participate in group activities due to their extreme anxiety.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.

Particularly in young children, selective mutism can sometimes be confused with an autism spectrum disorder, especially if the child acts particularly withdrawn around his or her diagnostician. Unfortunately, this can lead to incorrect treatment.

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

The 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.

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:

• They find it difficult to maintain eye contact.
• 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

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 disorders
• Schizophrenia
• Social anxiety disorder (social phobia)

Epidemiology and Demographics

Prevalence

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

Risk Factors

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

Diagnostic Criteria

DSM-V Diagnostic Criteria for Selective Mutism

“

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.

”

Treatment

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.

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

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.

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

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.

Stimulus Fading

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. This can take a relatively long time for the first one or two faded in people.

Desensitization

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.

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

• (1948) 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.

• (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.

• (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.

• (1993) In the film The Piano, the main character, Ada McGrath, is a selective mute.

• (1994) In the film Corrina, Corrina, the main character, Molly Singer (played by Tina Majorino) has selective mutism.

• (2000) The title character of Dori Jones Yang's novel The Secret Voice of Gina Zhang has selective mutism.

• (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.

• (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.

• 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.

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