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Selective mutism (SM)
Classification and external resources
ICD-10 F94.0
ICD-9 309.83 313.23
MedlinePlus 001546
eMedicine ped/2660
MeSH D009155

Selective mutism (SM) is a severe childhood[citation needed] anxiety disorder[1][2] in which a person who is normally capable of speech is unable to speak in given situations, or to specific people.

Contents

Description

In the Diagnostic and Statistical Manual of Mental Disorders, selective mutism is described as a rare psychological mental disorder in children. Children and adults with the disorder are fully capable of speech and understanding language, but can fail to speak in certain social situations when it is expected of them.[3] It is in presentation an inability to speak in certain situations. They function normally in other areas of behavior and learning, though appear withdrawn and some are unable to participate in group activities. 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. There appears to be a hierarchical variation among those suffering from this disorder in that some children participate fully in school and appear social, but just don't speak; others will speak only to peers, but not to adults; others will speak only to adults when asked questions requiring short answers, but not to peers in social situations; while others speak to no one and can not participate at all in any activities presented to them. In its most severe form, known as "Progressive Mutism", selectively mute children stop speaking to everyone, even their parents.

Particularly in young children, SM can sometimes be confused with an autism spectrum disorder, especially if the child acts particularly withdrawn around his or her diagnostician.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. Individuals with SM can communicate normally when in a situation in which they feel comfortable, as can many individuals on the autism spectrum, especially those with Asperger syndrome. Although children on the autism spectrum may also be selectively mute, they display other behaviors—hand flapping, repetitive behaviors, social isolation even among family members (not always answering to name, for example), sensory integration difficulties, poor eye contact—that set them apart from a child with selective mutism. If a child is simply not speaking in social situations, this is likely not an autism spectrum disorder, but may be SM. Children with SM are not necessarily autistic, but children with autism frequently are nonverbal. Evaluation of children with these symptoms by a developmental pediatrician is critical for early intervention. Evaluations should accompany a video of the child in the home environment where he/she is the most comfortable in order to assist in making a differential diagnosis.

Selective mutism is by definition characterized 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 was changed to selective mutism in 1994 . Though views on the involuntary nature of this disorder are not without some controversy . Some researchers have contended that it's mainly caused by oppositional behaviour [4], while others maintain that it's the result of anxiety and shyness in general and social anxiety in particular [5].

The incidence of selective mutism is not certain. Due to the poor understanding of this condition by the general public, many cases are likely 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.

Causes

Most children with selective mutism are believed to have an inherited predisposition to anxiety. They often have inhibited temperaments, which is hypothesized to be the result of over-excitability of the area of the brain called the amygdala.[6] This area receives indications of possible threats and sets off the fight-or-flight response.

Some children with selective mutism may have sensory integration dysfunction (trouble processing some sensory information). This would cause anxiety, which may cause the child to "shut down" and not be able to speak. Many children with SM may have some auditory processing difficulties.

About 20-30% of children with SM have speech or language disorders that add stress to situations in which the child is expected to speak.[7]

There is no evidence that children with SM are more likely to have suffered abuse, neglect, or trauma, though these cannot be ruled out. Children with SM nearly always speak in some situations (though their mutism may progress to the point where they cannot speak anywhere) while children with trauma-induced mutism usually suddenly become silent in all situations.

Despite the change of name from "elective" to "selective", a common misconception remains that a selectively mute child is defiant or stubborn. In fact, children with SM have a lower rate of oppositional behavior than their peers in a school setting.[8]

Treatment

Contrary to popular belief, people suffering from selective mutism do not necessarily improve with age[9]. 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. They then stop attempting to initiate verbal contact with the sufferer, making the prospect of talking seem even more difficult. Sometimes in this situation, a change of environment (such as changing schools) may make a difference. In some cases, with psychological help, the sufferer's condition may improve. Treatment in teenage years may, though not necessarily, become more difficult because the sufferer has become accustomed to being mute.

Forceful attempts to make the child talk are not productive, usually resulting in higher anxiety levels, which reinforces the condition. The behavior is often viewed externally as willful, or controlling, as the child usually shuts down all vocal communication and body language in such situations, which can often be wrongly perceived as rudeness.

The exact treatment depends a lot on the subject, his or her age, and other factors. Typically, stimulus fading is used with younger children, because older children and teenagers can recognize the situation as an attempt to make them speak.[10]

Some in the psychiatric community believe that anxiety medication may be effective in extremely low dosages but 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 purely behavioral and psychological interventions.

Effective treatment is necessary for a child to develop properly. Without treatment, selective mutism can contribute to chronic depression and other social and emotional problems.[11][12]

Stimulus fading

In this technique the patient is brought into a controlled environment with someone with whom they are at ease 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 slowly brought 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 indirect means to prepare them mentally for the next step. This might include email, instant messaging (either text, audio, and/or video), online chat, or voice or video recordings, until they are in a position to try more direct communication.

Shaping

The child is slowly encouraged to speak. The child is reinforced first for interacting nonverbally, then making certain sounds, then whispering, and finally saying a word or more.[13]

Drug treatments

Many practitioners believe that there is evidence indicating that antidepressants such as fluoxetine may be helpful in treating children with selective mutism and even that medicine is essential to effective treatment. The medication is used to decrease anxiety levels to speed the process of therapy. Use of medication would end after nine to twelve months, once the child has learned skills to cope with anxiety and has become more comfortable in social situations.[14] Medication is more often used for older children and teenagers whose anxiety has led to depression and other problems.

However, 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[15] 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.

Medication, when used, should never be considered the entire treatment for a child with selective mutism. The child should, while on medication, be in therapy to help him or her to know how to handle anxiety and prepare him or her for the life without medication.[16]

History

In 1877, a German physician named the disorder aphasia voluntaria to describe children who were able to speak normally but often "refused" to.[17]

In 1980, a study by Torey Hayden identified four "subtypes" of Elective Mutism.[18] First, and most common, she described "symbiotic mutism" characterized by a vocal and dominating mother and absent father and the use of mutism as controlling behavior around other adults. Second and least common was "speech phobic mutism" in which the child showed distinct fear at hearing a recording of his or her voice. This also involved ritualistic behaviors and was thought to be caused by having been told to keep a family secret. Third was "reactive mutism" thought to be caused by trauma or abuse. These children all showed symptoms of depression and were notably withdrawn, usually showing no facial expressions. Finally, Hayden described "passive-aggressive mutism" in which silence is used as a display of hostility, connected to antisocial behavior. Some of the children in her study had not been mute until age 9-12. These subtypes are no longer recognized.

The Diagnostic and Statistical Manual of Mental Disorders (DSM), first published in 1952, first included Elective Mutism in its third edition, published in 1980. Elective Mutism was described as "a continuous refusal to speak in almost all social situations" despite normal ability to speak. While "excessive shyness" and other anxiety-related traits were listed as associated features, Predisposing factors included "maternal overprotection", mental retardation, and trauma. Elective Mutism in the third edition revised (DSM III-R) is described similarly to the third edition except for specifying that the disorder is not related to Social Phobia.

In 1994, the fourth edition of the DSM reflected the name change to selective mutism and described the disorder as a failure to speak. The relation to anxiety disorders was emphasized, particularly in the revised version (DSM IV-TR).

Status

In the United States, schoolchildren who have received a professional diagnosis are usually placed in normal classroom settings and given special education Individualized Education Programs similar to schoolchildren with other disabilities (i.e. ADHD) and learning disabilities. Children with selective mutism may qualify for special education under the Individuals with Disabilities Education Act (IDEA) or Section 504. Under IDEA, they may fall under the category of "other health impairment," "emotional disturbance," or "speech or language impairment."[19]

In Australia, where the condition is classified as a disability, diagnosed adults who are independent from a spouse or parent qualify for entitlement welfare.

Cultural references

  • The 2001 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 are running freely like water from a tap").
  • The little boy in the nonfiction children's book "Why Dylan Doesn't Talk" suffers with selective mutism. He tells his story to help other children who also live with a fear of speaking.
  • In Little Voice, the main character suffers from selective mutism.
  • The title character of Dori Jones Yang's novel The Secret Voice of Gina Zhang has selective mutism complicated by bilingual issues. When she begins school in America, she finds that her throat closes up when she attempts to speak in English or her native language, Mandarin.
  • Alvin Ho: Allergic to Girls, School, and Other Scary Things by Lenore Look, the title character is a second-grader who wants to make friends despite being afraid of almost everything and selectively mute.
  • In Leap Day by Wendy Mass, one character, Zoey, appears to have had selective mutism as a child, though she overcame it when she moved to a new town and felt that she could redefine herself. Another minor character stops being able to speak to most people after she sees something that could make her parents divorce if she accidentally told anyone. This is a rare cause at best, but seeing her inability to speak helps Zoey understand herself better.
  • In Obasan by Joy Kogawa, the main character often seems to be selectively mute. "Inside the house... there is confidence and laugher... but outside, even in the backyard... speech hides within me, watchful and afraid." However, twice in the book, she answers aloud when someone asks her if she can speak.
  • In The Playmaker by J. B. Cheaney, the main character explains that, since childhood, he literally cannot speak in moments of high emotion. While this problem rarely appears, this is an example of selective mutism being used in characterization.
  • The song "Mariella" by Kate Nash is about a girl who never speaks, has no friends, and is likely depressed, but she is described as being "happy in her own little world" and not wanting to talk. This may be an outsider's view of selective mutism.

Wristbands

Many across the globe wear the turquoise wristband to help raise awareness of Selective Mutism. The message on the wristband says "Breaking the Silence"

See also

References

  1. ^ What is Selective Mutism (SM)?.
  2. ^ SMart Center: What is Selective Mutism?.
  3. ^ Adelman, L. (2007). Don't Call me Shy, LangMarc Publishing
  4. ^ Paez, P.; M. Hirsch (1988). "Oppositional disorder and elective mutism". Handbook of clinical assessment of children and adolescents 2: 800–811. 
  5. ^ Steinhausen, H. C.; C. Juzi (1996). "Elective mutism: an analysis of 100 cases". Journal of Amer Academy of Child & Adolescent Psychiatry 35 (5): 606. 
  6. ^ SMart Center: What is Selective Mutism?
  7. ^ Cohan, Sharon L. Refining the Classification of Children with Selective Mutism: A Latent Profile Analysis
  8. ^ Sharp, William G. Selective Mutism and Anxiety: A Review of the Current Conceptualization of the Disorder
  9. ^ Johnson, Maggie; Alison Wintjens (2001-06-21). The Selective Mutism Resource Manual. Speechmark Publishing Ltd. ISBN 0863882803. 
  10. ^ Ricki Blau. "The Older Child or Teen with Selective Mutism"
  11. ^ Selective Mutism Group: Ask the Doc archives http://www.selectivemutism.org/faq/faqs/when-do-i-need-to-seek-professional-help-for-my-child http://www.selectivemutism.org/faq/faqs/what-about-adults-what-are-the-long-term-effects-of-sm
  12. ^ Virginia Tech University mass killer Cho Seung Hui diagnosed with Selective Mutism
  13. ^ [1] Excerpt of and article by Gail Kervatt
  14. ^ Selective Mutsim Group: Ask the Doc archives
  15. ^ CNN.com - Documents: Prozac use reports more likely to list suicide - Jan 4, 2005
  16. ^ Selective Mutism Group: Ask the Doc archives
  17. ^ http://www.brighttots.com/Selective_Mutism.html Bright Tots: Selective Mutism
  18. ^ Torey Hayden. Classification of Elective Mutism
  19. ^ Special Education for the child with Selective Mutism
  20. ^ "The Terminator Decoupling". The Big Bang Theory. March 9, 2009. No. 17, season 2.

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