Elective mutism

MIAMI BEACH -- Delayed acquisition of speech is not always due to late maturation in children, Dr. N. Paul Rosman reminded physicians at a pediatric meeting sponsored by Miami Children's Hospital.

Medical conditions and psychosocial factors can influence the process as well.

Dr. Rosman defined speech delay as the failure to acquire words by 18-24 months of age or phrases by 3 years of age.

Because speech is the most complex skill that people acquire, many factors can produce delays, including:

* Hearing Loss. "This is the most frequently overlooked disorder affecting speech development," said Dr. Rosman, chief of pediatric neurology at the Floating Hospital for Children in Boston. Common causes include recurring middle ear infections, congenital malformations, meningitis, trauma, and genetic disorders.

Suspect hearing loss when a child does not seem to understand; is inattentive; looks intently at others who are speaking; or better recognizes sounds with more lip movement, such as the letter W.

A child's hearing can be tested with behavioral or physiologic audiometry. The latter does not require cooperation from the child and is preferable for very young or willful children.

* Left Cerebral Lesion. If acquired before 6 years of age, left-brain lesions shift the language center of the brain to the right hemisphere, where it normally does not reside.

This may cause speech delay and "pathologic" left-handedness--that which appears too early or without a family history of left-handedness.

Aphasia, the loss of previously acquired speech, is almost always traced to a left cerebral lesion.

* Seizures. When these begin in the first decade, they can cause delayed speech or aphasia and can result in verbal auditory gnosia (word deafness) in which children are unable to decode speech.

"If you see a bright child who seems to have difficulty understanding what he or she hears, think of this condition," Dr. Rosman said.

Anticonvulsants cure one-third of these patients, significantly improve one-third, and leave another third with residual deficits.

* Mental Retardation. Over half of all mentally retarded children are speech delayed. But don't overlook common coexisting contributors such as deafness, dysarthria, or sensory deprivation.

* Disordered Emotionality. Both elective mutism and pervasive developmental disorders such as autism fall in this category.

Children who choose not to speak may do so because of anxiety, attention seeking, or embarrassment about a speech deficit.

About half of autistic children don't develop useful speech by age 5 and have a poor prognosis. Patients with higher IQs and useful speech tend to do better.

* Psychosocial Factors. Speech development can be slower in twins, younger siblings, children in lower socioeconomic classes, children of deaf-mute parents, and children exposed to more than one language.

* Developmental Delay. Speech delay caused by late maturation can be mild, moderate, severe, or very severe, depending on the level of impairment of word sounds, spoken language, and language comprehension.

Speech pathologists can make the difference between the child having rudimentary or normal speech. Parents and teachers can help by being supportive, functioning as "cotherapists," and remembering not to be overly responsive to gestures.

"Confronted with a child who fails to speak, there are many causes, many treatments, and many outcomes. But happily most children do well," Dr. Rosman said.

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