Elective mutism

Elective mutism is diagnosed, according to DSM III, when there is "a continuous and persistent refusal to speak in school or in other social situations, an ability to comprehend spoken language, an ability and willingness to speak to at least one person and no clinical evidence of a mental or physical disorder that would account for the refusal to speak."(1) The onset of the disorder is usually between 3 and 5 years of age, and it is more common in children who evince signs of emotional conflict-excessive shyness, susceptibility to teasing, social isolation and withdrawal, clinging, difficulty in separating from their mothers to go to school, phobias, encopresis, enuresis, negativism, and temper tantrums.(2) A predisposing factor can be immigration to a country in which a different language is spoken.(3)

The first description of the disorder was by Kussmaul(4) in 1877; he termed it aphasia vollintaria to emphasize that the patients were of sound mind and forced themselves to be mute for undisclosed reasons. Most of the literature since then has been written by psychologists, psychiatrists, and social workers, and, indeed, there is no mention of the condition in standard textbooks of pediatrics and family medicine.(5-9) A family physician, in his function as gatekeeper, is likely to be the first to encounter a case of elective mutism. Three instances are reported here diagnosed over the course of 2 years in three geographically proximate family practices serving 4500 patients of all ages. ILLUSTRATIVE CASES Case I A 9-year-old girl, an only child, was electively mute for 5 years. She had immigrated to Israel from the Caucasus region of the Union of the Soviet Socialist Republics at the age of 3 years and, until the time she was registered for kindergarten, spoke only Russian. She bore much of the responsibility for maintaining the house because her mother was severely handicapped. A grandmother and maternal aunt were also members of the household. Her parents had been married for only I year when it developed that the father was an alcoholic and prone to violence. He remained in the USSR when the family moved to Israel and to this day has no contact with his daughter, who is not clear about his whereabouts and the circumstances of the separation. The family lived in isolation from the surrounding society. The child was good at school but would not speak with her peers. Shortly after the family moved to another city, she began speaking outside the home. Case 2 A 7-year-old middle child living with his parents and two brothers refused to speak with anyone outside the home. The family immigrated to Israel from Chile 9 years ago but were never happy, and after 6 years the mother took her three sons back to their country of origin in an attempt to take up the threads of her former life. She was not successful and rejoined her husband in Israel I year ago. The patient was in the fourth grade when he came to the attention of his family physician. He was doing well in school, but would not speak to his teachers or his peers. The patient attended to his homework, reading and writing Hebrew fluently, and at home he was fluent both in Spanish and in Hebrew. The family had few outside contacts and lived in modest circumstances with the father spending much of his time at work as a laborer in an industrial plant. A consultation with a speech therapist was sought; while the child was still on the waiting list, he began to speak of his own accord. Case 3 A 5-year-old boy was brought to the clinic by his mother for refusing to speak outside the home, where he was fluent in Russian with his parents and older sister. The family immigrated to Israel from the USSR 9 years ago, but was not comfortable in their adopted country. Both parents were embittered about their situation and felt that they were better off before immigrating. They were isolated socially and neither had learned Hebrew well. The mother recalled that the boy's older sister, too, at one time refused to speak in school, persisting in her refusal for nearly 2 years. The patient was very attached to his mother and would not leave the house without her. The father generally kept to himself and seemed remote from his family. After a few meetings between the family and their physician, the child began to speak outside the house. DISCUSSION The prevalence of elective mutism in school children has been reported as ranging from 0.3 to 0.6/1000 in several studies,(10) although among those who have attended school for only 2 months it may be as high as 7.2/1000.(11) The cause is almost certainly multifactorial. Families with electively mute children seem to have much in common: social isolation, disharmony, an absent father or one who distances himself from the family by maintaining a cold and indifferent aspect, and an overprotective mother inclined to depression. (11) Speech difficulties in one or more of the family members are not rare, and excessive shyness is a frequent finding. (10) Furthermore, children of new immigrant families are particularly prone to the disorder.(3)

The three electively mute children reported here seem typical of what is known about the disorder. The first patient belonged to an immigrant family that was experiencing difficulties with a new language and the mother's severe physical handicap. The child was expected to perform many adult tasks and lived in a house full of women, being quite in the dark concerning her father. The second patient also came from a family that was not happy in its country of adoption and had even been taken back to Chile for a time in the hope of a better future. His father was seldom at home. The third patient had an older sister who had been electively mute for 2 years. His, too, was an immigrant family, much embittered over their loss of status. The boy was inordinately attached to his mother, and his father kept himself remote and silent. All three families lived in considerable social isolation, perhaps their most important common denominator.

Many authors believe that the prognosis of elective mutism is good, provided that the disorder is diagnosed early and some form of intervention is undertaken. Difficulties in developing social contacts during adolescence have been reported in electively mute children followed up for long periods.(11,12) The outcome of cases 1 and 2 suggest that the disorder may be self-limiting.

Finally, it is well to consider the effect electively mute children have on their surroundings. Teachers and professionals responsible for treating them often feel rejected, frustrated, angry, and insulted by the persistent silence with which they are faced, even when the child is functioning well at school.(13) These feelings can lead to an emotional abandonment of the patient and can increase his sense of isolation.

Although to date elective mutism has been more within the purview of psychologists and psychiatrists, the family physician can be called on to deal with it.(12) The ease with which three cases were accumulated within a short period suggests that it is not rare. References 1. Diagnostic and Statistical Manual of Mental Disorders, ed 3 (DSM

III). Washington, DC, American Psychiatric Association, 1980 2. Kaplan Hi, Sadock BJ: Modem Synopsis of Comprehensive Textbook

of Psychiatry. Baltimore, Williams & Wilkins, 1981, pp 901-905 3. Bradley S, Sloman L: Elective mutism in immigrant families. J Am

Acad Child Psychiatry 1975; 14:510-514 4. Kussmaul A: Die storungen der sprache (Banol 12. Anhang In

Handbuch Der Speciellien Pathologie und Therapie). Leipzig, FCW

Vogel, 1877 5. Vaughan V, McKay J, Behrman R: Nelson Textbook of Pediatrics,

ed 13. Philadelphia, WB Saunders, 1987 6. Illingworth R: The Normal Child, ed 9. Edinburgh, London, Churchill

Livingstone, 1987 7. Hoeckelman RA: Primary Pediatric Care. St Louis, CV Mosby, 1987 8. Rakel RE: Textbook of Family Practice. Philadelphia, WB Saunders,

1984 9. Taylor RB: Family Medicine: Principles and Practice. New York,

Springer-Verlag, 1983 10. Wikins RA: Comparison of elective mutism and emotional disorders

in children. Br J Psychiatry 1985; 146:198-203 11. Hesselman S. Elective mutism in children 1877-1981. Acta Paediatr

Psychiatry 1983; 49:197-310 12. Furst AL: Elective mutism: Report of a case successfully treated by

a family doctor. Isr J Psychiatry Relat Sci 1989; 26:96-102 13. Meijer A: Elective mutism in children. Isr Ann Psychiatry 1979;

17:93-100 Submitted, revised, March 12, 1990. From the Department of Family Medicine, University Center for Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel Requests for reprints Should be addressed to Pesach Shvartzman, MD, Department of Family medicine, University Center for Health Sciences, Ben-Gurion University of the Negev, POB 653, Beer-Sheva, Israel 84105.

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