S.K., a 5-year-old girl, hadn't spoken to her teachers during preschool, and she was about to begin kindergarten. S.K.'s preschool teachers told her parents that she seemed uncomfortable in class. Her parents noted that she had always exhibited nonverbal behavior away from home but was verbal at home.
The mother reported that S.K. had good social skills and was animated when she was at home or with friends at home. When leaving school with friends, S.K. remained silent until they were in a car, heading toward home. Then, S.K. would begin to talk, laugh, and play.
S.K's parents adopted her when she was age 2 months. In her birth records, her birth mother described her as quiet and smart. She had normal development and speech acquisition. She didn't have symptoms of other psychiatric disorders, and physical examinations proved consistently normal.
S.K.'s Diagnosis
Based on S.K.'s history of normal development, normal speech at home, and a normal physical examination, organic causes of mutism were unlikely. The presence of S.K.'s mutism in only certain environments and the lack of sudden onset was characteristic of selective mutism.
* S.K.'s Treatment
We placed S.K. on fluoxetine and referred her to a psychologist who outlined a behavioral program. All adults involved with S.K.'s care instituted a reward system at school and in situations where S.K. was inhibited. In the beginning, S.K. received a reward for behavior such as nodding or smiling. Later in the year, she received a reward for saying a word to a classmate or raising her hand.
Over 2 years, S.K. slowly began to respond verbally to her teacher and friends. After the 2-year period, we tapered the fluoxetine until, eventually, she didn't receive any; she didn't exhibit any behavioral changes.
Five years after her diagnosis, S.K. demonstrates some inhibited behavior but actively participates in school and communicates with teachers, coaches, friends, and new adults. She performs verbal presentations at school and has participated in several plays.
* What is selective mutism?
In the 1930s, Tramer described elective mutism as the behavior of children who spoke only in certain situations or only to certain people.1,2 Reports of the disorder's frequency range from 0.8 to 7.24 per 1,000 children;34 however, use of more selective criteria reduces the rate to 1.8 per 1,000 children, with a 1.5:1 ratio of girls to boys.5
Selective mutism is the consistent failure to speak in specific social situations, when there is an expectation for speaking, despite speaking in other situations.6 This categorization excludes children with mutism secondary to communication and other psychiatric diagnoses. The term selective mutism conveys that these children don't choose mutism; rather, mutism presents when children are in anxiety-producing situations.7
Etiologic concepts once focused on biologic factors, traumatic events, and disordered family dynamics;8-10 however, since 1990, researchers have considered the condition an anxiety disorder-a social phobia-based on findings that the disorder runs in families and that children respond to psychopharmacologic interventions.1,2,7 Research on biologic components of temperament have also proved influential in guiding this etiologic framework.11,12
* Research
Researchers found that selectively mute children were most likely to speak at home and to family members. Children exhibited mutism at school and with unfamiliar adults, although great variability exists among children and settings.7,13 In studies of children with selective mutism, many also had diagnoses of social phobia, avoidant disorder, or simple phobia; however, these children rarely had symptoms of other psychiatric disorders.13,14 Although a family history of social phobia and selective mutism was common in these subjects, researchers noted a history of psychological or physical trauma in only 4 of 30 subjects.13
* Assessment
Determine if children with mutism have other psychological, neurological or developmental disorders. If the child exhibits mutism in all settings or has transient mutism, consider neurologic conditions (trauma, brain lesions and masses, aphasia) or infections.15 Psychiatric disorders that may present with mutism include pervasive developmental disorder, psychosis, and anxiety disorders (panic disorder, agoraphobia, separation disorder, and obsessive-compulsive disorder).7,16
Differentiate selective mutism from developmental disorders and psychosis, as children with selective mutism have normal social interactions in many situations. Many children with selective mutism have anxiety; therefore, differentiating the exact anxiety disorder may prove challenging! Further complicating the matter, as children with selective mutism usually refuse to talk to the clinician, you must gather information from parents, siblings, and teachers. Mutism in the clinical setting doesn't indicate severity, nor does it correlate with improvement in other settings 16 (see Table 1, "Diagnostic Criteria for Selective Mutism").
Assessment includes a complete medical history with a developmental and prenatal history (see Table 2, "Assessing Selectively Mute Children").1,15 A history of neurologic deficits, developmental delays, or language problems suggests other neuropsychiatric etiologies. Useful information includes details of prior language ability and any past treatments for language problems. Because of the family link, a family history of psychiatric problems, especially anxiety disorders, mutism, and shyness, also proves useful. A complete history of psychological, social, and behavioral symptoms and problems in the child can help differentiate other etiologies.
Details of mutism onset clarify the etiology, as children with selective mutism don't have a specific or sudden onset. Parents usually report that mutism has been the norm,15 although they don't usually seek clinical care until the start of school, when teachers and classmates expect the child to speak. Obtain a detailed history of the child's ability to socialize, including settings in which he or she seems uninhibited and inhibited.
A physical examination, including audiologic and neurologic assessments can help rule out physiologic causes of mutism.1,15 If the initial history suggests social deficits, initiate formal speech and language testing. A videotape of the child interacting at home can help you evaluate language and behavior in an anxiety-free environment. When children have a history suggestive of selective mutism and a normal physical examination, refer them to a mental health clinician knowledgeable about selective mutism.
* Treating Selective Mutism
Pharmacologic therapy. Selective mutism treatment experienced a breakthrough in the last 10 years: The use of the selective serotonin reuptake inhibitor (SSRI), fluoxetine. In several studies, researchers rated fluoxetine-- treated children as significantly improved.16-18 Recommendations include initiating a trial of fluoxetine as adjunctive treatment to cognitive-- behavior therapy;9,15-17 the literature doesn't support the efficacy of psychodynamic therapy.9,17
Education. Educate parents and teachers,9 clarifying that the child suffers from anxiety and isn't deliberately refusing to speak. This understanding encourages parents and teachers to offer support to the child rather than to reprimand him or her for not speaking. Education can decrease the frustration and confusion school personnel may have, providing a concrete way of dealing with a child. The education also provides a basis for a behavioral program.9
Several organizations provide support and information: The Selective Mutism Foundation, Inc., Box 450632, Sunrise, Florida 33345-0632; and the Selective Mutism Group-Childhood Anxiety Network, Inc., http://www. selectivemutism.org.
Cognitive-behavior therapy. Cognitive-- behavior approaches can encourage verbal and nonverbal communication in selectively mute children.7,15,16 Because most children display nonverbal behavior at school, parents should choose a mental health clinician willing to meet with school personnel. The therapist sets up a home and school program that rewards communication and socialization and discourages behaviors that increase anxiety, such as punishment for nonverbal behavior, insistence on speech, or pressuring a child to speak. Parents and teachers must achieve a balance that provides encouragement and rewards for communication, but doesn't make the child feel more anxious by speech expectations.
Successful programs include a slow, deliberate increase in behavioral change with rewards for small increases in communication. In the beginning, give rewards for small behavior changes such as turning to a classmate or nodding at an appropriate time. For students who haven't spoken in school for many years, progress is challenging. For this reason, early intervention is particularly helpful, preferably before kindergarten. The home program includes play dates that allow a child to play with classmates at home. The child then successfully transfers the home speech experience to school.
REFERENCES
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6. American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 4th edition. Washington, D.C.: American Psychiatric Association, 1994.
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8. Hayden TL: The classification of elective mutism.
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14. Dummit ES, Klein RG, Tancer NK, et al.: Systematic assessment of 50 children with selective mutism. J Am Acad Child Adolesc Psychiatry 1997;36(5):653-60.
15. Dow SP, Sonies BC, Scheib D, et al.: Practical guidelines for the assessment and treatment of selective mutism. J Am Acad Child Adolesc Psychiatry 1995;34(7):836-46.
16. Black B, Uhde T: Elective mutism as a variant of social phobia. J Am Acad Child Adolesc Psychiatry 1992;31:1090-94.
17. Black B, Uhde T: Treatment of elective mutism with fluoxetine: A double-blind, placebo-controlled study. J Am Acad Child Adolesc Psychiatry 1994;33(7):1000-06.
18. Dummit S, Klein R, Tancer NK, et al.: Fluoxetine treatment of children with selective mutism: An open trial. J Am Acad Child Adolesc Psychiatry 1996;35(5):615-21.
Susan Jo Roberts, ANP, DNSc
ABOUT THE AUTHOR
Susan Jo Roberts is associate professor, Northeastern University School of Nursing, Boston, Mass., and an adult NP, Harvard Vanguard Medical Associates, Wellesley, Mass.
Copyright Springhouse Corporation Oct 2002
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