In the DSM-IV 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 They function normally in other areas of behaviour and learning, though appear severely withdrawn and might be unwilling to participate in group activities. 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.

The disorder is not regarded as a communication disorder, in that most children communicate through facial expressions, gestures, etc. In some cases, selective mutism is a symptom of a pervasive developmental disorder or a psychotic disorder.

In diagnosis, it can be easily confused with autistic spectrum disorder, or Aspergers, especially if the child acts particularly withdrawn around his or her psychologist. Unfortunately, this can lead to incorrect treatment.

Selective mutism is usually characterised by the following:

The person does not speak in specific places such as school or other social events.
The person can speak normally in at least one environment. Normally this is in the home.
The person's inability to speak interferes with his or her ability to function in educational and/or social settings.
The mutism has persisted for at least a month and is not related to change in the environment.
The mutism is not caused by another communication disorder and does not occur as part of other mental disorders.

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 has 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. Owing 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.

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Identifying mutism's etiology in a child
From Nurse Practitioner, 10/1/02 by Roberts, Susan Jo

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

1. Leonard H, Dow S: Selective mutism. In: Marsh iS, ed. Anxiety disorders in children and adolescents. New York, N.Y.: Guilford Press, 1995;23550.

2. Leonard H, Topol D: Elective mutism. Child Adolesc Psychiatr Clin N Am 1993;2(4):695-07.

3. Fundudis T, Kolvin I, Garside RF: Speech retarded and deaf children: Their psychological development. London, England: Academic Press, 1979.

4. Brown BI, Lloyd H: A controlled study of children not speaking at school. The Association of Workers for Maladjusted Children 1975;3:49-63.

5. Kopp S, Gilberg C; Selective mutism: A population-based study: A research note. J Child Psychol Psychiatry 1997;38(2):257-62.

6. American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 4th edition. Washington, D.C.: American Psychiatric Association, 1994.

7. Black B: Social anxiety and selective mutism. In: Dickstein LJ, Oldham JM, Riba, MB, eds. American Psychiatric Press review of psychiatry. Washington, D.C.: American Psychiatric Association Press, 1996;469-95.

8. Hayden TL: The classification of elective mutism.

J Am Acad Child Psychiatry 1980;19:118-33. Kolvin I, Fundudis T. Elective mute children: Psychological development and background factors. J Child Psych Psychiatry 1981;22:219-32. 10. Wright HH, Miller MD, Cook MA, et al.: Early identification and intervention with children who refuse to speak. I Am Acad Child Psychiatry 1985;24(6):739-46.

It. Biederman J, Rosenbaum JF, Bolduc-Murphy EA, et al.: Behavioral inhibition as a temperamental risk factor for anxiety disorders. Child Adolesc Psych Clin N Am 1993;2:667-84.

12. Kagan J, Reznick S, Snidman, N: Biological bases of childhood shyness. Science 1988;240:167-72. 13. Black B, Uhde TW: Psychiatric characteristics of children of children with selective mutism: A pilot study. J Am Acad Child Adolesc Psychiatry 1995;34(7):847-56.

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.

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