Selective mutism as a childhood anxiety disorder: diagnosis and treatment

¶ … Mutism

Parents not with great joy as their children meet important developmental milestones. Both first steps and first words are celebrated and described in detail to friends and family. But sometimes as a child gets older, changes occur. Inexplicably, sometimes children who have talked for several years suddenly stop talking. Typically the child becomes selectively silent, talking animatedly with family and known friends but becoming mute at school or with strangers. When the problem is severe and exists over a period of time, the child may be diagnosed with selective mutism.

In one example, a child who was almost five years old started preschool, and after two weeks, refused to speak either to the teacher or his classmates. He also cried at arrival and would ask his parents to take him home. At home he spoke, but only to his mother, but clearly and in complete sentences. He communicated only nonverbally with his father and siblings. When the parents took him to the pediatrician, the doctor could not get him to speak (Rapin, 2001).

While selective mutism isn't well understood, it has been reported in the literature since 1877 (McCracken, 2002), when a doctor by the name of Kussmaul described a case of "aphsia voluntaria." (Fairbanks, 1997). For a very long time, selective mutism was believed to be triggered by some severe trauma. Recent research, however, has shown it to be a part of a larger social anxiety disorder (Fairbanks, 1997). In all likelihood, anxious children would be more likely to respond to trauma with a more severe response such as selective mutism, so there may be some connection, but the underlying cause is believed to be anxiety. In fact the majority of children with selective mutism have not experienced significant trauma (Rapin, 2001).

WHAT IS IT?

Because of those discoveries, the medical view of what selective mutism is has changed. Through the most recent version of the psychiatric manual Diagnostic and Statistical Manual (IV, published in 1994 and known as DSM IV), selective mutism is listed under "Other Disorders of Childhood and Adolescence," suggesting that it doesn't fit well into the diagnostic system of the manual (Fairbanks, 1997). DSM-IV describes it as "the persistent failure to speak in specific social situations despite speaking in other situations. In addition, the disturbance must interfere with achievement or social communication and last for more than 1 month (McCracken, 2002)." The diagnostic criteria allow diagnosticians to separate selective mutism out from other causes, such as aphasia or autism.

Selective mutism is a disorder that emerges after a previously normal language development. The children speak selectively, being nearly or completely silent in some environments. Typically the problem emerges early in the child's education, often coinciding with the start of preschool or school attendance (Rapin, 2001). The children don't actively choose to be mute, but become mute when present in situations that produce anxiety within themselves (Roberts, 2002). It is now widely viewed as a form of social phobia with possible biologic predispositions, as the problem tends to run in families. It often responds positively to the selective use of medications (Roberts, 2002). Early intervention may e important; in one study, the selective mutism maintained for five years or more once children who were mute for less than a month were eliminated (4). Often those transitory episodes corresponded with the start of school, but for those children the problem was self-limiting (Rapin, 2001).

HOW COMMON IS IT?

Although selective mutism has not been thoroughly researched, it may be more common than previously thought (McCracken, 2002). Until 1997, only two studies of its prevalence in the general community had been conducted, neither of them in the United States. In 1975, researchers in Great Britain identified about.7 of five-year-olds as being completely mute at school. Eight months later, however, only.08% were still completely mute (McCracken, 2002). Another study in Great Britain looked at 3,000 children and found that.3% were "speech retarded," or failing to use three or more words for meaningful communication. Only.02% met their definition of selective mutism: "inordinate and selective shyness of strangers" (McCracken, 2002). Both these studies are problematic in that they do not use accepted definitions of selective mutism, which does not require a complete failure to talk in given settings.

More significantly, children with selective mutism have been shown to show signs of social anxiety and other internalizing problems. While the children tended to improve in their willingness to communicate over six months, they still show significant other symptoms related to anxiety (McCracken, 2002). Thus selective mutism is usually seen in the presence of other signs of significant levels of anxiety. In addition, one study found that 1% of children seen in mental health centers showed selective mutism, compared to.1% in the general population (Rapin, 2001).

TREATMENT

As Fairbainks (1997) said, "The findings of very high rates of anxiety disorders, low rates of disruptive behavior disorders, and a lack of traumatic history in children with SM are consistent with other recent reports and provide further support for the view that selective mutism is typically a behavioral manifestation of a social anxiety disorder." This new perspective has important treatment implications. We don't typically think of four-year-olds, much less 30-month-olds, as being anxious, but to help children with selective mutism we need to adjust that perspective, because most typically, selective mutism is part of an anxiety disorder (Fairbanks, 1997). In addition, it is a form of anxiety that significantly impairs their function, and while some children spontaneously improve, they still show signs of anxiety, and a in a significant number of children the selective mutism persists (McCracken, 2002).

Case studies combine the use of medications and psychological support using systematic behavioral interventions. In one study, the child was placed on Prozac (generic name, fluoxetine) and provided psychological support. All adults who worked with the child participated in a carefully planned intervention. At first the child was rewarded for nonverbal communication such as smiling or nodding. Gradually she was rewarded for more verbal responses, such as saying a word to a classmate (Roberts, 2002). In spite of this careful intervention, five years later the child still demonstrated some reluctance to interact on occasion, but participated fully in school activities. She talked to teachers, friends, and unknown adults. She gave oral reports in school and had parts in plays (Roberts, 2002).

The outcome of the child described above is a markedly better outcome than trusting to time, because some of those children remain mute for years. Effective treatment of selective mutism will require that those involved learn the newer findings regarding this disorder and consider it from the view that the child has an anxiety disorder. With prompt diagnosis and intervention, over time these children can make great strides in communication.