Selective Mutism (SM) is defined by the inability to speak in certain situations, and the ability to do so in other more familiar circumstances. Selective mutism should not be confused with a physical disability to speak, as it is merely a failure to speak due to anxiety rather than brain-dysfunction-related. The disorder is mostly present in children, teenagers, and young adults. Because of its selective nature, most parents are oblivious to their child’s impediment and as a consequence, SM is often detected only when the child enters school. It is diagnosed between the ages of 5 and 8 years old and it has a very high probability to disappear as the child becomes an adult. Although Selective Mutism Disorder has the potential to fade in time it might still constitute a sign of underlying psychopathology. SM is associated in over 70 % of the cases with anxiety, but also with obsessive-compulsive symptoms and phobias. When the young adult becomes an adult, mutism dims but the anxiety persists throughout adulthood. Fortunately, a wide range of non-medication and medication-based interventions have shown to be effective in treating Selective Mutism.
The present article contains:
- Definition
- Studies reports
- Treatments
Definition:
According to DSM-5 Selective Mutism is the persistent failure to speak in certain situations despite the ability to do so [1]. It was first diagnosed in 1877 and it was named aphasia voluntaria. The name implies that the suffering person withholds speech voluntarily in certain situations. For this reason, later in 1994, the term was changed to “selective mutism”. The word “selective” underlines the selective situation in which the person fails to speak rather than intentionally refusing to speak. It is a rare disorder that can emerge in infancy, childhood, or adolescence and can persist throughout adulthood. It is more common among girls than boys, with ratios that range from 2.6:1 to 1.5:1.
It can manifest itself at school, playdates, and other social situations whereas at home, or in more familiar settings, the child might be able to have a normal conversation. The disorder is labeled as “selective” mutism if it persists for more than a month, excluding the first month of school. Moreover, the disorder can be diagnosed if the child does NOT present :
- Another communication disorder (hearing disorders, deafness, stuttering, etc.)
- Concurrent diagnosis of schizophrenia, other developmental, or psychotic disorder.
- An inability to comprehend and speak the language.
There have been observed inconsistencies in establishing the diagnosis due to the infrequent use of standardized assessments [12]. Despite this, typically the onset of selective mutism occurs between ages 3 and 6, and the diagnosis is given around ages 5 and 8. Most likely, this disorder is discovered when the child is confronted with more unfamiliar social situations [10].
Study reports
A growing body of evidence reflects that SM is closely related to anxiety disorders. A study including 54 children with selective mutism showed that the disorder is associated with developmental delay in 68.5 % of the cases and with anxiety disorder in 74.1% of the cases [8, 5]. Another study by Dummit et al., [6] reported that the whole sample (50) of children with SM from their study met the criteria for avoidant disorder or social phobia, and half of their sample presented additional anxiety disorders, such as separation anxiety and simple phobias [6].
Moreover, it has been found that children who have SM experience significantly higher levels of internalizing problems, and low levels of externalizing problems when compared to a control group. No child with SM was found to display solely externalizing behavior [8]. Similar findings were reported by Cunningham et al., [4] who complement the previous study. They showed that in addition to anxiety disorders, children with SM demonstrated higher rates of obsessive-compulsive symptoms and somatic complaints. Individuals diagnosed with SM continue to struggle during adulthood as well. Although the selective mutism disappears in time they still present some levels of anxiety and shyness. It has been found that the relatives of children with SM present high levels of anxiety disorders themselves, potentially implying that SM might be a familial transmitted anxiety disorder [9].
The first long-term controlled study of SM, which took 13 years to assess the evolution of children and now young adults with SM, posits that it has not been demonstrated that family genetics contribute to the prognosis of SM, but that the family trait of taciturnity and/or mutistic behavior can contribute to the outcome [11]. Moreover, the long-term study suggested a favorable outcome of SM regarding the symptoms. They have described 2 major types of SM:
- One that does not change significantly over time, but which disappears suddenly in adolescence or young adulthood.
- The second type is where SM gradually declines until it finally disappears.
The definite outcome included a minority of 18% with SM with only s small improvement whereas the others were significantly or completely improved.
This extensive research suggests that SM can constitute an indicator of underlying psychopathology. Though, it is worth bearing in mind that immigrant children are more likely to develop SM, as bilingualism showed to be a risk factor contributing to SM.
Treatments
There are a number of treatments given that consist of both medical and non-medical based interventions.
Medication-based interventions. Antidepressants are most used to treat SM, but also anti-anxiety medication and psychotropic interventions (depending on the child's comorbidities) were effective in treating SM. The SSRI* fluvoxamine and fluoxetine showed to decrease symptoms of selective mutism (*SSRI = selective-serotonin-reuptake inhibitors). A group of six children who were administered fluoxetine for a period of 12 weeks showed improved symptoms of anxiety and mutism [2]. Significant changes were also shown in a case study of a 12-year-old girl who had never spoken at school [3]. After one month of taking fluoxetine, the girl was able to speak with teachers and peers.
Non-Medication-Based Interventions
Psychodynamic therapy, which for children is translated into play therapy is used for treating SM. The purpose of this treatment is to expose an underlying intrapsychic conflict [7].
Behavioral therapy is a “multimethod” that takes into consideration childrens’ environment and seeks to identify and address both verbal and non-verbal negative reinforcement [7].
Within the behavioral therapy approach, we meet Self-modeling (which can include video technology), Self-reinforcement, Contingency management, and Response initiation.
Family therapy is a treatment that is relevant when the family plays a role in the development of SM. Involving the family helps the child overcome anxiety and avoidance [2].
Conclusion
Selective mutism constitutes the failure to speak despite the ability to do it. It is manifested in children and has the potential to disappear as the child enters adulthood. The majority of the studies indicate that selective mutism is associated with anxiety [5] and it can be an indicator of a more pregnant issue. Selective mutism can be treated by using both medication and therapy. Medications such as fluoxetine proved to be a very efficient treatment for this disorder. There is a high probability that the SM will fade in time, but one should not ignore its correlation with other disorders as these might need professional attention as well.
References:
- American Psychiatric Association, D. S., & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (Vol. 5). Washington, DC: American psychiatric association.
- Black, B., & Uhde, T. W. (1994). Treatment of elective mutism with fluoxetine: a double-blind, placebo-controlled study. Journal of the American Academy of Child & Adolescent Psychiatry, 33(7), 1000-1006.
- Black, B., & Uhde, T. W. (1995). Psychiatric characteristics of children with selective mutism: A pilot study. Journal of the American Academy of Child & Adolescent Psychiatry, 34(7), 847-856.
- Cunningham, C.E., McHolm, A., Boyle, M.H., & Patel, S. (2004). Behavioral and emotional adjustment, family functioning, academic performance, and social relationships in children with selective mutism. Journal of Child Psychology and Psychiatry, 45 (8), 1363-1372.
- Driessen, J., Blom, J. D., Muris, P., Blashfield, R. K., & Molendijk, M. L. (2020). Anxiety in children with selective mutism: a meta-analysis. Child Psychiatry & Human Development, 51(2), 330-341.
- Dummit, E.S. III, Klein, R., Tancer, N.K., Ashe, B., Martin, J., & Fairbanks, J.A. (1997). Systematic assessment of 50 children with selective mutism. J Am Acad Child Adolesc Psychiatry (36), 653-660.
- Krysanski, V. L. (2003). A brief review of selective mutism literature. The Journal of Psychology, 137(1), 29-40.
- Kristensen, H. (2000). Selective mutism and comorbidity with developmental disorder/delay, anxiety disorder, and elimination disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 39(2), 249-256
- Kumpulainen, K. (2002). Phenomenology and treatment of selective mutism. CNS Drugs, 16(3), 175-180.
- Sharp, W. G., Sherman, C., & Gross, A. M. (2007). Selective mutism and anxiety: A review of the current conceptualization of the disorder. Journal of anxiety disorders, 21(4), 568-579.
- Steinhausen, H. C., Wachter, M., Laimböck, K., & Metzke, C. W. (2006). A long‐term outcome study of selective mutism in childhood. Journal of Child Psychology and Psychiatry, 47(7), 751-756.
- Viana, A. G., Beidel, D. C., & Rabian, B. (2009). Selective mutism: A review and integration of the last 15 years. Clinical psychology review, 29(1), 57-67.