Selective mutism

Articleissues
expert = PsychologyInfobox Disease
Name = Selective mutism


Caption =
DiseasesDB =
ICD10 = ICD10|F|94|0|f|90
ICD9 = ICD9|309.83 ICD9|313.23
ICDO =
OMIM =
MedlinePlus = 001546
eMedicineSubj = ped
eMedicineTopic = 2660
MeshID =

Selective mutism is a social anxiety disorder in which a person who is normally capable of speech is unable to speak in given situations, or to specific people.

Description

In the Diagnostic and Statistical Manual of Mental Disorders 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 can fail to speak in certain social situations when it is expected of them. It ranges in presentation from a reluctance to speak in certain situations to physical and social ‘frozen’ unresponsiveness. They function normally in other areas of behaviour and learning, though appear severely withdrawn and some are unable to participate in group activities. 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.

Particularly in young children, selective mutism can sometimes be confused with an autism spectrum disorder, especially if the child acts particularly withdrawn around his or her diagnostician. Unfortunately, this can lead to incorrect treatment. Individuals with selective mutism can communicate normally when in a situation in which they feel comfortable, as can many individuals on the autism spectrum, especially those with Asperger's Syndrome. Although children on the autism spectrum may also be selectively mute, they display other behaviors--hand flapping, repetitive behaviors, social isolation even among family members (not always answering to name, for example), sensory integration difficulties, poor eye contact--that set them apart from a child with selective mutism. If a child is simply not speaking in social situations, this is likely not an autism spectrum disorder, but may be selective mutism. Children with selective mutism are not necessarily autistic, but children with autism, which has a large anxiety component, frequently display symptoms of selective mutism. It is critical to have a child with these symptoms evaluated by a developmental pediatrician.

Selective mutism is usually characterized by the following:
*Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.
*The disturbance interferes with educational or occupational achievement or with social communication.
*The duration of the disturbance is at least 1 month (not limited to the first month of school).
*The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
*The disturbance is not better accounted for by a communication disorder (e.g., stuttering) and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder.

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 was changed to "selective mutism" in 1994. However, misconceptions still prevail; for instance, ABC News erroneously attributed the cause of selective mutism to trauma and described it as willful in a report dated May 26, 2005. [ [http://abcnews.go.com/Primetime/Health/story?id=794677&page=1 ABC News: Traumatized Girl Wills Herself to Silence ] ]

The incidence of selective mutism is not certain. Due to the poor understanding of this condition by the general public, many cases are likely 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.

Typical sufferers have some of the following traits, some of which are often perceived as rudeness [ [http://www.selectivemutism.org/faq/faqs/are-there-other-associated-behaviors-or-personality-traits Selective Mutism Group FAQs: Are there other associated behaviors or personality traits?] ] :

*A difficulty in maintaining eye contact
*A reluctance to smile and a tendency to have a blank facial expression
*Stiff, awkward body movements
*Particular anxiety in situations where speech is normally expected (answering school registers, saying hello, goodbye, thank you, etc.)
*A tendency to worry about things more than other people, sometimes Generalized Anxiety Disorder
*A sensitivity to noise and crowds or crowded situations
*Difficulty with verbal and non-verbal expression
*Frequent temper tantrums at home
*Fear of using public restrooms
*Compulsive traits, even Obsessive-Compulsive Disorder
*Clinging behavior

Causes

Most children with selective mutism have an inherited predisposition to anxiety. They often have inhibited temperaments, which is hypothesized to be the result of over-excitability of the area of the brain called the amygdala [SMart Center: What is Selective Mutism? http://www.selectivemutismcenter.org/WhatisSM.htm] . This area receives indications of possible threats and sets off the fight-or-flight response.

Some children with selective mutism may have Sensory Integration Dysfunction (SID), which causes the child to have trouble processing some sensory information. This would cause anxiety, which may cause the child to "shut down" and not be able to speak.

About twenty to thirty percent of children with selective mutism have speech or language disorders that add stress to situations in which the child is expected to speak. Similarly, some children come from bilingual families, have lived in a foreign country, or have been exposed to a foreign language during young childhood and are insecure with the language they are expected to speak. In both these situations, the children have inhibited temperaments, but the stress caused by their language difficulties cause them to become anxious enough about speaking to become mute.

There is no evidence at all that children with selective mutism have suffered abuse, neglect, or trauma but these cannot be ruled out. Children with selective mutism nearly always speak in some situations (though their mutism may "progress" to the point where they cannot speak anywhere) while children with trauma-induced mutism usually "suddenly" become silent in all situations.

Treatment

Contrary to popular belief, people suffering from selective mutism do not necessarily improve with age [Johnson M & Wintgens A (2001) "The Selective Mutism Manual". Bicester: Speechmark] , or just "grow out of it." Consequently, treatment at an early age is important. If not addressed, selective mutism tends to be self-reinforcing: those around such a person may eventually expect him or her not to speak. They then stop attempting to initiate verbal contact with the sufferer, making the prospect of talking seem even more difficult. Sometimes in this situation, a change of environment (such as changing schools) may make a difference. In some cases, with psychological help, the sufferer's condition may improve. Treatment in teenage years may, though not necessarily, become more difficult because the sufferer has become accustomed to being mute.

Forceful attempts to make the child talk are not productive, usually resulting in higher anxiety levels, which reinforces the condition. The behavior is often viewed externally as willful, or controlling, as the child usually shuts down all vocal communication and body language in such situations - this can often be wrongly perceived as rudeness.

The exact treatment depends a lot on the subject, their age and other factors. Typically, stimulus fading is used with younger children, because older children and teenagers can recognize the situation as an attempt to make them speak. [ [http://www.selectivemutism.org/resources/library/SM%20General%20Information/Older%20Children%20and%20Teens.pdf Ricki Blau "The Older Child or Teen with Selective Mutism"] ]

Some in the psychiatric community believe that anxiety medication may be effective in extremely low dosages but that higher doses may just make the problem worse. Others in the field believe that the side-effects of psychiatric medications — in any dose and on any child — are so dangerous as to negate any temporary benefit, preferring purely behavioral and psychological interventions.

Effective treatment is necessary for a child to develop properly. Without treatment, Selective Mutism can contribute to chronic depression and other social and emotional problems. [Selective Mutism Group: Ask the Doc archives http://www.selectivemutism.org/faq/faqs/when-do-i-need-to-seek-professional-help-for-my-child http://www.selectivemutism.org/faq/faqs/what-about-adults-what-are-the-long-term-effects-of-sm] [Virginia Tech University mass killer Cho Seung Hui diagnosed with Selective Mutism http://news.bbc.co.uk/1/hi/programmes/this_world/7336053.stm]

timulus fading

In this technique the patient is brought into a controlled environment with someone who they are at ease with and can communicate. Gradually another person is introduced into the situation involving a number of small steps.

These steps are often done in separate stages in which case it is called the "sliding-in" technique, where a new person is slid into the talking group.This can take a relatively long time for the first one or two faded in people.

Desensitization

The subject is allowed to communicate via non-direct means to prepare them mentally for the next step. This might include email, instant messaging, or online chat, until they are in a position to try more direct communication.

Drug treatments

Many practitioners believe that there is evidence indicating that antidepressants such as fluoxetine (Prozac) may be helpful in treating children with selective mutism and even that medicine is essential to effective treatment. The medication is used to decrease anxiety levels to speed the process of therapy. Use of medication would end after nine to twelve months, once the child has learned skills to cope with anxiety and has become more comfortable in social situations [Selective Mutsim Group: Ask the Doc archives http://www.selectivemutism.org/find-help/ask-the-doc-archives/index_html/question4-meds] . Medication is more often used for older children and teenagers whose anxiety has led to depression and other problems.

However, other practitioners and activists (see articles on Peter Breggin and David Healy (psychiatrist)) stringently decry any use of psychiatric medications on children and note the lack of medical proof of genetic links to behavioral disorders. The denunciation of psychotropic intervention on children with behavioral anxiety disorders has intensified particularly since lawsuits against several drug companies — current to 2005 — have exposed previously unseen internal research documents [ [http://www.cnn.com/2005/HEALTH/01/04/prozac.documents/index.html CNN.com - Documents: Prozac use reports more likely to list suicide - Jan 4, 2005] ] linking fluoxetine and other SSRI antidepressants with increased risk of suicide, psychosis and — ironically enough — damage to areas of the brain which could affect language production and normal social development.Medication, when used, should never be considered the entire treatment for a child with selective mutism. The child should, while on medication, be in therapy to help him or her to know how to handle anxiety and prepare him or her for the world [Selective Mutism Group: Ask the Doc archives http://www.selectivemutism.org/find-help/ask-the-doc-archives/index_html/question27-meds] .

References

Cultural references

* (1948) "The Makioka Sisters", a novel by Jun'ichirō Tanizaki, is published in Japan, its characters modeled upon real members of the author's third wife's family. The distinctively 'shy' character of Yukiko, who challenges her family with a stubborn refusal to marry, is based on a sister who may have had selective mutism.
* (1995) Misato Katsuragi from the anime Neon Genesis Evangelion did not speak for the two years fallowing the Second Impact.
* (2000) The title character of Dori Jones Yang's novel "The Secret Voice of Gina Zhang" has selective mutism complicated by bilingual issues. When she begins school in America, she finds that her throat closes up when she attempts to speak in English or her native language, Mandarin.
* (c. 2001) In the Disney Channel original series "Lizzie McGuire" the character Lenny Onassis, a friend of Matt McGuire, is selectively mute and only communicates to Matt.
* (2001) The song "She's Given Up Talking" by Paul McCartney (from the album "Driving Rain") conforms almost perfectly to a clinical description of selective mutism in childhood, describing a young girl who is mute at school yet normally talkative at home ("When she comes home it's a yap yap yap/ words start to flow like water from a tap").
* (2008) Rajesh Koothrappali in the series "The Big Bang Theory" is unable to speak around women, but this is suppressed at different points by alcohol and an experimental anti-anxiety drug.

ee also

* Social Phobia
* Glossophobia
* Shyness
* Social anxiety
* Separation Anxiety Disorder
* School refusal

Other organizations

* SMIRA (Selective Mutism Information and Research Association) (UK) http://www.selectivemutism.co.uk
* SMG-CAN (Selective Mutism Group Childhood Anxiety Network) http://www.selectivemutism.org
* SMF (Selective Mutsim Foundation) http://www.selectivemutismfoundation.org/
* SMart Center (Selective Mutism Anxiety Research and Treatment Center) http://www.selectivemutismcenter.org/
*The Selectively Silent Child- Information regarding Selective Mutism and the Selectively Silent Child Support Group of Toronto http://www.designandcopy.ca/silentchild/