Overview
Selective Mutism is classified as an Anxiety Disorder, and occurs primarily in children. The disorder is characterized by a pervasive inability to speak in social settings, or settings that require verbal communication.
Typically, children suspected to have Selective Mutism are able to communicate verbally with their family in the home environment, but are unable to carry out the same in other settings, including in school settings.
This inability to verbally communicate can potentially hinder the formation of peer relationships as well as academic performance that requires vocalization (such as reading out loud, answering questions, etc.).
The onset of symptoms of Selective Mutism may be observed before the age of 5, but the disorder often remains undiagnosed until the child enters a school setting that requires interaction with individuals outside the immediate family.
The aetiological factors of the disorder encompass a range of dimensions that speculate correlation from genetic, environmental, temperamental, and developmental aspects. The disorder is closely related to Social Phobia and Social Anxiety.
The treatment of Selective Mutism is considered to be largely based in psychotherapy and other psychosocial approaches.
Medication may be considered as a treatment alternative in case non-pharmacological interventions prove ineffective.
Signs and Symptoms
The signs and symptoms of Selective Mutism may include:
- Being unable to speak with peers or adults that are not part of immediate family
- Using non-verbal modes to communicate (such as writing or gestures)
- Shyness
- Fear of and withdrawal from social situations
- Clinging to familiar people
- Mild oppositional behavior
Risk Factors
Selective Mutism is diagnosed largely during childhood rather than in adolescence or adulthood. The onset of symptoms may be observed before age 5.
Symptoms of the disorder may not receive adequate attention until children begin to assimilate into social settings, such as during admission into pre-school. While Selective Mutism is considered by and large to occur evenly among sexes, some studies have found a female preponderance in its prevalence.
The aetiology of Selective Mutism is varied, and takes into account an array of factors that include genetic, developmental, temperamental and environmental correlates.
Genetic correlates of Selective Mutism often also take into consideration the occurrence of social phobia, social anxiety and its traits, which share a significant overlap with the disorder, and also present shared genetic elements.
Studies have found that individuals who presented with Selective Mutism tended to have parents who also exhibited traits such as shyness or social anxiety.
The presence of psychiatric comorbidities including generalized social phobia and avoidant personality disorder was also heightened among parents of children with Selective Mutism. Genetic variations have also been established in the occurrence of social anxiety symptoms and traits that may be antecedents of Selective Mutism.
Certain innate temperamental inclinations have also been associated with the disorder. Behavioral inhibition, which is illustrated by fear and avoidance in situations that are new and unfamiliar, has been linked as a precedent to the development of Selective Mutism.
Shyness as a trait is often considered to be associated with Selective Mutism, but is not necessarily always a confirmation of diagnosis. However, there are also instances wherein cases of Selective Mutism are attributed simply to shyness and dismissed, which may lead to an eventual exacerbation of symptoms.
Selective Mutism is classified as an anxiety disorder, which sets the stage for emotional and environmental antecedents, but neurodevelopmental factors have also been considered in its aetiology.
The occurrence of speech and communication disorders, as well as neurological abnormalities, is postulated to be heightened among individuals presenting with Selective Mutism. Additionally, social deficits and general developmental delays have also been speculated.
Environmental factors have included the experience of trauma, experiences of major life events that may have been traumatic in nature (such as the hospitalization or death of a family member), family-related correlates (including divorce, dysfunctional families, and abusive households), and physical and sexual abuse.
Parenting styles, particularly parental control, has also been speculated as an antecedent of higher anxious traits. Setting-specific problems, especially problems at school, may be identified as correlates due in part to the significant tendency for children to experience Selective
Mutism in a school setting. Academic hurdles and poor peer relationships may be contributing factors. An observable prevalence of Selective Mutism has also been reported among children from immigrant families, which could be attributed to numerous factors including problems in cultural assimilation, acquiring and adapting to a second language, as well as experienced discrimination among peer groups.
Diagnosis
A formal diagnosis for Selective Mutism consists of a multidimensional process, including screening for possible neurological and speech-related disorders.
Clinicians conduct thorough assessments that also rely on information from adults involved in the child’s life such as their parents or guardians and teachers, in order to determine the extent to which the child attempts to assimilate in social settings.
An analysis of the child’s behavioral and temperamental condition is made, and some inference regarding their speaking habits is also taken into consideration. This process relies on observation on the part of the clinician as well as documentation of case history and correspondence.
Diagnostic interviews and the implementation of specific tools aids the process of psychiatric symptom identification.
The use of certain evaluations may be made to rule out underlying psychiatric disorders or to identify comorbidities. Physical tests to rule out hearing disabilities, as well as testing for cognitive deficits and language testing may be carried out.
The DSM-5 mentions the following diagnostic criteria for formal diagnosis of Selective Mutism:
- 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 attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
- The disturbance is not better explained by a communication disorder (e.g., childhood onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.
Treatment
Treatment for Selective Mutism may be individualistic, but broadly consists of pharmacological and non-pharmacological interventions for management.
The use of psychotherapy, in the form of psychodynamic, behavioral, and family therapy, is considered the mainstay of treatment for Selective Mutism. Psychodynamic therapy is based largely on resolving underlying conflicts, and hence places significance on history.
Behavioral therapy involves a multimethod approach, and an array of techniques can be implemented in order to alleviate symptoms. Psychoeducation focuses on informing the patient as well as their close ones about the implications of the disorder.
Breathing and muscle relaxation may also be implemented in order to deal with anxiety. Behavioral and cognitive training targets the individual’s self-perception, and works through exposure and modelling methods.
The use of SSRIs (Selective Serotonin Reuptake Inhibitors) is largely considered, due to the classification of Selective Mutism as a childhood anxiety disorder.
SSRIs have been known to show symptomatic improvement, typically in terms of mutism and anxiety. However, medication as a mode of management is only taken into account when non-pharmacological intervention shows no efficacy.
Specialist
The diagnosis of Selective Mutism may invite the participation of various professionals, including audiologists, psychiatrists, psychologists, and speech/language pathologists.
Further, child specialists, psychiatrists, and clinical psychologists may be involved. Professionals with adequate training with regards to behavioral and psychodynamic therapy may facilitate the treatment and management of symptoms.
Differential Diagnosis
1. Communication disorders: Selective mutism should be distinguished from speech disturbances that are better explained by a communication disorder, such as language disorder, speech sound disorder, childhood-onset fluency disorder, or pragmatic communication disorder. Unlike selective mutism, the speech disturbance in these conditions is not restricted to a specific social situation.
2. Neurodevelopmental disorders and schizophrenia and other psychotic disorders: Individuals with an autism spectrum disorder, schizophrenia or another psychotic disorder, or severe intellectual disability may have problems in social communication and be unable to speak appropriately in social situations.
3. Social anxiety disorder: The social anxiety and social avoidance in social anxiety disorder may be associated with selective mutism. In such cases, both diagnoses may be given.
Comorbidity
The most common comorbid conditions are social anxiety disorder, separation anxiety disorder and specific phobia and oppositional behaviors. Communication delays or disorders also may appear in some children with selective mutism.
In Conclusion
Parents usually mistake selective mutism for disobedience. Selective Mutism stems from childhood and may continue in adulthood. It may cause issues in the personal and social growth of the child.
Early identification of selective mutism is crucial for families, schools, and other stakeholders so that they can collaborate to lessen a child’s anxiety. Staff members in early childhood institutions and schools must be aware of the symptoms to enable them to offer proper support.
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