Selective mutism

Selective mutism (SM) is an anxiety disorder in which a person who is normally capable of speech does not speak in specific situations or to specific people. Selective mutism usually co-exists with shyness or social anxiety.^[1] People with selective mutism stay silent even when the consequences of their silence include shame, social ostracism or even punishment.^[2]

Selective mutism affects about 0.8% of people at some point in their life.^[3]

Signs and symptoms

Children and adults with selective mutism are fully capable of speech and understanding language but fail to speak in certain situations, though speech is expected of them.^[4] The behaviour may be perceived as shyness or rudeness by others. A child with selective mutism may be completely silent at school for years but speak quite freely or even excessively at home. There is a hierarchical variation among people with this disorder: some people participate fully in activities and appear social but do not speak, others will speak only to peers but not to adults, others will speak to adults when asked questions requiring short answers but never to peers, and still others speak to no one and participate in few, if any, activities presented to them. In a severe form known as "progressive mutism", the disorder progresses until the person with this condition no longer speaks to anyone in any situation, even close family members.

Selective mutism is by definition characterized by the following:^[5]

• 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., childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

Selective mutism is strongly associated with anxiety disorders, particularly social anxiety disorder. In fact, the majority of children diagnosed with selective mutism also have social anxiety disorder (100% of participants in two studies and 97% in another).^[6][7][8] Some researchers therefore speculate that selective mutism may be an avoidance strategy used by a subgroup of children with social anxiety disorder to reduce their distress in social situations.^[9][10]

Particularly in young children, SM can sometimes be confused with an autism spectrum disorder, especially if the child acts particularly withdrawn around his or her diagnostician, which can lead to incorrect treatment. Although autistic people 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)—that set them apart from a child with selective mutism. Some autistic people may be selectively mute due to anxiety in social situations that they do not fully understand. If mutism is entirely due to autism spectrum disorder, it cannot be diagnosed as selective mutism as stated in the last item on the list above.

The former name elective mutism indicates a widespread misconception among psychologists that selective mute people choose to be silent in certain situations, while the truth is that they often wish to speak but have difficulty doing so. To reflect the involuntary nature of this disorder, the name was changed to selective mutism in 1994.

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, 0.1%.^[11] However, a 2002 study in The Journal of the American Academy of Child and Adolescent Psychiatry estimated the incidence to be 0.71%.^[12]

Other symptoms

Besides lack of speech, other common behaviors and characteristics displayed by selectively mute people include:^[13][14]

• Shyness, social anxiety, fear of social embarrassment, and/or social isolation and withdrawal
• Difficulty maintaining eye contact
• Blank expression and reluctance to smile
• Difficulty expressing feelings, even to family members
• Tendency to worry more than most people of the same age
• Sensitivity to noise and crowds

On the positive side, many people with this condition have:

• Above-average intelligence, perception, or inquisitiveness
• Creativity and a love for art or music
• Empathy and sensitivity to others' thoughts and feelings
• A strong sense of right and wrong^[14]

Causes

Selective mutism (SM) is an umbrella term for the condition of otherwise well-developed children who cannot speak or communicate under certain settings. The exact causes that affect each child may be different and yet unknown. There have been attempts to categorize, but there are no definitive answers yet due to the under-diagnosis and small/biased sample sizes. Many people are not diagnosed until late in childhood only because they do not speak at school and therefore fail to accomplish assignments requiring public speaking. Their involuntary silence makes the condition harder to understand or test. Parents often are unaware of the condition since the children may be functioning well at home. Teachers and pediatricians also sometimes mistake it for severe shyness or common stage fright.

Selective mutism occurs in all ethnic groups. The majority of reported cases are of white and multiethnic children. However this could be due to under-diagnosis and under-reporting in other ethnic groups.

Most children with selective mutism are hypothesized to 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.^[15] This area receives indications of possible threats and sets off the fight-or-flight response. Given the very high overlap between social anxiety disorder and selective mutism (as high as 100% in some studies^[6][7][8]), it is possible that social anxiety disorder causes selective mutism.

Some children with selective mutism may have trouble processing sensory information. This would cause anxiety and a sense of being overwhelmed in unfamiliar situations, which may cause the child to "shut down" and not be able to speak (something that some autistic people also experience). Many children with selective mutism have some auditory processing difficulties.

About 20–30% of children with SM have speech or language disorders that add stress to situations in which the child is expected to speak.^[16]

Despite the change of name from "elective" to "selective", a common misconception remains that a selectively mute child is defiant or stubborn. In fact, children with SM have a lower rate of oppositional behavior than their peers in a school setting.^[17] Some previous studies on the subject of selective mutism have been dismissed as containing serious flaws in their design. According to a more recent systematic study it is believed that children who have selective mutism are not more likely than other children to have a history of early trauma or stressful life events.^[18] Another recent study by Dummit et al., in 1997 did not find any evidence of trauma in their sample of children. Recent evidence has shown that trauma does not explain why most children with selective mutism develop the condition.^[19] Many children who have selective mutism almost always speak confidently in some situations. Children who have experienced trauma however are known to suddenly stop speaking.

Treatment

Contrary to popular belief, people with selective mutism do not necessarily improve with age.^[20] Effective treatment is necessary for a child to develop properly. Without treatment, selective mutism can contribute to chronic depression, further anxiety, and other social and emotional problems.^[21][22]

Consequently, treatment at an early age is important. If not addressed, selective mutism tends to be self-reinforcing. Others may eventually expect an afflicted child to not speak and therefore stop attempting to initiate verbal contact. Alternatively, they may pressure the child to talk, increasing their anxiety levels in situations where speech is expected. Due to these problems, a change of environment may be a viable consideration. However, changing school is worth considering only if the alternative environment is highly supportive, otherwise a whole new environment could also be a social shock for the individual and/or deprive them of any friends or support they have currently. Regardless of the cause, increasing awareness and ensuring an accommodating, supportive environment are the first steps towards effective treatment. Most often afflicted children do not have to change schools or classes and have no difficulty keeping up except on the communication and social front. Treatment in teenage or adult years can be more difficult because the afflicted individual has become accustomed to being mute.

The exact treatment depends on the person's age, any comorbid mental illnesses, and a number of other factors. For instance, stimulus fading is typically used with younger children because older children and teenagers recognize the situation as an attempt to make them speak, and older people with this condition and people with depression are more likely to need medication.^[23]

Like other disabilities, adequate accommodations are needed for the afflicted to succeed at school, work, and in the home. Under the U.S. federal law and the Individuals with Disabilities Education Act (IDEA), those with the disorder qualify for services based upon the fact that they have an impairment that hinders their ability to speak, thus disrupting their lives. This assistance is typically documented in the form of an Individual Educational Plan (IEP). Post-secondary accommodations are also available for people with disabilities.

Under another law, Section 504 of the Rehabilitation Act of 1973, public school districts are required to provide a free, appropriate public education to every "qualified handicapped person" residing within their jurisdiction. If the child is found to have impairments that substantially limit a major life activity (in this case, learning), the education agency has to decide what related aids or services are required to provide equal access to the learning environment.

Self-modeling

An afflicted child is brought into the classroom or the environment where the child will not speak and is videotaped. First, the teacher or another adult prompts the child with questions that likely will not be answered. A parent, or someone the child feels comfortable speaking to, then replaces the prompter and asks the child the same questions, this time eliciting a verbal response. The two videos of the conversations are then edited together to show the child directly answering the questions posed by the teacher or other adult. This video is then shown to the child over a series of several weeks, and every time the child sees himself or herself verbally answering the teacher/other adult, the tape is stopped and the child is given positive reinforcement.

Such videos can also be shown to afflicted children's classmates to set an expectation in their peers that they can speak. The classmates thereby learn the sound of the child's voice and, albeit through editing, have the opportunity to see the child conversing with the teacher.^[24][25]

Mystery motivators

Mystery motivation is often paired with self-modeling. An envelope is placed in the child's classroom in a visible place. On the envelope, the child's name is written along with a question mark. Inside is an item that the child's parent has determined to be desirable to the child. The child is told that when he or she asks for the envelope loudly enough for the teacher and others in the classroom to hear, the child will receive the mystery motivator. The class is also told of the expectation that the child ask for the envelope loudly enough that the class can hear.^[24][25][26]

Stimulus fading

Afflicted subjects can be brought into a controlled environment with someone with whom they are at ease and can communicate. Gradually, another person is introduced into the situation. One example of stimulus fading is the sliding-in technique,^[20] where a new person is slowly brought into the talking group. This can take a long time for the first one or two faded-in people but may become faster as the patient gets more comfortable with the technique.

As an example, a child may be playing a board game with a family member in a classroom at school. Gradually, the teacher is brought in to play as well. When the child adjusts to the teacher's presence, then a peer is brought in to be a part of the game. Each person is only brought in if the child continues to engage verbally and positively.^[24][25][26]

Desensitization

The subject communicates indirectly with a person to whom he or she is afraid to speak through such means as email, instant messaging (text, audio, and/or video), online chat, voice or video recordings, and speaking or whispering to an intermediary in the presence of the target person. This can make the subject more comfortable with the idea of communicating with this person.

Shaping

The subject is slowly encouraged to speak. The subject is reinforced first for interacting nonverbally, then for saying certain sounds (such as the sound that each letter of the alphabet makes) rather than words, then for whispering, and finally saying a word or more.^[27]

Spacing

Spacing is important to integrate, especially with self-modeling. Repeated and spaced out use of interventions is shown to be the most helpful long-term for learning. Viewing videotapes of self-modeling should be shown over a spaced out period of time of approximately 6 weeks.^[24][25][26]

Drug treatments

Many practitioners believe that there is evidence indicating that antidepressants such as SSRIs may be helpful in treating children and adults 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 may end after nine to twelve months, once the person has learned skills to cope with anxiety and has become more comfortable in social situations.^[28] Medication is more often used for older children, teenagers, and adults whose anxiety has led to depression and other problems.

Medication, when used, should never be considered the entire treatment for a person with selective mutism. While on medication, the person should be in therapy to help them learn how to handle anxiety and prepare them for life without medication.^[29]

Anti-depressants have been used in addition to self-modeling and mystery motivation to aid in the learning process.^[24][25]

History

In 1877, German physician Adolph Kussmaul described children who were able to speak normally but often refused to as having a disorder he named aphasia voluntaria.^[30] Although this is now an obsolete term, it was part of an early effort to describe the concept now called selective mutism.

In 1980, a study by Torey Hayden identified what she called four "subtypes" of elective mutism, although this set of subtypes is not in current diagnostic use.^[31] First, and most common, she described "symbiotic mutism" characterized by a vocal and dominating mother and absent father and the use of mutism as controlling behavior around other adults. Second, the least common, was the "speech phobic mutism" subtype, in which the child showed distinct fear at hearing a recording of their voice. This subtype also involved ritualistic behaviors and was thought to be caused by having been told to keep a family secret.

Hayden's third subtype was "reactive mutism," thought to be caused by trauma or abuse, though not all children put in this category were known to have been abused. These children all showed symptoms of depression and were notably withdrawn, usually showing no facial expressions. In her fourth and last subtype, Hayden described "passive-aggressive mutism" in which silence is used as a display of hostility, connected to antisocial behavior. Some of the children in this group had not been mute until age 9–12. These subtypes are no longer recognized, though "speech phobia" is sometimes used to describe a selectively mute person who appears not to have any symptoms of social anxiety.

The Diagnostic and Statistical Manual of Mental Disorders (DSM), first published in 1952, first included elective mutism in its third edition, published in 1980. Elective mutism was described as "a continuous refusal to speak in almost all social situations" despite normal ability to speak. While "excessive shyness" and other anxiety-related traits were listed as associated features, predisposing factors included "maternal overprotection", mental retardation, and trauma. Elective mutism in the third edition revised (DSM III-R) is described similarly to the third edition except for specifying that the disorder is not related to social phobia.

In 1994, Sue Newman, co-founder of the Selective Mutism Foundation, requested that the fourth edition of the DSM reflect the name change from elective mutism to selective mutism and describe the disorder as a failure to speak. The relation to anxiety disorders was emphasized, particularly in the revised version (DSM IV-TR). As part of the reorganization of the DSM categories, the DSM-5 moved selective mutism from the section "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" to the section for anxiety disorders.^[32]

One of the most infamous examples of a person with selective mutism is Seung-Hui Cho, the gunman of the Virginia Tech Massacre (Virginia Polytechnic Institute and State University in Blacksburg, Virginia) on April 16, 2007. He was not diagnosed with selective mutism until the age of 13, and consequently, Cho did not receive the specialized treatment his condition requires. However, once diagnosed, he did begin treatment with a psychiatrist who performed counseling and prescribed antidepressants which slowly improved his condition. Unfortunately, he requested, and was subsequently allowed, to discontinue treatment and eventually left his hometown to attend Virginia Tech. Although his high school was aware of his selective mutism and his depression, mental health laws prevented the high school from informing Virginia Tech about his condition, and neither Cho nor his parents chose to share this information with the university. Had Virginia Tech known of his mental health diagnoses, Cho would have been eligible to receive support services to help him cope with his new atmosphere and provide him with additional resources to aid him with his affliction. He was a good student, but as a senior, he killed 32 people and wounded 17 others over two separate attacks spanning two hours. Cho's selective mutism has not been identified as the reason for his behavior.

Popular culture

Possibly the most well-known instance of selective (as opposed to total) mutism in popular culture was depicted by the character of Raj Koothrappali (played by Kunal Nayyar) in the television sitcom The Big Bang Theory. Due to social anxiety, he was unable to speak to women who were not family members, due to fear of rejection. Drinking alcohol suppressed his anxiety, allowing him to speak; however, it negatively affected his personality, making him arrogant, obnoxious, whiny, and perverted. In the episode "The Terminator Decoupling", however, he unknowingly drank alcohol-free beer and due to the placebo effect, was able to hold a normal conversation with actress Summer Glau, who found him interesting and charming. He was later cured in the season six finale "The Bon Voyage Reaction" after his severely socially anxious girlfriend Lucy (played by Kate Micucci) broke up with him.

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