Selective Mutism

“I have packed myself into silence so deeply and for so long that I can never unpack myself using words. When I speak, I only pack myself a little differently” –Herta Müller

Introduction: Selective Mutism

One of a very prominent anxiety disorder is Selective mutism (SM) in which a child is not able to speak in certain environment or to certain individuals. The very common place where a child has to struggle the most is the school.

This disorder makes the situations painful for the kids and at the same time confusing for the adults because they experience a good amount of anxiety in certain situations that they are unable to speak and on the other side are very much comfortable talking to their parents or other people.

It has been seen that the children with SM seems frozen while asked a question rather than looking anxious. The more chances of discovering this disorder starts when a child goes to the school and the teacher finds out that something is wrong because the children talking normally with their parents won’t make the parents wonder about any problem.

Children might suffer a lot because they are not able to even whisper in the extreme situations. They might keep sitting for hours without going to the bathroom, might not speak even if they know he correct answer.

According to Diagnostic and Statistical Manual of Mental Disorder V (DSM-V) – Selective mutism is an anxiety disorder where a child is not able to speak where he/she is supposed to speak and on the other hand speak comfortably at home.

Prevalence and Gender difference: Selective Mutism

SM affects approximately 1% of the child population. Its rate of prevalence varies from 0.1% to 2.2%, depending upon the diagnostic criteria used and the sample. The research suggests that the girls are affected more by this disorder than the boys with the ratio of 1.5:1 to 2.6:1 respectively.

The parents find it hard to tell when asked about the onset of the disorder because they never felt anything suspicious. Adults suffer from communication issues and social anxiety, along with that they also get more prone to developing other psychiatric disorders. However, adults might have a lesser pressure of talking to someone because they can decide to whom they want to speak to as compared to the children.

Myths about Selective Mutism

There are certain myths which we generally come across while talking or knowing about SM which are as follows-

SM is basically a form of autism.
SM children are manipulative or oppositional.
SM children have speech problems.
SM children are either abused or traumatized.

Symptoms: Selective Mutism

A child might show certain signs which help to conclude that he/she might have SM. These signs are as follows:

Being nonverbal completely or mostly in school or around strangers but are able to be speak freely when they are at home.
They tend to seem frozen or paralyzed with fear when are asked to speak.
They use gestures, nodding and facial expressions when they have to communicate. In extreme cases a child might not even able to use these form of nonverbal communication.

Causes: Selective Mutism

There is not one single cause of SM. There is interplay of genetic, neuro-developmental, temperamental and environmental factors which lead to this disorder. These factors are summarized below:

Genetic factors- Various studies have found out that SM run in the families. There is a specific gene variation which has been linked to both Social anxiety disorder and SM.
Neuro-developmental factors- it has been concluded that SM children have higher rates of several neuro-developmental conditions. The most common are language and speech problems whereas motor delay and elimination disorders are also said to be exist in many cases. SM can be seen to have lower intellectual capacity and seem to have a minor overlap with autism spectrum disorders, however the intelligence quotient of these children fall in normal range only.
Temperamental factors- the generally associated behavioral inhibition trait with a higher risk for anxiety disorder later on are avoidance and fearfulness in unfamiliar situations. The link between SM and social anxiety disorder is very much consistent and there seems to have an association between behavioral inhibition and SM.
Environmental factors- In SM bilingual children are overrepresented. The transitions from a child starting with going to school to meeting new individuals may trigger SM and is said to be hard for those who are genetically predisposed to this disorder. Children might warm up in certain situations but the case seems to be tough when it comes to SM children.

Treatment available: Selective Mutism

Three groups of factors need to be taken into consideration while formulating the treatment plan for a patient with SM which is as follows:

Vulnerability factors (behavioral inhibition, genetics, social anxiety, temperament and neuro-developmental disorders)- the main purpose of treatment s not just to change the temperament rather it is to look at some substantial clue for an neuro-developmental disorders so that adequate help can be provided or implemented at the school level.
Triggering factors (unexpected events and transitions such as starting kindergarten or school, use of a new language, migration)- The triggering factors need to be find out so that a better preparation and training can be provided to the children with SM, so that they can adjust well to a new transition or situation.
Sustaining factors (the behavior of the individuals surrounding the mute child)- the two major risks associating with the these factors is that sometimes the acceptance from the others about their behavior of not responding might create discomfort and can aggravate symptoms.

Psychosocial treatments:

Some psychosocial interventions which help in the treatment are as follows:

Emphasize on the behavioral component of the CBT because the Mutism at the young age make cognitive restructuring not that feasible.
Psychoeducation provided to the family is very much important. It will make the family more fully equipped with the necessary information and hence come up with better care.
The schools teachers also need to extensive involve with the children and should be imparted psychoeducation or training to deal effectively.
The therapist can make plan to work on lessening the speech anxiety by increasing comfort and reducing the pressure to speak.

Pharmacotherapy:

I very extreme cases there can be usage of certain medications for the child with SM. But the evidences for its effectivity are still under work. Though, two small blind trials, one for fluoxetine and the other for sertraline is going on but still there is long way to achieve something substantial.

References:

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Association.

Bergman, L. R. (2013). Treatment for Children with Selective Mutism. An integrative Behavioral approach. New York: Oxford University Press.

Gensthaler, A. , Dieter, J. & Raisig, S. et al (2018). Evaluation of a novel parent-rated scale for selective mutism. Assessment, epub ahead of print. Doi: 10.1177/1073191118787328

Kearney, C. A. (2010). Helping Children with Selective Mutism and their Parents: A Guide for School-Based Professionals. New York, NY: Oxford University Press.

McHolm, A. E. , Cunningham, C. E. & Vanier, M. K. (2005). Helping your Child with Selective Mutism: Practical Steps to Overcome a Fear of Speaking. Oakland, CA: New Harbinger Publications.