All material Copyright © 2009 Selective Mutism Group ~ Childhood Anxiety Network
Reprinted with the express permission of SMG as originally published on their website.
PLEASE NOTE: This document was written for parents rather than clinicians. We include it here on this website so that therapists may learn from it and also share this information with the parents of their students and clients.
What is Selective Mutism
Selective mutism (SM), formerly called elective mutism, is defined as a disorder of childhood characterized by an inability to speak in certain settings (e.g. at school, in public places) despite speaking in other settings (e.g. at home with family). SM is associated with anxiety and may be an extreme form of social phobia according to researchers and clinicians who are familiar with the disorder (Black & Uhde, 1995; Dow et al., 1995, Dummit et al., 1997, Kristensen, 2001; Leonard & Dow, 1995).
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, referred to by clinicians as the DSM-IV, (APA,1994) recognized that the social anxiety and avoidance characteristic of social phobia may be associated with SM, and thus, both diagnoses may be given. More than 90% of children with SM also meet the diagnostic criteria for social anxiety disorder, now termed social phobia (Black et al., 1996).
Diagnosis of other comorbid anxiety disorders are also commonly diagnosed with SM and social phobia (Biedel & Turner, 1998). The name change from “elective” to “selective mutism” in DSM-IV deemphasized the oppositional behavior connotation that a child elected not to speak and rather emphasized the characteristic of the disorder, that there are select environments in which speaking does not occur (APA, 1994). The term selective mutism is consistent with new etiological theories that focus on anxiety issues (Dow et al., 1995).
The current edition, DSM-IV-TR (APA, 2000) states that the following criteria must be met in order to qualify for a diagnosis of selective mutism:
An inability to speak in at least one specific social situation where speaking is expected (e.g., at school) despite speaking in other situations (e.g., at home); The disturbance has interfered with educational or occupational achievement or with social communication; The duration of the selective mutism is at least one month and is not limited to the first month of school; The inability to speak is not due to to a lack of knowledge of or discomfort with the primary language required in the social situation; and, The disturbance cannot better be 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.
Consistent with current research, SMG believes that Selective Mutism is best understood as a childhood social communication anxiety disorder. SM is much more than shyness and most likely on the spectrum of social phobia and related anxiety disorders. SM is NOT a child willfully refusing to speak.
Are there other associated behaviors or personality traits?
Associated features of SM may include profound shyness, little eye contact, social isolation, fear of social embarrassment, withdrawal, clinging behavior, compulsive traits, negativism and oppositional behavior when attempting to avoid feared social situations, and temper tantrums, particularly at home. Since children are unable to communicate verbally, they may opt for using nonlinguistic cues such as gestures, nodding or shaking the head to get their messages across. A child may pull or push objects and obstacles, and in some cases, communicate in monosyllabic, short or monotone utterances or in an altered voice (APA, 2000). Some of these behaviors may not be present at the onset of SM. At the onset of SM, children may often stand motionless and expressionless due to anxiety and then slowly progress from nonverbal and non-communicative stages to communicative and verbal stages in treatment (Shipon-Blum, 2001). Fundis et al. (1979) reported that 71 percent of the children in their studies displayed difficulty in performing motor activities and had bowel and bladder problems or, enuresis and encopresis. Some individual with social anxiety symptoms may also experience parureis, the fear of using public restrooms perhaps to fear of making sounds while urinating that others may hear (Stein & Walker, 2002).
How can I advocate for my child and make others more aware?
SMG offers a wealth of resources for parent use in informing professionals, teachers and others who interact with their child about selective mutism. We recommend that parents provide these resources to help educate others about SM. Family and Professional memberships with SMG also provide many opportunities for interaction with experts and experienced parents and teachers among other benefits to help educate yourself and others about SM. Advocacy for SM consists of educating oneself, educating others who interact with the child with SM, developing a plan to increase the child’s comfort and facilitate improvement at school and other social settings, and finding a treating professional who will help develop appropriate treatment and also serve as an advocate for the child.
Parents and professionals should remove all pressures and expectations for the child to speak. This conveys to the child that he/she is understood, that he/she is scared to speak and has difficulty speaking at times. Rest assured that most parents and professionals are “guilty” of using pressure or bribes with a child to encourage speaking before they learn more about SM, however, most report that removing these pressures and letting the child know that they understand has been the beginning of helping a child to overcome his/her symptoms.
How common is this problem, to be worthy of our attention?
DSM-IV-TR estimates that SM affects 1 in 1000 children referred for mental health treatment (APA, 2000). However, several researchers have suggested that the true prevalence of SM in the general population is largely underestimated (Bergman et al., 2002; Hayden, 1980; Hesselman, 1983; Kupietz & Schwartz, 1982; & Thompson, 1988). Recent studies show that SM is not as rare as it was previously believed to be but is comparable to other, widely known disorders of childhood. A study targeting a large sample of children in a Los Angeles, CA school district identified children who met the diagnostic criteria for SM and found a prevalence rate of 7.1 per 1,000 children (Bergman et al., 2002). A subsequent study in Israel found an almost identical prevalence rate (Elizur & Perednik, 2003). These numbers suggest that SM has a higher prevalence than autism (.5 per 1000), major depressive disorder (.4 to 3 per 1000), Tourette’s disorder (.5 per 1000), obsessive-compulsive disorder (.5 to 1 in 1000) and other well-known disorders. In comparison to other studies, which only accounted for diagnosed cases of SM, provides evidence that a large number of individuals with SM are undiagnosed or misdiagnosed. Parents of children with SM who enter treatment often report that their child was misdiagnosed with autism or another pervasive developmental disorder, mental retardation or oppositional-defiant disorder. Most are told (if anything) by uniformed professionals that there is nothing wrong with their child, that their child is “just shy,” or will grow out of this behavior. Thus, the lack of awareness among educators and treating professionals leads to delays in diagnosis and missed opportunities for treatment.
SM is slightly more common in females than in males. Although the duration of SM often lasts for several months, left untreated, it may sometimes persist longer and may continue for several years (APA, 2000). The average age of onset is 5 years, even though most parents report that their children’s symptoms began years earlier (Leonard & Dow, 1995). In his treatment of children with SM, Thompson (2000) found that children who establish speech in previously mute settings before age eight typically become verbal in school and social settings within one year. Children who demonstrated longer-term mutism were likely to continue their silence into upper grades and into adulthood (Thompson, 2000). While reports of older children and adolescents with SM are scarce, based on our collective clinical experience, individuals who to enter into treatment later may suffer from depression and other disorders in addition to SM but can make treatment gains and overcome SM without it continuing into adulthood.
How does SM differ from shyness?
Shyness is a normal personality trait. It is marked by a voluntary tendency to withdraw from people, particularly unfamiliar people. Everyone has some degree of shyness; it may be experienced a lot, a little bit or somewhere in between. Shyness, like other inheritable traits, such as height and eye color, is largely influenced by genes (Stein & Walker, 2002). Shyness is not a psychiatric disorder like SM, social phobia and avoidant personality disorder which all characterize different forms of extreme inhibition that interferes with a person’s daily functioning. People who are shy are able to function adequately in society. Shyness may fluctuate and change as a person matures and encounters new social challenges without treatment (Carducci, 1999). People with psychiatric disorders such as SM do not adapt well to social situations nor are they able to communicate effectively with others. They may have limited academic and occupational achievement and require treatment in order to overcome their symptoms and function at an adaptable level.
How is a child evaluated for SM?
A trained professional familiar with SM and/or childhood anxiety disorders will generally begin by conducting a thorough assessment to accurately diagnose the condition, rule-out similar or comorbid conditions, and formulate a treatment plan. Information will be gathered about the child’s developmental history (including achievement of developmental milestones and whether or not there were any delays in hearing, speech and motor and cognitive development), family history (including determining whether or not other anxiety disorders are present in the family), behavioral characteristics, medical history, and significant stressors (including divorce, frequent moves or a death in the family). The treatment professional may also request permission to contact the child’s school, physician and other significant players in the child’s life to gain further information about the child’s behavior in other settings. It can also be helpful for the professional to view a videotape of the child in a comfortable setting and/or do an observation of the child before the child has met the professional so that the child’s behavior will not be influenced by the professional’s presence.
The professional will then arrange to meet with the child. While most children with SM will not speak to the treating professional, some may be comfortable in the treatment setting and speak normally, although this behavior does not rule out selective mutism. The “selective” nature of the mutism varies from child to child and setting to setting so this needs to be considered in conducting a thorough assessment. It is important that the professional develops rapport with the child and evaluates his/her behaviors, preferably in more than one setting. An appropriate professional will be able to interact with the child whether or not he or she is speaking and use appropriate methods to begin to develop a therapeutic relationship.
Because some children with SM may have difficulties with expressive language or other communication disorders, a speech and language evaluation might also be necessary. In addition, a physical exam (including testing of hearing), standardized testing, psychological assessment and developmental screenings are often recommended, especially if the diagnosis is not clear.
Featured Organization: Selective Mutism Group ~ Childhood Anxiety Network (SMG)
We thank Selective Mutism Group ~ Childhood Anxiety Network for allowing PediaStaff to reprint their article. Selective Mutism Group ~ Childhood Anxiety Network is the nation’s premier resource for information on SM. SMG, a part of the Childhood Anxiety Network is a nonprofit organization dedicated to providing information, resources and support to those impacted by a child with the anxiety disorder known as Selective Mutism (SM). Visit their website at :www.selectivemutism.org