Mutism

Definition

Mutism is a rare childhood condition characterized by a consistent failure to speak in situations where talking is expected.

Description

In mutism, the child has the ability to converse normally and does so, for example, in the home, but consistently fails to speak in specific situations such as at school or with strangers. The condition is also called selective mutism, to differentiate it from children who are physically unable to speak. Experts believe that this selective problem is associated with anxiety and fear in social situations such as in school or in the company of adults. It is, therefore, often considered a type of social phobia. This is not a communication disorder because the affected children can converse normally in some situations. It is not a developmental disorder because their ability to talk, when they choose to do so, is appropriate for their age level. This problem has been linked to anxiety, and one of the major ways in which both children and adults attempt to cope with anxiety is by avoiding whatever provokes the anxiety. Affected children are typically shy and are especially so in the presence of strangers and unfamiliar surroundings or situations. However, the behaviors of children with this condition go beyond shyness.

These children understand language and are able to talk normally in settings where they are comfortable, secure and relaxed. Over 90 percent of children with mutism also have social phobia or social anxiety, and some experts view mutism as a symptom of social anxiety. Others view it as a separate, but related, disorder. It is not yet understood why some individuals develop typical symptoms of social anxiety, like reluctance to speak in front of a group of people or feeling embarrassed easily, while others experience the inability to speak that characterizes mutism. What is clear is that children and adolescents with mutism have an actual fear of speaking and of social interactions where there is an expectation to talk. They may also be unable to communicate nonverbally, may be unable to make eye contact, and may stand motionless with fear as they are confronted with specific social settings. This can be quite heart wrenching to watch and is often very debilitating for the child as well as frustrating for parents and teachers.

A child meets the criteria for mutism if the following are true:

• The child does not speak in certain selected places such as school or at particular social events.
• The child speaks normally in at least one environment, usually in the home, but a small percentage of children with mutism are mute at home.
• The child's inability to speak interferes with his or her ability to function in school and/or social settings.
• The mutism has persisted for at least one month.
• The mutism is not caused by a communication disorder (such as stuttering) and does not occur as part of other mental disorders (such as autism).

Demographics

It is estimated that one in every 1,000 school-age children are affected by mutism.

Causes and symptoms

Mutism is believed to arise from anxiety experienced in social situations where the child may be called upon to speak. Refusing to speak or speaking in a whisper spares the child from the possible humiliation or embarrassment of saying the "wrong" thing. When asked a direct question by teachers, for example, the affected child may act as if they are unable to answer. Some children may communicate via gestures, nodding, or very brief utterances. Additional features may include excessive shyness, oppositional behavior, and impaired learning at school.

The majority of children with mutism have a genetic predisposition to anxiety. In other words, they have inherited the tendency to be anxious from family members and may be vulnerable to the development of an anxiety disorder. Very often, these children show signs of anxiety, such as difficulty separating from parents, moodiness, clinging behavior, inflexibility, sleep problems, frequent tantrums and crying, and extreme shyness starting in infancy. When they reach the age when they begin to interact socially outside the family environment, their persistent fear of speaking or communicating begins to manifest in symptoms like freezing, lack of response, stiff posture, blank facial expression, lack of smiling, and mutism. Studies have shown that some children are born with inhibited temperaments, which means that even as infants, they are more likely to be fearful and wary of new situations. There is reason to believe that many or most children with mutism were born with this inhibited personality type.

Research has also shown that these behaviorally inhibited children have a decreased threshold of excitability in the area of the brain called the amygdala. The normal function of the amygdala is to receive and process signals of potential danger and set off a series of reactions that will help individuals protect themselves, such as the fight-or-flight response. In anxious individuals, the amygdala seems to overreact and set off these responses even when the individual is not really in danger. In the case of selectively mute children, the anxiety responses are triggered by social interactions in settings such as school, the playground, or social gatherings. Over time, a child with selective mutism becomes mute because of an inability to cope with fearful feelings that occur when he or she is expected to speak. When the child does not respond, the pressure is usually removed and the child feels relief from fear.

Besides genetics and biological factors, researchers believe that other factors may contribute to the development of selective mutism. A significant number of children with mutism also have expressive language disorders, and a fairly large number come from a bilingual environment, which may add to a child's vulnerability to mutism. Anxiety is still the root cause of the mutism, and it is theorized that these language difficulties may make the child more self-conscious about his or her speaking skills and thus may increase the fear of being judged by others. These risk factors are probably additive; in other words, if a child has genetic risk of anxiety, plus a bilingual environment or a speech disorder, the likelihood of that child developing selective mutism becomes higher with each added factor.

When to call the doctor

If selective mutism persists for more than a month, parents should discuss this pattern with their child's teachers, family physician, or pediatrician. The doctor may refer the child to a speech therapist, psychiatrist or psychologist.

Diagnosis

The diagnosis of mutism is fairly easy to make because the signs and symptoms are clear-cut and easily observable. However, other social disorders effecting social speech, such as autism or schizophrenia, must be considered in the diagnosis. The average age of diagnosis is between three and eight years of age; however, in retrospect many parents will say that their child displayed signs of excessive shyness and inhibition since infancy. It is not until children enter school, where there is an expectation to perform, interact, and speak, that mutism becomes more apparent. Often a parent suspects during the preschool years that there is a problem, but lack of knowledge about selective mutism makes it difficult to find help. It is all too common for parents to question their child's pediatrician about the child's inability to speak in public and be told that the child is just shy and will outgrow the behavior. Once a child enters school, though, teachers often point out the severity of the problem to the parents. Some parents are also reluctant to have their child evaluated and treated.

Treatment

Since selective mutism is an anxiety disorder, successful treatment focuses on methods to lower anxiety, increase self-esteem, and increase confidence and communication in social settings. The emphasis should never be on "getting a child to talk," nor should the goal of treatment be for the child to speak to the therapist. Progress outside the clinic or doctor's office is much more important than whether the child speaks during the therapy session. Initially, all expectations for verbalization should be removed. As the child's anxiety is lowered and confidence increases, verbalization usually follows. If it does not occur spontaneously, techniques can later be added to help encourage progress. A professional should devise an individualized treatment plan for each child and allow the child, family, and school to have a great deal of input into the treatment process. Therapy usually involves some combination of behavioral therapy, cognitive behavioral therapy, play therapy, or psychoanalytic therapy, medication, and in some cases, family therapy.

Behavioral therapy

The primary types of behavioral therapy used for selective mutism are desensitization, fading, and positive reinforcement techniques. Desensitization means exposing a child to something that is feared in a gradual way, in order to help the child overcome the fear. Fading therapy is a type of desensitization that creates a series of events or exposures that starts with a situation that is comfortable for the child, such as being alone in the classroom with a parent and playing a board game. New variables that are progressively more difficult are gradually added. For example, having the teacher walk past the room and overhear the child speaking to the parent, and then having the teacher enter the room, and eventually have the child interacting with the teacher in the classroom. Positive reinforcement, or the use of rewards for changes in behavior, should only be introduced after anxiety is lowered and the child is ready to begin working on goals. It is also important to realize that there are many intermediate steps between being mute and being verbal. During the early stages of treatment, nonverbal communication such as pointing, nodding, and use of pictures to express needs, can be encouraged and rewarded. Though some may fear that allowing nonverbal communication will enable the mutism to continue, many therapists believe it is a necessary step for most children with mutism to overcome their communication anxiety in a step-by-step manner.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) helps children change their thoughts (the cognitive part) and their actions (the behavioral part). CBT therapists recognize that anxious children tend to exaggerate the frightening aspects of certain situations, so they help the children gain a more realistic perspective in order to decrease anxiety. They also know that anxious children avoid situations they fear or (in the case of selectively mute children) avoid speech in anxiety-provoking situations. Avoidance makes anxiety worse. Therefore, CBT helps the child overcome avoidance by gradually facing what is feared with lots of praise and positive reinforcement for doing so. Parents, teachers, and other adults around the child can be very helpful in this process. Cognitive strategies for the selectively mute child aim to reduce the social anxiety that is often part of the disorder. Cognitive strategies help the child challenge negative expectations and replace them with more realistic ones. This process is combined with behavioral strategies that focus on helping the selectively mute child to talk in increasingly challenging situations. The therapist carefully collects information on where and with whom the child already speaks and then helps the child choose a goal to work on in a situation that is just slightly more challenging.

Play therapy

Play therapy is an adaptation of psychoanalytic therapy, which is a psychological treatment based on helping people understand their unconscious thoughts. This field of psychology includes Freudian theories but also many other modern theories about how our minds work. Play therapy refers to the use of play as communication; therapists who are trained in these techniques observe and participate in play activities with the child and interpret the child's actions as a form of subconscious communication. There is not a lot of evidence for play therapy being effective in the treatment of mutism; however, a well trained play therapist might be able to help a child with mutism better understand and express emotions and may be a part of an overall treatment plan. It may be especially useful when a stressful event or environment is a factor. For some children there may be contributing factors such as the death of a parent or other loved one, a divorce, or a move. Play therapists may be able to help a child to express and better understand the emotions that they are experiencing in these situations.

Family therapy

Since there is no evidence of family pathology being the cause of most cases of mutism, this type of therapy is not necessary in most cases. However, if there are unusual circumstances or a highly stressful family environment, then it may be advisable for families to participate in more intensive family therapy.

Prognosis

The prognosis for mutism is good. Sometimes it disappears suddenly on its own. The negative impact on learning and school activities may, however, persist into adult life.

Prevention

Mutism cannot be prevented because the cause is not known. However, family conflict or problems at school contribute to the seriousness of the symptoms.

Parental concerns

Parents should remove all pressure and expectations for the child to speak, conveying to their child that they understand he or she feels "scared" to speak or has difficulty speaking at times. Many parents report that simply removing the pressure and letting the child know that they understand can help to improvement the child's symptoms. Parents should also reassure their child that they will help him or her through this difficult time. The child's accomplishments and efforts should be praised, and support and understanding should be offered when the child has difficulties and frustrations. Parents should read as much information as they can to become well informed about selective mutism.

It is important for family members to be educated and informed about selective mutism and to be included in the child's treatment plan in order to provide a supportive environment for the child's recovery. The stress of dealing with the child's mutism may have created various imbalances in family dynamics, and parents may need help in coming to terms with their own emotions and becoming more consistent in their parenting styles. It is also common for parents to begin to recognize their own anxiety as they are learning to help their child. Many times they will seek help in overcoming social anxiety to improve their ability to advocate for their child's needs and to become a positive role model for their child.

BOOKS

Baldwin, Sylvia, and Tony Cline. Selective Mutism in Children. London: Whurr Publishers Ltd., 2004.

Spencer, Elizabeth DuPont, et al. The Anxiety Cure for Kids: A Guide for Parents. Hoboken, NJ: Wiley, 2003.

PERIODICALS

Bergman, R. Lindsey, et al. "Prevalence and Description of Selective Mutism in a School-Based Sample." Journal of the American Academy of Child and Adolescent Psychiatry 41 (August 2002): 938–46.

Krysanski, Valerie L. "A Brief Review of Selective Mutism Literature." The Journal of Psychology 137 (January 2003): 29–40.

Schum, Robert L. "Selective Mutism: An Integrated Treatment Approach." ASHA Leader 7 (September 24, 2002): 4–6.

Yeganeh, Robin, et al. "Clinical Distinctions Between Selective Mutism and Social Phobia: An Investigation of Childhood Psychopathology." Journal of the American Academy of Child and Adolescent Psychiatry 42 (September 2003): 1069–1075.

ORGANIZATIONS

Anxiety Disorders Association of America. 8730 Georgia Avenue, Suite 600, Silver Spring, MD 20910. Web site: <www.adaa.org>.

National Academy of Child & Adolescent Psychiatry. 3615 Wisconsin Ave. NW, Washington, DC 20016. Web site: <www.aacap.org>.

WEB SITES

Gallagher, Richard. "About Selective Mutism—Profiles of Silence." New York University Child Study Center, 2004. Available online at <www.aboutourkids.org/aboutour/articles/about_mutism.html> (accessed November 12, 2004).

"Selective Mutism." American Speech-Language-Hearing Association, 2004. Available online at <www.asha.org/public/speech/disorders/Selective-Mutism.htm> (accessed November 12, 2004).

Donald Garner Barstow

Ken R. Wells