Selective Mutism -Diagnostic criteria -Differential Diagnosis -Assessment -Etiology -Intervention

1. Selective Mutism

2. Selective Mutism ( Definition)
Selective Mutism is the inability to communicate in select
social settings despite being able to verbally communicate in
others.
For example,
a child who speaks freely at home with his/her family,
but verbally is completely shut down every day at school

3. Diagnostic Criteria
• Failure to speak in specific social situations in which there is
an expectation for speaking (e.g. at school) despite speaking
in other situations.
• Disturbance interferes with educational or occupational
achievement or with social communication.
• Duration of the disturbance is at least 1 month.
• Failure to speak is not attributable to a lack of knowledge of,
or comfort with, the spoken language required in the social
situation.

4. Criteria
• 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 other psychotic disorder.

5. Symptoms Manifestation
 Children with selective mutism shows the following symptoms.
They may not be able to give you eye contact and may seem:
• Nervous
• Uneasy and socially awkward
• Clingy
• Excessively shy and withdrawn, dreading that they will be
expected to speak
• Serious

6. Symptoms
• Stubborn or aggressive, having temper tantrums when they get
home from school
• Frozen, reluctant to smile and oftentimes he will have blank
facial expressions.
• The child's body movements are often stiff and awkward.
• Has a tendency to worry more about things than other people do.
• Extraordinarily sensitive to noise, crowds and crowded situation
also have a fear of using public restrooms or washrooms etc.

7. Symptoms
• Chew or twirl their hairs
• Fear of social embarrassment
• Social isolation and withdrawal
• Picky eating tendencies
• Over sensitivity to feel of fabrics, hair brushing/washing and
hugging, handholding and being touched. They often pull out
tags from their clothes and prefer elastic band pants
compared to buttoned pants.

8. Shyness vs. Selective Mutism
• Slow warm up ~Warm-up time MUCH longer
period than expected.
• Can often respond ~ Cannot respond at all, may
with a nod or small appear frozen.
smile
• Same demeanor ~Dual personality-restrained at
everywhere – quiet school and talkative at home.
and reserved

9. Associated Features
• Excessive shyness
• Fear of social embarrassment
• Social isolation and withdrawal
• Clinging
• Compulsive traits
• Negativism
• Temper tantrums
• Mild oppositional behavior

10. Associated Features (cont.)
Communication Skills:
Generally normal
language skills
Occasional comm.
Disorder
No association with
specific comm. Disorder
Additional diagnosis of
anxiety (SAD) is usually
given in clinical settings.

11. Prevalence
 Rare Disorder
 Prevalence: 0.03% to 1% using clinic and school sample
 It depends on the setting (clinic vs. school vs. general
population) and ages.
 Disorder does not vary by sex, race/ ethnicity.
 More likely in young children than in adolescents or adults

12. Prevalence
• 4-7 years old .03% - .72% (England 1975, 1979)
• 7-8 years old 2% (Finland 1998)
• 7-15 years old .18% (Sweden 1997)
• 5-8 years old .71% (California 2002)
• 1.5-2.6/ 1 Female/Male
(Garcia et al., 2004; Bergman et al., 2002)

13. Families which have migrated may choose
not to speak the language because of lack of
knowledge.
However, if understanding of the language is
clear and refusal to speak persists, diagnosis
is warranted.
Culture-Related Issues

14.  Social Impairment: Too anxious to engage in
reciprocal social interaction with other children
 Social Isolation: As they mature
 Academic Impairment: Lack of communication
with teachers about personal or academic needs
 Teasing by Peers: Severe impairment in school
and social functioning is common
 Compensatory Strategy: Decrease of anxious
arousal in social encounters.
Functional Consequences

15. Development and Course
Onset before 5 years
Disturbance comes to clinical
attention when entry into school
Usually outgrow the disorder
But no longitudinal evidence
In SAD, selective mutism
disappears but social anxiety
symptoms remain

16. Differential Diagnosis
Selective Mutism
• Social avoidance present
• Usually occurs in childhood
• Unwillingness to speak in
some or most situations.
• Anxiety occurs in situations
where strangers are
present.
Social Anxiety Disorder
• Social avoidance also
present
• Usually occurs in
adolescence or adulthood
• Fear of interpersonal
interaction in social
situations.
• Intense irrational fear of
being evaluated or watched
and scrutinized by others.
Both the diagnosis may be given

17. SM and Social Anxiety Disorder
• Children with SM avoid speaking out of fear of being
teased for mispronouncing a word (Krysanski,
2003).
• McInneset al. (2004) suggests that children with
Selective Mutism have shorter, linguistically
simpler narratives with less detail than children
with social phobia.

18. Differential Diagnosis
Selective Mutism
• Speech disturbance
restricted to a specific
social situation
Communication Disorders
• Speech disturbance not
restricted to a specific
social situation
Speech Disturbances that are better explained by
comm. disorder should be distinguished from
selective mutism.

19. SM and Speech-Language Disorders
• Cleator and Hand (2001) estimate that 80% of
children with SM also have speech and language
disorders
• Steinhausenet al., (1996) suggest that about 38%
have pre-morbid speech and language problems.

20. Differential Diagnosis
Selective Mutism
• Diagnosed when child has
established capacity to
speak in some social
situations
Neurodevelopmental Disorders,
Schizophrenia and other psychotic
disorders
• Problems in social
communication and unable
to speak appropriately in
social situations
Problems in social communication in autism
spectrum disorder, intellectual disability,
schizophrenia or other psychotic disorder.

21. SM and Autism Spectrum Disorders
• Kopp and Gillberg(1997) found that 7.4 percent of
children with Selective Mutism also met criteria for
Asperger’s disorder.
• More recently, Stein et. al. (2010) found a partially
shared etiology between Autism Spectrum
Disorders and Selective Mutism.

22. Comorbidity
Common comorbidity:
 Anxiety disorders; SAD
 Separation anxiety disorder
 Specific phobia
Oppositional behavior: Limited to situations requiring speech
Communication delays or disorder

23. Etiology
• There are many theories on the causes of selective mutism and the origins or roots
of the disorder. Often selective mutism is not diagnosed properly. It may be
diagnosed as a form of autism or as an anxiety disorder, which prevents accurate
data to be gathered to fully understand the causes of selective mutism.
Genetics & Hereditary :
• Doctors are unable to say that this is a hereditary or genetic disorder. However,
they do notice that selective mutism does occur more often when the child's
parents have passed on to them a predisposition towards anxiety. (Selective
Mutism Anxiety Research and Treatment Center (SMart Center)

24. Biological factors
• Selective Mutism and the Fight-or-Flight Response.
Another thing that doctors have noticed is that those who suffer from selective
mutism also have an overly excitable amygdala. This is the part of the brain that
received indications of possible threats and thus sets off the fight-or-flight response
within a person. Therefore, it is believed that those who suffer from selective mutism
have their speech shut down whenever they enter into a situation where they need to
speak. This is because their fight response is on high and thus they see such situations
as a threat to their safety.
• Selective Mutism and Speech Disorders & Injury that affects the mouth
It is also interesting to note that between 20 to 30% of these children also have
another speech or language disorder that adds additional stress, which in turn
increases their inability to speak.

25. Family Factor
• Family conflicts and marital disharmony have been cited as common in
selectively mute children (Atoynatam, 1986)
• Mothers of selectively mute children are described as lonely, anxious,
deprived, or depressed, with a resentment toward the father and a desire to
be enmeshed with the client. They achieved this enmeshment by
overprotecting the child and encouraging regression in the child.
• Sensing the needs and anxieties of the mother, the child rejects interaction
with other people in order to maintain the symbiotic and enmeshed
relationship

26. psychodynamic
• Psychodynamic theories overlap heavily with family theories, beginning with a
focus on the mother-child relationship.
• Fearing the expression of these aggressive impulses, they choose to be silent. This
withholding of speech reflects a fixation at the anal stage of development. The
source of aggressive impulses and related fear is hypothesized to be the mother-
child relationship and parental discipline of the expression of id impulses.
• Children who are orally fixated wish to punish their parents
– They may be maintaining a family secret, displacing hostility toward the
mother, or regressing to a pre-verbal stage
• Atoynatan (1986) believed the mutism was a vehicle for the mother’s unexpressed
hostility
– Through it, the child achieves an exclusive relationship with the mother
(Atoynatan, 1986)

28. Behavioral
• Operant conditioning:
explanations conceptualize mutism as a behavior that is reinforced by
attention and being kept home from school.
• Classical conditioning
suggests that the child has associated speech with some negative event,
such as pain, humiliation, anxiety, or parental discipline for speaking failed social
social interactions could also lead to the development of mutism through this classical
conditioning model.
Thus the child avoids speech in order speech in order to avoid the conditioned fear
response.

29. Social factors
• Social learning theories may explains the development of selective mutism in a
child who is modeling the behavior of a quiet parent or sibling .
• findings are consistent with theories that children with SM avoid speaking out of
fear of being teased for mispronouncing a word (Krysanski, 2003).
• Growing up in a bilingual family or having lived in a foreign country may cause
some of these speech disorders. In either case these children may be extremely
insecure in the language that they are suppose to speak.

30. Traumatic Mutism
• Abuse and Selective Mutism
While it has also been said that children who suffer from selective mutism have
suffered from abuse, neglect or trauma, there is no evidence of this being the case.
The main difference is the fact that those children who have selective mutism almost
always speak in some situations. However, those children who suffer from mutism
that has been induced by trauma will simply become suddenly silent in all situations,
not just "some."
• However, this type of speech withdrawal may lead to SM if the triggers are not
addressed and the child develops a more general anxiety about communication.

31. Quiz

32. Treatment
Two pronged approach:
• Individual psychotherapy
• A behavioral program at school
Treatment revolves around:
contingency management
stimulus fading
response initiation

33. Psych educational Approach:
• Multidisciplinary approach
• Psychotherapy and Speech and
Language Therapy
• Encourage nonverbal gestures
• Leads to Stimulus Fading
• Response Initiation

34. Peer Approach:
• Involve the child with peers
• Most selectively mute children are well accepted and liked
• SLP identifies which peers show a mutual interest in the child
• Collaborates with teacher to set up instructional situations in
which the child is paired with a preferred peer
• Peer can also attend speech and language therapy sessions

35. Videotape/Audiotape Approach:
• Self Modeling
• Tape at home, listened to at therapy
• Video freeforward

36. Treatment Issues:
• The longer the child is silent, the more entrenched
the behavior gets
• Course of treatment is unpredictable
• Selectively mute children often found in immigrant
populations