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Selective mutism


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Selective mutism

  1. 1. In 1980, when the DSM III (third edition) was published, it included “Elective Mutism” (now renamedSelective Mutism)Selective Mutism, (previously Elective Mutism) until the inception of our organization in 1991, was virtuallyignored, and regardedas a rare and low public interest disorder. As such, input for the DSM III and DSMIII-R had to be drawn from available literature. There were no comprehensive research studies prior to thedevelopment of the Selective Mutism Foundation, Inc., only a fewcompromised studies and single case studies, based upon theories. The available literature presentedconflicting theories, withmost describing Elective Mutism’s essential feature as a “refusal” to speak alongwith characteristics of willful, controlling, andmanipulative behaviors, caused by maternal over protection, abuse, trauma, or family dysfunction. Eventhe name, ElectiveMutism, was indicative of a deliberate refusal to speak to EVERYONE and in ALLenvironments. There was no distinctionbetween sudden mutism possibly caused by a traumatic event, and shyness or social anxiety. There wasalso no distinctionbetween a speech or language communication disorder and social phobia. All of thesecharacteristics, and more, were summed together within the diagnostic and associated features ofElective Mutism in the DSM III and III-R. The Selective MutismFoundation’s input, in 1991, was the majorsource in eliminating theories and replacing them with sound facts, including renamingthe disorder to Selective Mutism, for the DSM IV, 1994.There were, indeed, some professionals who were intuitive and recognized social anxiety, however, forthe most part, manyparents were blamed for their child’s silence. Parents were blamed, and felt guilty, for something thatthey themselves did notunderstand. Many parents reported previously having mutism themselves, however they were confusedby the theories. Theywere not yet equipped with evidence, or specifically, credible published research studies to defend theirchildren or themselves.The Selective Mutism Foundation’s efforts, through research encouragement and participation, since1991, have been andcontinue to be the only major source acknowledged nationally to positively effect Selective Mutism criteriafor the DSM.It is important to clarify 2 crucial issues of confusion that are not visible in the DSM. The 2 areas ofongoing confusion pertain towhy Selective Mutism was not classified as an Anxiety Disorder, or under “Communication Disorders”,within “Disorders UsuallyFirst Diagnosed In Infancy, Childhood, or Adolescence”. The DSM Children’s Anxiety Disorders sectionwas discontinued prior torecognition of Elective Mutism in the DSM, in an effort to prevent misdiagnosis. As children may notrecognize or be able toexpress their fears or symptoms, assumptions or uncertainty was thereby eliminated. The DSM doeshave an Anxiety Disorderssection for diagnosing adults, with inferences to those under 18 years of age. In addition, the listedconditions under “AnxietyDisorders” (e.g. social phobia, specific phobia) obviously cannot imply the essential feature to be a failureto speak in specific
  2. 2. situations. Within the Associated Features and Disorders for Selective Mutism, it is however indicted, thatthe additionaldiagnosis of Anxiety Disorder, especially Social Phobia is usually given (DSM-IV TR)The placement of Selective Mutism under “Communication Disorders” was prior to the inception of ourorganization, a controversialissue. Current published studies, some that include research participants from our organization confirmthat Selective Mutism isnot a language impairment. Published studies and statistics also reveal that Speech/Languagetherapy including within schoolsystems is inappropriate for the Selective Mutism population. It has been established, for over a decade,that childrenexperiencing Selective Mutism have the ability to comprehend and to speak normally in comfortablesettings.The DSM IV and DSM IV-TR, as you can see, under Selective Mutisms Diagnostic Features andDifferential Diagnosis, clearlyindicate that Selective Mutism should be distinguished from speech impairments, and that SelectiveMutism should be diagnosedif the child’s failure to speak is not considered a language impairment. It is further clarified thatcommunication disorders are notrestricted to certain settings in contrast to Selective Mutism.The DSM IV and DSM IV-TR reflect that language impairments, an Associated Disorder, mayoccasionally coexist with SelectiveMutism, although not an essential feature and confirms, in Diagnostic Criterion E that Selective Mutism isnot better accounted forby a Communication Disorder. As a result, Selective Mutism remains classified in “Disorders Usually FirstDiagnosed in Infancy,Childhood, or Adolescence”, under “Other Disorders”, rather than under "Communication Disorders". DSM IV-TR 2000 Diagnostic and Statistical Manual of Mental Disorders USUALLY FIRST DIAGNOSED IN INFANCY, CHILDHOOD, OR ADOLESCENCE 313.23 Selective Mutism (formerly Elective Mutism)Diagnostic FeaturesThe essential feature of Selective Mutism is the persistent failure to speak in specific social situations(e.g., school, withplaymates) where speaking is expected, despite speaking in other situations (Criterion A). Thedisturbance interferes witheducational or occupational achievement or with social communication (Criterion B). The disturbancemust last for at least 1month and is not limited to the first month of school (during which many children may be shy and reluctantto speak) (CriterionC). Selective Mutism should not be diagnosed if the individual’s failure to speak is due solely to a lack ofknowledge of, or comfortwith, the spoken language required in the social situation (Criterion D). It is also not diagnosed if thedisturbance is betteraccounted for by embarrassment related to having a Communication Disorder (e.g., Stuttering) or if itoccurs exclusively during a
  3. 3. Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder (Criterion E). Instead ofcommunicating bystandard verbalization, children with this disorder may communicate by gestures, nodding or shaking thehead, or pulling orpushing, or, in some cases, by monosyllabic, short, or monotone utterances, or in an altered voice.Associated Features and DisordersAssociated features of Selective Mutism may include excessive shyness, fear of social embarrassment,social isolation andwithdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling or oppositionalbehavior, particularly at home.There may be severe impairment in social and school functioning. Teasing or scapegoating by peers iscommon. Althoughchildren with this disorder generally have normal language skills, there may occasionally be anassociated CommunicationDisorder (e.g., Phonological Disorder, Expressive Language Disorder, or Mixed Receptive-ExpressiveLanguage Disorder) or ageneral medical condition that causes abnormalities of articulation. Mental Retardation, hospitalization,or extreme psychosocialstressors may be associated with the disorder. In addition, in clinical settings, children with SelectiveMutism are almost alwaysgiven an additional diagnosis of an Anxiety Disorder (especially Social Phobia).Specific Culture and Gender FeaturesImmigrant children who are unfamiliar with or uncomfortable in the official language of their new hostcountry may refuse to speakto strangers in their new environment. This behavior should not be diagnosed as Selective Mutism.Selective Mutism is slightlymore common in females than in males.PrevalenceSelective Mutism is apparently rare and is found in fewer than 1% of individuals seen in mental healthsettings.CourseOnset of Selective Mutism is usually before age 5 years, but the disturbance may not come to clinicalattention until entry intoschool. The degree of persistence of the disorder is variable. It may persist for only a few months or maycontinue for severalyears. In some cases, particularly in those with severe Social Phobia, anxiety symptoms may becomechronic.Differential DiagnosisSelective Mutism should be distinguished from speech disturbances that are better accounted for by aCommunicationDisorder, such as Phonological Disorder, Expressive Language Disorder, Mixed Receptive-Expressive LanguageDisorder, or Stuttering. Unlike Selective Mutism, the speech disturbance in these conditions is notrestricted to a specific socialsituation. Children in families who have immigrated to a country where a different language is spokenmay refuse to speak thenew language because of lack of knowledge of the language. If comprehension of the new language isadequate, but refusalto speak persists, a diagnosis of Selective Mutism may be warranted. Individuals with a PervasiveDevelopmental Disorder,
  4. 4. Schizophrenia or other Psychotic Disorder, or severe Mental Retardation may have problems insocial communication andbe unable to speak appropriately in social situations. In contrast, Selective Mutism should only bediagnosed in a child who hasan established capacity to speak in some social situations (e.g., typically at home). The social anxietyand social avoidance inSocial Phobia may be associated with Selective Mutism. In such cases, both diagnoses may be given. Diagnostic criteria for 313.23 Selective Mutism A. 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. B. The disturbance interferes with educational or occupational achievement or with social communication. C. The duration of the disturbance is at least 1 month (not limited to the first month of school). D. The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation. E. The disturbance is not better accounted for by a Communication Disorder (e.g., Stuttering) and does not occur exclusively during the course of a Pervasive Development Disorder, Schizophrenia, or other Psychotic Disorder.iagnosis of other comorbid anxiety disorders are also commonly diagnosed with SM and socialphobia (Biedel & Turner, 1998). The name change from "elective" to "selective mutism" inDSM-IV deemphasized the oppositional behavior connotation that a child elected not to speakand rather emphasized the characteristic of the disorder, that there are select environments inwhich speaking does not occur (APA, 1994). The term selective mutism is consistent with newetiological 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 inorder to qualify for a diagnosis of selective mutism:
  5. 5. An inability to speak in at least one specific social situation where speaking is expected (e.g., atschool) despite speaking in other situations (e.g., at home); The disturbance has interfered witheducational or occupational achievement or with social communication; The duration of theselective mutism is at least one month and is not limited to the first month of school; Theinability to speak is not due to to a lack of knowledge of or discomfort with the primary languagerequired in the social situation; and, The disturbance cannot better be accounted for by acommunication disorder (e.g. stuttering) and does not occur exclusively during the course of apervasive developmental disorder, schizophrenia or other psychotic disorder.Consistent with current research, SMG believes that Selective Mutism is best understood as achildhood social communication anxiety disorder. SM is much more than shyness and mostlikely on the spectrum of social phobia and related anxiety disorders. SM is NOT a childwillfully refusing to speak.Most children with selective mutism are believed 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.[5] This area receives indications ofpossible threats and sets off the fight-or-flight response.Some children with selective mutism may have sensory integration dysfunction (troubleprocessing some sensory information). This would cause anxiety and a sense of beingoverwhelmed in unfamiliar situations, which may cause the child to "shut down" and not be ableto speak (something that some autistic people also experience). Many children with SM havesome auditory processing difficulties.About 20–30% of children with SM have speech or language disorders that add stress tosituations in which the child is expected to speak.[6]Despite the change of name from "elective" to "selective", a common misconception remainsthat a selectively mute child is defiant or stubborn. In fact, children with SM have a lower rate ofoppositional behavior than their peers in a school setting.[7] Another common belief is thatselectively mute children have experienced abuse or trauma. A study of six adults who wereselectively mute as children suggests that those with selective mutism are more likely to havesuffered abuse, which may contribute to the onset of their mutism. The interviewees also saidthat there was a conscious determination not to speak and that they were afraid of speaking,indicating that both choice and fear may be involved in selective mutism. Only two of theinterviewees specifically reported childhood social anxiety, and those were twins. Other anxietyand emotional problems seemed to have appeared after the onset of the disorder. This studyshows that selective mutism may be more complex than currently believed, with both past andcurrent understandings of the disorder both being partly true.[8]In their book Adoption Detective: Memoir of an Adopted Child, Judith and Martin Land mentionhow selective mutism, extreme shyness, and other social anxiety disorders can be evidence oftrauma frequently associated with adoption, especially in children under three years old.Selective mutism might be highly functional for a child by reducing anxiety and protecting thechild from perceived challenges of social interaction, particularly in situations with high
  6. 6. performance expectations, such as school. Adoptees with this anxiety might be highly talkativeat home with family and friends, but avoid speaking altogether in classrooms, large groups, andsocial functions. Adoptees with selective mutism likely have difficulty verbalizing personalthoughts when they are excessively revealing and painful or of a subconscious nature.The Diagnostic and Statistical Manual of Mental Disorders (DSM), first published in 1952, firstincluded Elective Mutism in its third edition, published in 1980. Elective Mutism was describedas "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.Elec2tive Mutism in the third edition revised (DSM III-R) is described similarly to the thirdedition 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 fourthedition of the DSM reflect the name change to selective mutism and described the disorder as afailure to speak. The relation to anxiety disorders was emphasized, particularly in the revisedversion (DSM IV-TR).There are no changes to the definition of selective mutism planned for the DSM V.TreatmentContrary to popular belief, people suffering from selective mutism do not necessarily improvewith age.[11] Effective treatment is necessary for a child to develop properly. Without treatment,selective mutism can contribute to chronic depression, further anxiety, and other social andemotional problems.[12][13]Consequently, treatment at an early age is important. If not addressed, selective mutism tends tobe self-reinforcing. Those around such a person may eventually expect him or her not to speakand therefore stop attempting to initiate verbal contact with the sufferer. Alternately, they maypressure the child to talk, making him or her have even higher anxiety levels in situations wherespeech is expected. Because of these problems, a change of environment (such as changingschools) may make a difference, and treatment in teenage or adult years can be more difficultbecause the sufferer has become accustomed to being mute.The exact treatment depends on the sufferers age, other mental illnesses he or she may have, anda 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 sufferers and people with depression are more likely to need medication.[14][edit] Self-ModelingThe child is brought into the classroom or the environment where s/he will not speak and isvideotaped answering a series of questions. First, his/her teacher, or adult representative of thoseto which the child will not speak asks the child questions. The child likely does not answer thequestions at this time. A parent or someone to whom the child will converse verbally then comes
  7. 7. in the room and the teacher goes out. The comfortable adult asks the child the same questions,this time eliciting a verbal response. This video is then edited so that the it looks like the child isanswering the questions posed by the teacher. This video is then shown the child over a series ofseveral weeks. The child is asked to view the tape and every time s/he sees him/herselfanswering the teacher verbally, stop the tape to receive a positive reinforcement.The video can also be shown to the child’s classroom in order to set an expectation in theclassroom by his/her peers that s/he speaks. The classmates now know the sound of the child’svoice and believe they have seen the child conversing with the teacher.[15][16][edit] Mystery MotivatorsMystery motivation is often seen paired with the self-modeling technique. An envelope is placedin the child’s classroom in a visible place. On the envelope, the child’s name is written alongwith a question mark. Inside is a prize determined with the child’s parent in order for it to besomething the child would want to have. The child is told that when s/he asks for the envelopeappropriately and loudly enough for the teacher and his/her peers to hear, s/he may then receivethe mystery motivator. The classroom is also told in this case about the expectation that the childask for the envelope loudly enough that the class can hear.[17][18][19][edit] Stimulus fadingThe subject is brought into a controlled environment with someone with whom they are at easeand can communicate. Gradually, another person is introduced into the situation. One example ofstimulus fading is the sliding-in technique, where a new person is slowly brought into the talkinggroup. This can take a long time for the first one or two faded-in people but may become fasteras the patient gets more comfortable with the technique.An example of this would be a child playing a board game with a family member in his/herclassroom at school. Gradually, the teacher is brought in to play as well. When the child adjuststo his/her presence, then a peer is brought in to be a part of the game. Each person is onlybrought in if the child continues to engage verbally and positively.[20][21][22][edit] DesensitizationThe subject communicates indirectly with a person he or she is afraid to speak to through suchmeans as email, instant messaging (text, audio, and/or video), online chat, voice or videorecordings, 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.[edit] ShapingThe subject is slowly encouraged to speak. He or she is reinforced first for interactingnonverbally, then for saying certain sounds (such as the sound that each letter of the alphabetmakes) rather than words, then for whispering, and finally saying a word or more.[23]
  8. 8. SpacingSpacing is important to integrate, especially with self-modeling. Repeated and spaced out use ofinterventions 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 treatmentsMany practitioners believe that there is evidence indicating that antidepressants such as SSRIsmay be helpful in treating children and adults with selective mutism and even that medicine isessential to effective treatment.[citation needed]The medication is used to decrease anxiety levels tospeed the process of therapy. Use of medication may end after nine to twelve months, once theperson has learned skills to cope with anxiety and has become more comfortable in socialsituations.[27] Medication is more often used for older children, teenagers, and adults whoseanxiety has led to depression and other problems.Medication, when used, should never be considered the entire treatment for a person withselective mutism. While on medication, the person should be in therapy to help him or her toknow how to handle anxiety and prepare him or her for life without medication.[28]Anti-depressants have been used in addition to self-modeling and mystery motivation in order toaid in the learning process.[29][30]Do Individuals Experiencing Selective Mutism Have Associated Behaviors?Yes. Associated behaviors may include no eye contact, no facial expression, immobility, or nervousfidgeting when confronted withgeneral expectations in social situations. These symptoms do not indicate willfulness, but rather anattempt to control risinganxiety.Some may withdraw by pulling back when approached or touched and exhibit different forms of bodylanguage. In many cases thebody language has been misinterpreted as abuse, however, we have found that these behaviors stemfrom anxiety. Based onresponses to the Foundation, we suspect that some may have Obsessive-Compulsive Disorder (OCD) orTourette Syndrome typesymptoms, and a variety of phobias as well.