describes nosology,etiopathogenesis, clinical features and management

2. Selective mutism
• Introduction
• Nosological aspects
• Etiopathogenesis
• Clinical features and diagnosis
• Management
• conclusion

3. introduction
• Elective mutism is considered when there is a
1.Consistent failure to speak in social situations where speaking
is expected.(eg.school)
2.Clear evidence that child does speak in other situations.

4. introduction
• Child may completely silent or near silent or he may be
whispering.
• Usually develop less than 5 years but may not be apparent
until child is expected to speak or read aloud at school.
• Most children meet the criteria of social phobia .
• In family most children will show these features to immediate
family members with whom they have close contacts.

5. introduction
• 50% of children meet the diagnostic criteria for language
disorder.
• When stressful condition these children are silent. Some
verbalize in single syllable words, some with eye contacts or
non-verbal gestures.
• If associated with emotional/physical trauma traumatic
mutism.

6. Nosology of selective mutism
• The classification and diagnostic position of selective mutism
evolved from -
• marginally treated “specific behavioral disorders” 
contemporary approaches recognizing SM as an extreme
manifestation of social phobia.

7. • In 1934, Moritz Tramer described the case of an eight-year
old child who refused to speak in certain situations and
introduced the term elective mutism (EM).
• This was to emphasize the lack of verbal contact as a
conscious choice of people affected by this disorder .
Kopp S, Gillberg C. Selective mutism: A population based study. J. Child Psychol.
Psychiatry1997; 38(2): 257–262.

9. • The term elective mutism and early American diagnostic criteria for
the disorder highlighted the importance of conscious
will of patients to withdraw from verbal contact.
• The term was used to define “refusal to talk” to most people
and in most social situations, dependent on the patient’s will.
• The withdrawal from verbal contact was interpreted as oppositional
defiant features, not as social anxiety manifestation

10. • In the DSM-IV, DSM-IV-R, and DSM-5 the term elective
mutism was replaced by selective mutism.
• It was done to highlight the phenomenon of mutism, which
consists in speech selectivity that applies only to some
(selected), not all social environments,and cannot be
combined with conscious manipulation of the
environment by refusing to speak.

11. • In the ICD-10, selective mutism is listed in “disorders of social
functioning with onset specific to childhood and
adolescence” .(F:94)
• According to the ICD-10, selective mutism is diagnosed when
the following conditions are present:
• a) normal or close to normal level of intelligibility;
• b) level of speech competence sufficient for social
communication;
• c) clear evidence that the child can speak and speaks
normally or almost normally in some situations.

12. • According to the ICD-10, selective mutism is still regarded as a
health problem limited to childhood and not a form of
anxiety disorders that may appear in different periods of life.

13. • InDSM-5,it was removed from “Disorders of childhood and
adolescence” and placed in “Anxiety disorders”.
• Two important changes in the interpretation of the symptoms
of selective mutism.
• It highlighted anxious etiology of the disorder and also
open the possibility to diagnose selective mutism in adults
as a special category of anxiety disorder.
• www psychiatria polska.pDOIhttps://doi.org/10.12740/PP/76088r.

14. Epidemiology
• Point prevalence –range between 0.03% to 1%
• Young children-common
• Girls are affected more than boys
• 7.4% of SM children also meet the criterion for other mental
disorder.( depression, OCD, panic disorder, dissociative d..)
• Sharp WG, Sherman C, Gross AM. Selective mutism and anxiety: A review of the current conceptualisation
• of the disorder. J. Anxiety Disord. 2007; 21(4): 568–

15. Etiopathogenesis
• Behavioural theory-
• In new social situations the sympathetic nervous system
takes inhibiting control on the ability to speak and on the
whole behavior of children with SM children with this
disorder in threatening situations (new social situations)
behave as if they were “immobile” or “frozen”.
• On the linguistic level it manifests itself as silence .
Wong P. Selective mutism: A review of etiology, comorbidities, and treatment. Psychiatry (Edgemont)
2010; 7(3): 23–31.

16. • Psychodynamic theory - unresolved oedipal conflict and
fixation at the oral or anal stage of psychosexual development
are important for the SM etiology.
• By transposing anger towards the same sex parent, the
regression to non-verbal stage of development appears as a
defense mechanism in situations which increase fear and
exacerbate the internal conflict.
• Silence becomes a defense mechanism to “punish” parents.
Giddan JJ, Milling L. Co morbidity of psychiatric and communication disorders in children.
Child Adolesc. Psychiatr. Clin. N. Am. 1999;

17. Systemic theory
• Dr binoy
Neurotic parenting control
over children- excessive
attachment to parents.
Lack of confidence in the
outside world, fear of
strangers, fear of verbal
communication
Clinical manifestation as
silence

18. integrated developmental theory.
• It stresses the importance of earlier biological and
temperamental anxiety predisposition in children with speech
development disorders.
• children with SM remain unaware of their language deficits
before starting pre-school education.

19. • In new, “demanding” social interaction with their peers with
normal development of language functions , children with SM
are excluded from that group.
• In children with anxiety response patterns  pattern of
avoiding confrontation in the kindergarten/school
environment - mutistic behavior

20. • most common period of social anxiety onset is not the same
as the onset of SM .
• The symptoms of SM usually show up in children aged 3–6
years, while the symptoms of social phobia – in adolescents
aged 11–13.
• In a study by Melfsen et al., the severity of anxiety in children
with SM symptoms was assessed.
• The level of social anxiety in SM children was lower as
compared with children with a diagnosis of social phobia.

21. Audiological and neurobiological theories of selective mutism
• Dysfunction in the efferent auditory processing
mechanism in children play an important role for SM
difficulty in simultaneous coping with incoming sounds
and loud self-vocalization children with SM adapt to
efferent dysfunction of the auditory system through
lowering the voice, whispering or total refusal to speak.
• Henkin Y, Bar-Haim Y. An auditory-neuroscience perspective on the development of
selectivemutism. Dev. Cogn. Neurosci. 2015; 12: 86–93.

22. Clinical features and diagnosis
• Child has adequate language skills in some environment but
not in others.
• A disturbing experience may be precedingly present.
• Age of onset- 4 to 8 years.
• Commonly manifest in school or outside home.(rarely mute at
home-not school)
• Behavioural disturbances like temper tantrum and
oppositional behaviour present at home

23. Differential diagnosis
.Communication disorder/autism spectrum disorder/social
anxiety disorder
- Excluded by child’s capacity to speak in certain situations.
- Selective autism children have less social competence
comparing to children with anxiety disorder.

24. • Transient adaption shyness
• most children who are mute on entering school/not speaking
in presence of strangers
• These may improve spontaneously.

25. Mental retardation/pervasive developmental disorder
• Symptoms are widespread(no single situation exists where
child can speak well)
• Child has inability rather than refusal to speak.
• (same situation occur when child child exposed to an
environment where different language is spoken)
What is this
language ?

26. Course and prognosis
• Child speak at home –not at school
• Academic difficulties/failures/lack of participation
shy/anxious/increased risk for depressive disorder difficulty
in social relationship/ teasing by peers refuse to go to
school

27. SELECTIVE
MUTISM
Develop
rigidity,compulsive
traits,negativism
temper
tantrums,oppositio
nal behaviour at
home
Tolerate the
situation by
communicating
with gestures
like nodding,
shaking head
Half –
improve
with in 5-
10 years
1/3 of
children
have
anxiety
/depression
Not improving-
worst prognosis
and long term
course

28. management
• Aim
• 1.To decrease the anxiety of child for speak in certain
situations.
• 2.To increase the context in which child may speak
comfortably.

29. • Multimodal approach
Psychoeducation for family
CBT SSRI

30. Management
• A significant minority of children with selective mutism have
delays in speech development , neuro developmental
disorders like autism spectrum disorder and auditory
processing deficits.
• Possibility of linguistic efficiency in formal speech but show
difficulty in fast processing of language (Asperger syndrome).
• The presence of such deficits are important for behavioural
techniques , pharmacological treatment and even in the way
child has to be take care of

31. • Case 1–selective autism +
delay in language development
• Case2-SM+ anxiety symptoms
• Case3-SM + developmental ds
Behavioural dysfunction/
Mental disorder in family
AUTISM SPECTRUM
DISORDER/
MENTAL RETARDATION /ODD
SOCIAL ANXIETY
DISORDER/MDD/ODD/
ASPERGERS SYNDROME

32. • Multimodal approach
Psychoeducation for family
CBT SSRI

33. • When selective mutism symptoms are severe or when
psychosocial intervention did not help  pharmacotherapy.
• SSRI decreases the severity of symptoms.
• Recent study showed Fluoxetine is effective for childhood
selective mutism in the dose of 20mg to 60mg/day.
• ->Fluvoxamine 50mg-300mg/day
• ->Sertraline 25-300 mg/day
• ->Paroxetine 10-50mg/day

34. • In one year observational study after completing behavioural
treatment ,half of children with mutism no longer met the
diagnostic criteria for the disorder.
• Auditory processing deficits should be considered in the
treatment of selective mutism.
• Training with exposure to ones own voice through
headphone addition of background voices simulation of
speech in social situations.
• Holka-Pokorska J, Piróg-Balcerzak A, Jarema M.Psychiatr Pol. 2018 Apr 30;52(2):323-343. doi: 10.12740/PP/76088. Epub 2018 Apr 30

35. • rTMS (tran scranial magnetic stimulation or trans cranial
direct current stimulation along with behavioural theory -
alleviate symptoms

36. conclusion
• 1. At the current stage of research on the pathogenesis and
psychopathology of selective mutism, the concept of SM as
social phobia type of anxiety disorder spectrum is most
convincing.
• 2. Selective mutism syndrome is a non-homogeneous group of
disorders of diverse etiology and course.
• 3. Co morbid developmental deficits and/or dysfunction of
the auditory processing are often observed in individuals with
selective mutism.

37. conclusion
• 4.SM can be a syndrome manifested at an important
developmental stages in children with neuro cognitive or
social cognition deficits.
• 5. The presence of co morbidities and developmental deficits
may determine the future course of the disorder and the final
effects of the therapy.

38. reference
• Synopsis of psychiatry-kaplan and sadok-11th edition
• CTP-kaplan and sadok
• Oxford text book of psychiatry
• Various journals
• Holka-Pokorska J, Piróg-Balcerzak A, Jarema M.Psychiatr Pol. 2018 Apr 30;52(2):323-343. doi:
10.12740/PP/76088. Epub 2018 Apr 30 (pubmed)
• Henkin Y, Bar-Haim Y. An auditory-neuroscience perspective on the development of
selectivemutism. Dev. Cogn. Neurosci. 2015; 12: 86–93.