Various existing childhood disorders have intrigued both mental healthcare professionals and school personnel throughout their careers. Many of these childhood disorders are rare in nature and more often than not are considered as frustrating to treat. “Selective Mutism (SM)” has been considered as one of the rare childhood disorders. In many cases, children suffering from the said disorder are not easily diagnosed until the time they are introduced to social situations (e. g. , school). This is so because children with selective mutism are not pressured to speak outside the home until they start schooling.
As such, it is only within the preschool and elementary school setting that selective mutism can be identified (Mennuti, Freeman, & Christner, 2006). In this regard, many people are not truly aware of such incidence, thereby contributing to the lack of knowledge about the said disorder. Hence, this paper seeks to gain insight on selective mutism, its nature, etiology, prevalence, and treatments so as to give further understanding of the degree and bearing of the pertained disorder among children.
Selective Mutism: A background Before the 19th century ended, a German physician known as Kussmaul (1877) identified a condition which he named as “aphasia voluntaria” (cited in Mennuti et al. , 2006). Kussmaul described the disorder’s characteristics of individuals with this disorder. For one, though they have the capability to speak, they would not do so in certain situations. Thus, Kussmaul (1877) thought that the individuals voluntarily decided not to speak, thereby naming the disorder as such (cited in Mennuti et al. 2006).
However, Kussmaul’s study received little attention. It was only during Tramer’s investigation of the same condition when this disorder started to gain the attention of the academic community. Tramer’s study, conducted 57 years after Kussmaul’s study, involved children who spoke in certain situations or with certain people, which prompted him to call the disorder “elective mutism,” as he believed that the children he observed were “electing” not to talk.
However, by 1983 Hesselman suggested that the term “selective mutism” is much more descriptive compared to “elective mutism. ” Thus, the new term was adopted by “American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)” and has remained in the said manual’s text revision (DSM-IV-TR) (APA, 1987, 1984, 2000 cited in Morris & Mach, 2004). The new term implies that “selective mutism” is characterized by a child’s persistent failure to speak in certain social situations, most especially in the school setting.
A child suffering from the said disorder may become completely silent or near silent within the whole time span in the social setting. In some cases, the child will just whisper rather than speak out loud. Recent conceptualization of the disorder has been more consistent with the etiological theories of social anxiety. Most of the children diagnosed with selective mutism were found to have been consistently silent during stressful conditions, while others were observed to verbalize single-syllable words inaudibly.
DSM-IV noted that children with selective mutism are highly capable of competently speaking when not in social situations. For instance, a child suffering from SM speaks well at home but says little or nothing at all when at school or other not so familiar settings (Sadock, B. , Kaplan, & Sadock, V. , 2007). Epidemiology Selective mutism has been found to exist in various countries throughout the globe including France, Canada, Great Britain, Germany, Israel, Japan, and the United States (Barowsky, 1999 cited in Reynolds & Fletcher-Janzen, 2007).
Recent evidence suggests that the onset of the disorder usually takes place from two to four years of age (Black & Uhde, 1995; Dummit et al. , 1997 Kristensen, 2000; Steinhausen & Juzi, 1996; cited in Morris & March, 2004) or during the preschool years and can be carried on until adolescence, though it becomes more transient during the said stage (Carlson, Kratochwill & Johnston, 1994 cited in Reynolds & Fletcher-Janzen, 2007) and can only last for several months (Kehle, Hintze & DuPaul, 1997 cited in Reynolds & Fletcher-Janzen, 2007).
Although the onset of the disorder develops at an early age, children are only referred for diagnosis and treatment during their entry to school (Morris & March, 2004). Thus, the longer the disorder persists, “the more debilitating it becomes” (Kehle, et al. , 1997 cited in Reynolds & Fletcher-Janzen, 2007, p. 1817). In addition, selective mutism is generally thought to be more prevalent among girls than boys, with an estimate ranging from approximately 2. 6:1 to 1. 5:1 (Dummit et al. , 1997; Kopp and Gillberg, 1997; Kristensen, 2000; Kumpulainen et al. 1998; Steinhausen and Juzi, 1996 cited in Morris and March, 2004). Likewise, the condition is observed in all social strata (Steinhausen & Juzi cited in 1996 Reynolds & Fletcher, 2007) and can affect children with varying levels of intellectual ability (Kehle et al. , 1997 cited in Reynolds and Fletcher-Janzen, 2007).
Although the disorder is relatively rare, several studies pointed out that it can be more prevalent than actually observed, as most cases are not brought to medical attention, and some are resolved with age, making the prevalence estimates inconclusive (Carlson et al. 1992; Haeberli & Kratochwill, 2005; cited in Reynolds & Fletcher-Janzen, 2007). It was discovered in one study that the prevalence rate of selective mutism is . 71 percent in a public school sample (Bergman, Piacentini, & McCraken, 2002 cited in Reynolds & Fletcher-Janzen, 2007), while another comparative study participated by native-born and immigrant children suggests that less than 1 percent of 1,000 children from the native-born sample suffer from selective mutism, and 7. percent out of 1,000 children that are immigrant-born have the disorder (Dummit et al. , 1997 cited in Reynolds & Fletcher-Janzen, 2007).
These findings suggest that “selective mutism,” although small in percentage, is not as uncommon among children as some believe it to be. Etiology To date, the cause of selective mutism is still uncertain. However, there is an emerging consensus that such condition is etiologically connected with anxiety disorder.
Though still widely debated, SM has been conceptualized as a form of childhood social phobia (Black & Uhde, 1992; Dummit et al. , 1997; Steinhausen & Juzi, 1996; cited in Evans, et al. , 2005). Such reasoning is based on the fact that children diagnosed with SM also manifest the characteristics of children suffering from social anxiety disorders such as social avoidance, fear of speaking with other people, and distress in social conditions (Beidel & Turner, 1998 cited in Mennuti et al. 2006). Nonetheless, several diagnostic studies of children with selective mutism were also found to meet the criteria of social phobia identified by the DSM-IV (Mennuti, Freeman, Christner, 2006). Yet, some still argue that SM should not be contemplated as a separate diagnostic criterion but a social phobia’s subtype or symptom (Anstendig, 1999; Black & Uhde, 1995; Dummit et al. , 1997; cited in Evans, et al. , 2005).
One study noted that selective mutism is associated with a child’s developmental delay more frequently than the concept of anxiety disorder, suggesting the disorder’s neurobiological etiology. Contrastingly, learning theory suggests that selective mutism is a behavior that can be learned and is maintained by social reinforcements, while psychoanalytically, selective mutism” is suggested to function in order to reduce the fear felt by a child when faced with anxiety-provoking situations by becoming unresponsive (Kehle, 1997 cited in Reynolds & Fletcher-Janzen, 2007).
Other than these, the following factors were also suggested to elevate the risks of children in developing selective mutism: migration background; early developmental risks factors such as pregnancy and delivery complications; delayed development of motor skills and toilet training; disorders related to speech and language; abnormalities in the behavior during infancy or preschool stage such as relationship issues, anxiety due to separation, sleeping and eating disorders; comorbid symptoms such as enuresis; and patterns of social interactions like withdrawal, depression and schizoid type behaviors (Steinhausen & Juzi, 1996 cited in Reynolds & Fletcher-Janzen, 2007).
Additionally, the family history of selective mutism, as well as anxiety disorders and extreme shyness, was also pointed out as contributing factors for the emergence of the disorder among children (Dow et al. , 1995 cited in Reynolds & Fletcher-Janzen, 2007). Assessment of Selectively Mute Children The assessment of children suffering from SM is profoundly difficult as there is an absence of verbal language that serves as a medium to communicate. However, recent studies pointed out that in order to rule out the possible explanation behind a child’s mutism, clinicians should be able to carry out comprehensive assessments by properly evaluating first the comorbid conditions.
Such assessment include the following: a structured interview with the parents of the child; a review of the academic, medical, and familial history; formal speech and language ability evaluation; interview with the child, giving him or her the opportunity to respond nonverbally; medical examination and standardized tests that would assess the child’s auditory and psychological function; and finally, an audiotape containing the recorded speaking of child at home (Dow et al. , 1995 cited in Reynolds & Fletcher-Janzen, 2007). Treatment Due to the low incidence of the disorder, treatment protocols that are substantially successful have not been thoroughly studied. It was also noted that selective mutism is resistant to treatment (Kehle et al. , 1997 cited in Reynolds & Fletcher-Janzen, 2007).
However, psychotherapy, which includes approaches centered on the child’s cognitive and cognitive-behavioral aspects, is the most common and the initial intervention in the clinical practice for the treatment of selective mutism. However, empirical treatment studies prove that behavioral strategies are the most effective form of intervention for children with SM. Such form of treatment includes programs for contingency management, self-modeling, stimulus-fading, and shaping and escape-avoidance strategies (Kehle et al. , 1997 cited in Reynolds & Fletcher-Janzen, 2007). Pharmacotherapy may also be used by clinicians in order to treat selective mutism.
Significant improvements among the sample of selectively mute children were found after 12 weeks of a placebo-controlled fluoxetine trial was carried out. However, it was also noted by the researchers that trial medication should only be considered if anxiety has also become a prominent feature of the disorder and all the other treatments available failed. The combination of medication and approaches of learning theory were also found to be effective for selective mutism patients (Kehle et al. , 1997 cited in Reynolds & Fletcher-Janzen, 2007). Similarly speech intervention with the focus language training and articulation were also found to be successful in treating “selective mutism” (Dow et al. , 1995 cited in Reynolds & Fletcher-Janzen, 2007). Conclusion
Based on the facts and information gathered, it can be inferred that selective mutism is indeed a rare childhood disorder that can last for months or even years. Oftentimes, such condition is associated with anxiety disorder and may develop through several factors. However, in line with the new developments in the study of selective mutism, it has been pointed out that the prognosis for such disorder varies from one case to another. As such, it should be taken into consideration that children suffering from selective mutism do not necessarily refuse to talk, but they have this sense of being unable to do so. There is still a need for further information on whether selective mutism should truly be classified as an anxiety disorder or a different criterion of diagnosis.
While the disorder has been reported to be rare, data have shown that to date, its prevalence remains inconclusive because of low incidence of reports, thereby suggesting that only few people are familiar with the disorder. Additionally, therapies and intervention for the disorder may be available. Nevertheless, there should be a continuous study in the efficacy of these treatments most especially in terms of medications, as it appears to be promising; yet, solid evidence of its side-effects has not yet been clarified. In this regard, early intervention could be the best preventive measure to avoid problems associated with the lack of proper understanding of this disorder.