Selective mutism

Definition
Selective mutism is a severe anxiety disorder where a person is unable to
speak in certain social situations, such as with classmates at school or to
relatives they do not see very often , It usually starts during childhood
and, if left untreated, can persist into adulthood , A child or adult with
selective mutism does not refuse or choose not to speak at certain times,
they're literally unable to speak , The expectation to talk to certain people
triggers a freeze response with feelings of panic, like a bad case of stage
fright, and talking is impossible , In time the person will learn to
anticipate the situations that provoke this distressing reaction and do all
they can to avoid them, However, people with selective mutism are able
to speak freely to certain people, such as close family and friends, when
.nobody else is around to trigger the freeze response

Diagnostic Features
When encountering other individuals in social interactions, children with
selective mutism do not initiate speech or reciprocally respond when
spoken to by others. Lack of speech occurs in social interactions with
children or adults. Children with selective mutism will speak in their
home in the presence of immediate family members but often not even in
front of close friends or second-degree relatives, such as grandparents or
cousins. The disturbance is often marked by high social anxiety. Children
with selective mutism often refuse to speak at school, leading to academic
or educational impairment, as teachers often find it difficult to assess
skills such as reading. The lack of speech may interfere with social
communication, although children with this disorder sometimes use
nonspoken or nonverbal means (e.g., grunting, pointing, writing) to
communicate and may be willing or eager to perform or engage in social
encounters when speech is not required (e.g., nonverbal parts in school
.plays)
Prevalence
Selective mutism is a relatively rare disorder and has not been included
as a diagnostic category in epidemiological studies of prevalence of
childhood disorders. Point prevalence using various clinic or school
samples ranges between 0.03% and 1% depending on the setting (e.g.,
clinic vs. school vs. general population) and ages of the individuals in the
sample ,The prevalence of the disorder does not seem to vary by sex or
race/ethnicity . While the average age of diagnosis is between 3 – 8
years old, Higher prevalence rates have been noted in immigrant
children and in language-minority children than in nonimmigrant
.children

Development and Course

The onset of selective mutism is usually before age 5 years, but the
disturbance may not come to clinical attention until entry into school,
where there is an increase in social interaction and performance tasks,
such as reading aloud. The persistence of the disorder is variable.
Although clinical reports suggest that many individuals “outgrow”
selective mutism, the longitudinal course of the disorder is unknown. In
some cases, particularly in individuals with social anxiety disorder,
selective mutism may disappear, but symptoms of social anxiety
.disorder remain

Risk and Prognostic Factors

Temperamental: Temperamental risk factors for selective mutism are
not well identified. Negative affectivity (neuroticism) or behavioral
inhibition may play a role, as may parental history of shyness, social
isolation, and social anxiety. Children with selective mutism may have
subtle receptive language difficulties compared with their peers,
.although receptive language is still within the normal range

Environmental: Social inhibition on the part of parents may serve as a

model for social reticence and selective mutism in children.
Furthermore, parents of children with selective mutism have been
described as overprotective or more controlling than parents of children
.with other anxiety disorders or no disorder

Genetic and physiological factors: Because of the significant overlap

between selective mutism and social anxiety disorder, there may be
.shared genetic factors between these conditions

Culture-Related Diagnostic Issues

Children in families who have immigrated to a country where a different
language is spoken may refuse to speak the new language because of
lack of knowledge of the language. If comprehension of the new
language is adequate but refusal to speak persists, a diagnosis of
.selective mutism may be warranted

Causes
No single cause of selective mutism has been identified, and its causes
seem to be multifactorial ,The following factors may coexist and play a
: role in selective mutism

Associated anxiety disorders: such as social phobia, separation anxiety,

.and obsessive compulsive disorder

Hereditary or genetic: component with a significant overlap between

.selective mutism and social anxiety disorder

Familial links coupled with environmental factors: such as reduced

opportunities for social contact, observing anxious behaviors, or
.reinforcing avoidance behaviors

Shy or timid temperament

Self-esteem problems

Functional Consequences of Selective Mutism

Selective mutism may result in social impairment, as children may be too
anxious to engage in reciprocal social interaction with other children. As
children with selective mutism mature, they may face increasing social
isolation. In school settings, these children may suffer academic
impairment, because often they do not communicate with teachers
regarding their academic or personal needs (e.g., not understanding a
class assignment, not asking to use the restroom). Severe impairment in
school and social functioning, including that resulting from teasing by
peers, is common. In certain instances, selective mutism may serve as a
.compensatory strategy to decrease anxious arousal in social encounters

Differential Diagnosis
Communication disorders: Selective mutism should be distinguished
from speech disturbances that are better explained by a communication
disorder, such as language disorder, speech sound disorder (previously
phonological disorder), childhood-onset fluency disorder (stuttering), or
pragmatic (social) communication disorder. Unlike selective mutism, the
speech disturbance in these conditions is not restricted to a specific social
situation

Neurodevelopmental disorders and schizophrenia and other psychotic

disorders: Individuals with an autism spectrum disorder, schizophrenia
or another psychotic disorder, or severe intellectual disability may have
problems in social communication and be unable to speak appropriately
in social situations. In contrast, selective mutism should be diagnosed
only when a child has an established capacity to speak in some social
.situations (e.g., typically at home)

Social anxiety disorder (social phobia):The social anxiety and social avoidance in
social anxiety disorder may be associated with selective mutism. In such
.cases, both diagnoses may be given

Treatment
Treatment options at Priory focus on reducing associated anxiety
symptoms surrounding speaking in certain situations, as opposed to
simply focusing on the speech itself. Whether triggering scenarios are
found during nursery, school, work or social settings, the aim of talking
and behavioural therapies will be a progressive, step-by-step process to
gradually reduce the pressure to speak, which is at the core of symptoms
.of selective mutism

therapies used in the treatment of selective mutism in both children and

:adults include

Cognitive behavioural therapy (CBT)

Among the most effective methods of treating symptoms of selective

.mutism is CBT

This action-based and problem-solving talking therapy is carried out by

highly trained therapists, where you or your older child can benefit from
further understanding of the disorder and anxiety in general. The therapist
will provide a range of techniques for managing anxiety during triggering
situations, focusing on how negative thoughts and feelings may be
.contributing to anxiety symptoms

Younger children can still benefit from CBT, although the focus will be
less on detailed understanding of anxiety and how your child feels they fit
in with the world around them, and more about assessing their general
.wellbeing

Stimulus fading

The child may talk at ease with someone, such as a parent. In stimulus
fading, another person is introduced to the situation. Then, as they
.become included in talking, the parent withdraws and talking continues

Desensitisation

This method attempts to reduce the fear of certain people hearing the
.sound of you or your child’s voice

Many people with social anxiety and selective mutism will feel more
comfortable through non-vocal means of communication such as instant
messaging or emailing, which can be used before increased exposure.
Exchange of voice recordings and voicemail messages builds to more
.direct forms of communication such as telephone or video conversations

Shaping
With two-way communication among people other than close friends and
family being the desired goal, shaping uses techniques which steadily
move towards this through activities such as reading aloud or taking part
in interactive reading games. This is before graduating to face-to-face
conversation when ready, and is particularly useful for treating young
.children with the condition as an entertaining form of engagement

Graded exposure

This involves gradual exposure to scenarios which cause increasing levels

of anxiety. Increasing a child's exposure to these scenarios can create
.positive reinforcement from positive experiences

Positive reinforcement

Selective mutism usually stems from your child associating pressured

talking with a negative experience. In order to reinforce that all forms of
communication can be acceptable, responding positively to any type of
communication can help your child learn to feel under less pressure to
.speak and not have to feel relief every time such a moment passes

Family therapy

Due to the fact that families and friends can have a significant impact on
whether treatment for selective mutism is successful, family therapy can
help you as parents to learn how to manage the condition and support
.your child with verbal and emotional encouragement when needed

Medication for selective mutism

There is no specific medication for the treatment of selective mutism.

However, medication may be appropriate for the treatment of other
disorders associated with selective mutism, including anxiety or
depression, usually only suitable for older children, adolescents and
adults. Antidepressants can help to relieve anxiety and depression
symptoms enough for therapy to be effective, especially if you or your
.child have not initially responded well to therapeutic techniques

Environmental Modifications

Changes in the style of adult interaction with the child with SM are often
vital in ensuring that any factors that maintain the mutism are removed.
Assessments such as the Environmental Checklists from the SMIRA
website (see link in the resources section) will help to identify which
maintaining factors are present and thus help to plan to remove them.
Often strategies such as removing any pressure to speak; doing things
with rather than for the child will be advocated and it is common that
parenting styles and interactions may need to be altered. Environmental
changes and strategies for school should be collaboratively developed and
.included on the child's Individual Education Plan

Therapy in Your Everyday Activities

Using strategies through play with both adults and children can help to
increase the child's confidence and practice the use of strategies. There
are many different options available e.g. school peer groups involving co-
operative interactions; home play sessions practicing removing pressures
to speak. These differ from play therapy sessions that take a more
psychoanalytic or counselling slant however, these too are reported in the
.literature

A Sensory Processing Treatment

approach is used at The Center for Therapeutic Strategies involves using

team approach with a mental health practitioner, an occupational
therapist, and a speech pathologist. We use multi-sensory methods which
:create calmness through modalities which

Improve sequencing of timing of the individual within his or her -1

environment

Train the auditory processing system to become more meaningfully -2

aware of the auditory patterns of the environmental sound arena

Build a gradual platform for social engagement and eventually verbal -3

communication with incremental steps

Role of occupational therapy

The Occupational Therapist will be able to support with clarifying any
difficulties with daily tasks and/or fine motor skills and will play a large
part in supporting with any difficulties with sensory regulation , used play
therapy initially to create a non-verbal play environment to increase
. social engagement