Write on clinical features of Elective mutism and its causes.

Elective mutism is characterized by a consistent failure to speak in social situations in which

there is an expectation to speak (e.g., school) even though the individual speaks in other
situations. The failure to speak has significant consequences on achievement in academic or
occupational settings or otherwise interferes with normal social communication. Characterized
by a marked, emotionally determined selectivity in speaking, such that the child demonstrates a
language competence in some situations but fails to speak in other (definable) situations. The
disorder is usually associated with marked personality features involving social anxiety,
withdrawal, sensitivity, or resistance.

Selective mutism, believed to be related to social anxiety disorder, although an independent

disorder, is characterized in a child by a persistent lack of speaking in one or more specific social
situations, most typically, the school setting. A child with selective mutism may remain
completely silent or near silent, in some cases only whispering in a school setting. Although
selective mutism often begins before age 5 years, it may not be apparent until the child is
expected to speak or read aloud in school. The current conceptualization of selective mutism
highlights a convergence of underlying social anxiety, along with an increased likelihood of
speech and language problems leading to the failure to speak in certain situations. Typically,
children with the disorder are silent during stressful situations, whereas some may verbalize
almost inaudibly single-syllable words. children with selective mutism speak fluently at home
and in many familiar settings. Selective mutism is believed to be related to social anxiety
disorder because of its expression primarily in selective social situations.

DIAGNOSIS AND CLINICAL FEATURES

The diagnosis of selective mutism is not difficult to make after it is clear that a child has
adequate language skills in some environments but not in others. The mutism may have
developed gradually or suddenly after a disturbing experience. The age of onset can range from 4
to 8 years. Mute periods are most commonly manifested in school or outside the home; in rare
cases, a child is mute at home but not in school. Children who exhibit selective mutism may also
have symptoms of separation anxiety disorder, school refusal, and delayed language acquisition.
Because social anxiety is almost always present in children with selective mutism, behavioral
disturbances, such as temper tantrums and oppositional behaviors, may also occur in the home.
Compared to children with other anxiety disorders, except social anxiety disorder, children with
selective mutism tend to have less social competence and more social anxiety.

Associated Features Supporting Diagnosis

Associated features of selective mutism may include excessive shyness, fear of social em-
barrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper
tantrums, or mild oppositional behavior. In clinical settings, children with selective mutism are
almost always given an addi- tional diagnosis of another anxiety disorder—most commonly,
social anxiety disorder (so- cial phobia).

ETIOLOGY
Genetic Contribution
Children with selective mutism are at greater risk for delayed onset of speech or speech
abnormalities that may be contributory. One survey showed that children showed high levels of
social anxiety without notable psychopathology in other areas, according to parent and teacher
ratings. Thus, selective mutism may not represent a distinct disorder but may be better
conceptualized as a subtype of social phobia. Maternal anxiety, depression, and heightened
dependence needs are often noted in families of children with selective mutism, similar to
families with children who exhibit other anxiety disorders.

Parental Interactions
Maternal overprotection and anxiety disorders in parents may exacerbate interactions that
unwittingly reinforce selective mutism behaviors. Children with selective mutism usually speak
freely at home and only exhibit symptoms when under social pressure either in school or other
social situations. Some children seem predisposed to selective mutism after early emotional or
physical trauma; thus, some clinicians refer to the phenomenon as traumatic mutism rather than
selective mutism.

Speech and Language Factors

Selective mutism is conceptualized as an anxiety-based refusal to speak; however, a
higher-than-expected proportion of children with the disorder have a history of speech delay. An
interesting ending suggests that children with selective mutism are at higher risk for a
disturbance in auditory processing, which may interfere with the efficient processing of incoming
sounds.

EPIDEMIOLOGY
The prevalence of selective mutism varies with age, with younger children at increased risk for
the disorder. According to the DSM-5, the point prevalence of selective mutism using clinic or
school samples has been found to range between 0.03 percent and 1 percent, depending on
whether a clinical or community sample is studied. Young children are more vulnerable to the
disorder than older ones. Selective mutism appears to be more common in girls than in boys.
Clinical reports suggest that many young children spontaneously “outgrow” this disorder as they
get older; the longitudinal course of the disorder remains to be studied. The disorder is more
likely to manifest in young children than in adolescents and adults.

Development and Course

The onset of selective mutism is usually before the age of 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.

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 the 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.

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 a 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.

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.

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

COURSE AND PROGNOSIS

Children with selective mutism are often excessively shy during preschool years, but the onset of
the full disorder is usually not evident until age 5 or 6 years. Many very young children with
early symptoms of selective mutism in a transitional period when entering preschool have a
spontaneous improvement over a number of months and never fulfill criteria for the disorder. A
common pattern for a child with selective mutism is to speak almost exclusively at home with
the nuclear family but not elsewhere, especially not at school. Consequently, a child with
selective mutism may have academic difficulties, or even failure due to a lack of participation.

Many children with early onset selective mutism remit with or without treatment. Recent data
suggest that fluoxetine (Prozac) may influence the course of selective mutism, and treatment
enhances recovery. Children in whom the disorder persists often have difficulty forming social
relationships. Teasing and scapegoating by peers may cause them to refuse to go to school. Some
children with any form of severe social anxiety are characterized by rigidity, compulsive traits,
negativism, temper tantrums, and oppositional and aggressive behavior at home.

Other children with the disorder tolerate the feared situation by communicating with gestures,
such as nodding, shaking the head, and saying “Uh-huh” or “No.” In one follow-up study, about
one half of children with selective mutism improved within 5 to 10 years. Children who do not
improve by age 10 years appear to have a long-term course and a worse prognosis. As many as
one third of children with selective mutism, with or without treatment, may develop other
psychiatric disorders, particularly other anxiety disorders and depression
.
TREATMENT
A multimodal approach using psychoeducation for the family, CBT, and SSRIs as needed is
recommended. Preschool children may also benefit from a therapeutic nursery. For school-age
children, individual CBT is recommended as a ϧrst-line treatment. Family education and
cooperation are beneficial. Published data on the successful treatment of children with selective
mutism is scant, yet solid evidence indicates that children with social anxiety disorder respond to
various SSRIs and, currently, CBT treatments are under investigation in a multisite, randomized
placebo-controlled trial of children with anxiety disorders.
A large NIMH-funded study of anxiety disorders in children and adolescents called Research
Units in Pediatric Psychopharmacology (RUPP), has shown the distinct superiority of
fluvoxamine over placebo in the treatment of a variety of childhood anxiety disorders. Children
with selective mutism may benefit similarly to those with social phobia given the current belief
that it is a subgroup of social phobia. SSRI medications that have been shown in randomized,
placebo-controlled trials to have beneϧt in the treatment of children with social phobia include
ϩuoxetine (20 mg to 60 mg per day), fluvoxamine (Luvox; 50 mg to 300 mg per day), sertraline
(Zoloft; 25 mg to 200 mg per day), and paroxetine (Paxil; 10 mg to 50 mg per day).

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