Causes of selective mutism, diagnosis, treatment options and case report

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Selective mutism (Selective Mutism); It is the inability of the child to speak in other social settings (such as school) where he is expected to speak, although he can talk to people with whom he is in close relationship. In situations where communication is imperative, they may communicate with limited nods, gestures, or short words to mean “yes”. Children who can read and write can communicate by writing small notes. In very severe situations, children may not be able to talk to people they are close to (Compas et al, 2012).
These children may be more exposed to peer pressure because they cannot express themselves. Since they do not speak in class, it may be difficult to evaluate their academic skills such as reading and writing at school. The language skills of children with SM symptoms for a long time may regress due to not using the language. Since the symptoms of selective mutism begin in early childhood, a specialist should be consulted immediately when symptoms are detected.

1. Selective Mutism (SM)

Selective mutism was first defined by the German Doctor Kussmaul in 1877 as “aphasia voluntaria”, that is, “not speaking voluntarily”. In 1934, by Swiss child psychiatrist Moritz Tramer, to describe the situation where children who can speak in a healthy and normal way cannot speak in certain environments; The term “elective mutism” has been used (Leonard and Topol, 1993). The same condition was named “selective mutism” in the DSM-4 (Application Manual for Mental Disorders Diagnostic Criteria) by the American Psychiatric Association (APA) in 1994.

1.1. Defining Selective Mutism

Selective mutism is the inability to speak in certain public situations where the child is expected to speak, such as school, social situations, which typically occurs during childhood. But in other situations, for example, at home or alone with the parent, it is quite normal for the child to talk. Contrary to previous editions, SM is classified as an anxiety disorder (APA,2013) in the DSM-5, and this is justified by a phenomenological and etiological overlap between SM and other anxiety disorders such as generalized anxiety disorder (Capozzi et al,2018).

To establish a diagnosis of SM, the DSM-5 states that at least 1 month of selective absence of speech is required. Many young children are worried when faced with a completely new situation, such as entering school for the first time, and therefore the diagnosis is not made in the first month of school. A certain degree of stagnation, which may manifest as a lack of speech or an inability to speak, may be considered normal from a developmental point of view (APA, 2013).

Although symptoms often begin in early childhood, parents may only notice the problem in their children towards school age, as these children often speak normally at home and have normal intelligence. In the first month of school, children may talk less than normal, but in some environments, SM is a complete non-speech and lasts longer than 1 month (Compas et al, 2012). In children with a diagnosis of selective mutism; shyness, social withdrawal, excessive attachment to parents, oppositional behaviors and aggression can be seen. In addition, according to DSM-5, SM cannot be diagnosed if speech failure is due to the lack of spoken language knowledge required in social situations. Again, the disturbance cannot be explained by a communication disorder, for example, childhood-onset fluency disorder cannot be explained by SM alone. Finally, SM must be interfering with the child’s daily functioning; the absence of speech prevents the child from doing well at school or in social interactions (APA 2013). The disorder negatively affects the daily functioning of children and adolescents (Schwartz et al., 2006) and progresses with communicative and mental problems in adulthood (Muris & Ollendick, 2015).
SM usually begins around 2-5 years and lasts for many years in a significant proportion of patients (Compare et al, 2017). Although symptoms generally decrease with age, many former patients still suffer from psychosocial disorders and higher rates of mental disorders (Remschmidt et al, 2001).

1.2. Selective Mutism and Anxiety

In a study in which 100 children living with SM were analyzed; (Steinhausen and Juzi, 1996), researchers found that a great majority of children, such as 66%, showed accompanying symptoms of anxiety. To begin with, most children reported exhibiting anxiety-related behaviors such as shyness, withdrawal, and avoidance prior to the onset of their SM.

Also, in standardized psychopathology questionnaires such as the Child Behavior Checklist (CBCL) (Achenbach, 1991), anxiety-related items, such as “worries”, “very fearful or anxious”, “fear of certain animals and situations” or “shy or reserved” were frequently supported. . Finally, the speech of these children was characterized by low frequency of words, low volume and less spontaneity, quite similar to children with social phobia.

However, based on the available literature, it is clear that anxiety, and especially social anxiety, is a prominent feature of children with SM. It is associated with social and performance situations in which embarrassment may occur and avoidance, indicating that SM “tends to be associated with a range of anxiety-related situations at a high frequency” and “shares many features that overlap with social phobia, including an intense fear”. ” (Sharp et al, 2007).

1.3. Selective Mutism and Temperament

SM also shares characteristics with the temperamental structure of behavioral inhibition, which tends to show persistent fear and avoidance when confronting unfamiliar people, situations, and objects (Kagan 1994).
Behavioral inhibition appears to manifest in different ways at various stages of children’s development, and interestingly, silence in the presence of unfamiliar adults and a lack of spontaneous conversation with unknown persons were found in the preschool years (Garcia-Coll et al. 1984).

It should be noted that these early features of behavioral inhibition closely match the core symptoms of SM and also correspond developmentally to the age of onset of the disorder. In addition, there is evidence that behavioral inhibition in early childhood is associated with a higher risk of developing anxiety disorders and especially social phobia in later childhood, and of course points to a common etiological pathway between SM and social anxiety (Clauss & Blackford, 2012).

A number of cross-sectional studies on the link between behavioral inhibition and SM have shown that children with SM exhibit traits that appear to be indicative of an inhibited temperament. For example, descriptive studies reported that shyness, which can be seen as a social type of behavioral inhibition, is common in children with SM, and the percentages vary between 68% and 85% (Kumpulainen et al. 1998).

1.4. Selective Mutism and Brain Development

With the classification of SM as an anxiety disorder in the DSM-5, it is likely that speech selectivity is primarily emotionally determined. However, studies have also revealed that factors related to brain development play a role in a significant proportion of children with SM. For example, it has been noted that the prevalence of speech and language problems increased in children with SM. For example, he noted that his sample of 24 selectively mute children spoke, on average, significantly (i.e., more than 5 months) later than the children in the nonclinical control group. Moreover, 11-50% of children with SM were found to have “speech immaturity” and other speech difficulties. (Kristensen, 2000)

In addition, children with SM also meet the criteria for communication disorder. For example, in Kristensen’s study examining comorbid disorders of SM, it was found that half of the children with this condition were diagnosed with mixed receptive-expressive language disorder in 17% and expressive language disorder in 17%. Attempts have also been made to measure the language skills of children with SM, and this research has generally confirmed the idea that the condition is associated with language deficiencies (Manassis et al., 2007).

In addition to speech and language problems, it has been suggested that children with SM may show deficiencies in social skills. According to both parents and teachers, children with SM were found to exhibit significantly lower levels of social assertion (for example, inviting others or starting a conversation) and verbal social skills compared to mixed anxiety and non-clinical control children (Carbone et al. 2010). . In addition, he argued that children with SM not only have speech, language, and social skills problems, but also show clear signs of a more general delay in their development (Kristensen, 2000).

It has been supported by studies that factors related to brain development such as language and speech problems, a general developmental delay and neurological abnormalities play a role in the origin of SM. Avoiding difficulties experienced as a result of neurological developmental problems and avoiding the negative emotions associated with them, especially anxiety, seems to be the most plausible mechanism behind this pathway (White et al, 2009).

1.5 Avoidance as a Sustainer

It has been suggested that the non-speech behavior of children with SM should actually be seen as an emotion regulation strategy. That is, by remaining silent, these children reduce anxiety or negative emotions (Scott and Beidel 2011). In an interesting study conducted by Young et al. in 2012; Thirty-five children aged 5-12 years (10 with SM, 11 with Social Phobia, and 14 without a diagnosis) participated in two social interaction tasks. 1- Responding to statements and questions given by a peer of the same age

2- Reading aloud in front of a small audience consisting of an adult and a peer of the same age.
Measurements included child and observer anxiety ratings, as well as psychophysiological measures (eg, electrodermal activity, heart rate). The SM group exhibited the highest levels of anxiety during interaction tasks, and these were significantly higher than the social phobia group. Unexpectedly, psychophysiological measures showed that children in the SM group experienced less arousal when performing social interaction tasks than other children.
Based on these findings, it was hypothesized that the lack of speech in children with SM might reflect “an effective avoidance strategy to reduce emotional and physiological discomfort” (Young et al, 2012). A similar mechanism is thought to play a role in the wider perpetuation of anxiety disorders; where avoidance leads to the elimination of unpleasant anxiety symptoms, which further strengthens the avoidance behavior (Mowrer, 1960).

2. Causes of Selective Mutism (Etiology)

No definite and clear conclusions have been reached about the etiology of SM. Many different experts have offered different explanations for the causes of SM. Initial research; low self-esteem, unsafe home environment, emotional problems and past traumatic experiences are among the causes of SM (Hayden, 1980).

Researchers working with SM sometimes explained this situation as a learned behavior or an effort to attract attention (Bozigar & Hansen, 1984). In addition, some studies have shown that the relationship between mother and child until the age of two is insufficient to ensure language development. (Hultquist, 1995).

Researchers with a psychoanalytic point of view have explained SM as the product of a physical and emotional trauma. In this context; The child with oral or anal period fixation may not be speaking to punish their parents. SM occurs as a result of unresolved psychic and developmental conflicts (Dow et al., 1995). Again, children who keep secrets about their families regress to the previous developmental stage and may not speak and reflect their anger on their parents (Giddan et al. 1997).

SM can occur as a result of a physical or mental trauma, and this has been defined as “traumatic mutism” (Kolvin and Fundudis, 1981). As in immigrant families, being bilingual, using different languages ​​at home and in other environments such as school, traumatic experiences and other important life events have also been shown among the causes of SM. (Steinhausen et al. 2006).

In general, research shows that various factors play a role in the etiology of SM, including genetics, temperament, environmental influences, brain development-related variables, and avoidance. Many of these factors have, of course, strengthened the treatment of SM as an anxiety disorder. From this point of view, it can be said that SM is not the result of a single variable and that there are complex interactions between many factors that increase the likelihood of this psychiatric condition (Cohan et al, 2006).

3. Selective Mutism Treatment

SM is a disabling psychiatric condition that severely interferes with a child’s academic and social functioning. While the key symptom “not speaking” tends to dissipate over time, it is also clear that SM has detrimental consequences for children in later life (Steinhausen et al., 2006). Therefore, it is crucial that effective interventions are available for the treatment of children with SM. The main purpose of SM treatment is to help children speak when they have not spoken before. Treatment can be provided in two ways: psychosocial interventions and/or pharmacotherapy.
Today, cognitive behavioral therapies (CBT) and psychopharmacological agents are generally used in the treatment of SM. In the past, psychodynamic psychotherapies and family therapies have been used (Kaakeh & Stumpf, 2008). With the acceptance of the classification of SM as an anxiety disorder, anxiolytic drugs are used in psychopharmacological treatment. (Kaakeh & Stumpf, 2008) The most frequently used and most researched drug for SM in children; fluoxetine ( Manassis, 2009).

3.1. The Most Commonly Used Behavioral Therapy Techniques in Practice

Behavioral therapy techniques in SM are the most frequently used intervention methods that are scientifically strong. Behavioral methods such as stimulus extinction, behavior shaping, self-modelling, systematic desensitization, reinforcement, token hoarding, and response induction are among the most commonly used techniques.

• ♦ Graded Approach: In this method, which is stated to have very successful results, verbal behaviors of the child are reinforced by rewarding and there is no reward for non-verbal behaviors (Giddan et al. 1997).

• ♦ Being a Self-Model: Video recordings are made of activities that involve the child himself and include attitudinal and behavioral gains for him. Later, this video is watched with the child (Kehle et al., 1990).

• ♦ Mysterious Motivation: In this method, a gift box with a question mark on it, an envelope, etc. is used in the classroom. is found. Here, it is aimed to increase the expectation and the strength of the reinforcer in the child. Inside the box is something that the child will like. If the child speaks in a voice that everyone can hear in the classroom, he or she deserves the award.(Giddan et al. 1997)

• ♦ Self-Reward: It is the child’s self-reward after positive behavior. It is the child’s doing something he likes as the stages progress in the treatment process (Kehle et al. 1990).

• ♦ Arousing Response: In this technique, the message is given that the child will be with the therapist for a full day and needs to talk. If the child says a word or a few, he is rewarded and let go, otherwise he stays in the therapist’s room all day. At the end of this study, it was observed that the children generally talked. Subsequently, new goals are set for the child to talk to his classmates or teacher (Giddan et al. 1997).

  In general, behavioral therapies are based on the evaluation of the environment and conditions in the child’s environment that cause and maintain silence. However, it is not possible to achieve success with a single behaviorist method. Multiple methods and different behavioral methods should be used together.

  4. Case Study

  In the case report by Tunca and Akdemir; “A seven-year-old male patient attending the 2nd grade of primary school applied to the clinic with complaints such as not being able to talk to his class teacher, friends and people older than him, and not being able to learn to read. From the information obtained from the family, it was learned that the patient spoke only to his family members and close relatives, that he did not communicate with his teacher in any way for 2 months after the school opened in the first grade, and that he contacted the teacher nonverbally with the help of some friends after about three months, and then by speaking in a very low voice.

While answering the patient’s questions asked from time to time in the first interview by nodding, he drew a very lively and colorful picture indicating a developmental level appropriate for his age. He could only write sounds and words he knew, and he mixed up the letters as he typed them. He tried to cooperate in later evaluation interviews, but behaviorally inhibited temperament traits were felt.

The patient, whose physical and neurological examination findings were normal, was evaluated by the pediatric neurology department and no additional pathology was detected. The patient, who was also evaluated by the speech and language center, was thought to have a speech disorder and speech therapy was recommended. As a result, the patient currently has selective mutism, attention deficit hyperactivity disorder (ADHD), specific learning disorder and speech disorder; In addition to these, it was seen that he met the diagnosis of separation anxiety disorder in the past.

It was decided that the patient should receive play therapy, counseling should be given to the family, and 10 mg/day fluoxetine and 10 mg/day long-acting methylphenidate should be started. The target dose of fluoxetine was 20 mg/day and the target dose of long-acting methylphenidate was 30 mg/day. Information about SM, ADHD and specific learning disorder was given by interviewing his teacher, suggestions were made regarding the handling of the patient in the school environment, he was given special education due to specific learning disability and speech therapy was initiated for speech disorder.

Non-directed play therapy was given as 15 sessions once a week. Reducing the attitudes that are likely to cause the child to not speak unintentionally (e.g. avoiding criticism and labeling, not forcing the child to speak, not questioning whether the child is speaking) and increasing the attitudes that positively reinforce the child’s verbal communication (e.g. listening effectively, verbally). communication) was focused.

It was observed that the patient was able to maintain attention for a longer period of time during clinical interviews and play therapy shortly after the initiation of multiaxial therapy. It was learned from his family that he started to do his homework. In the telephone conversation with the teacher in the sixth week of the treatment, it was learned that the patient listened to the lesson better and was able to maintain his attention for a longer period of time.

The patient’s communication with his teacher and friends increased gradually during the treatment process. In the third month of the treatment, he started to communicate verbally with the treatment team and to talk to people older than him. Towards the fourth month of the treatment, she was able to say the sounds that she could not speak, to initiate communication spontaneously in the sixth month, and to speak with a normal speaking voice. He learned to read and his academic success increased. The treatment of the patient, who has been followed for ten months, continues with monthly interviews” (Tunca and Akdemir, 2020).

Evaluation and Recommendations

Children suffering from selective mutism typically display symptoms and behaviors associated with anxiety. They can also fulfill the diagnostic criteria of intimate anxiety disorders. The combined use of behavioral and cognitive-behavioral therapies and drugs is considered to be the most effective way to treat children with SM.

Many researchers show that SM is associated with other anxiety disorders, especially with specific phobias, separation anxiety disorder, and excessive anxiety or generalized anxiety disorder (Edison et al, 2011).
In addition, in some studies, researchers suggest reconceptualizing SM as a specific expressive speech phobia. It can be thought that the silence of children with SM is mainly a result of separation from parents or anxiety elicited by an alarming event, anxiety. Thoughts triggered by certain aspects of situations, such as going to school, are the cause of this anxiety. It was stated that it would be preferable to see SM as a specific type of avoidance behavior that may arise from various reasons (Young et al. 2012).

As a result, SM can be considered as a functional strategy that regulates coping with negative emotions created by anxiety or as a mechanism used to cope with other difficulties. At this point, the acceptance of this issue requires the removal of the SM from the DSM; this can have negative consequences such that children suffering from this condition no longer receive the necessary, specialized clinical attention.

Addressing SM as anxiety will enable clinicians to focus more on the anxiety experienced by many of these children and to provide effective interventions to treat this problem. However, a disadvantage of this situation is that the non-anxiety aspects of the disorder can be neglected and receive less clinical attention. Psychologists and psychiatrists who encounter children with SM should be very careful about the multifaceted nature of this condition (Wright et al, 1995).

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