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 The SELECTIVE MUTISM FOUNDATION’S
Influence over “Selective Mutism”
in the Diagnostic and Statistical Manual of
Mental Disorders (DSM)

  Summary of DSM history, DSM impact on Selective Mutism.  Important issues in diagnosing Selective Mutism and Inappropriate Remedial Treatment, Essential Differences between the DSM III’s and the DSM IV’s.    © 1/2004 by Sue Newman, Co-Founder, Selective Mutism Foundation, Inc.
www.selectivemutismfoundation.org

 SUMMARY of DSM HISTORY

In 1952, the first DSM(I) was published in an effort to provide descriptive diagnostic categories to serve as a useful guide for clinicians in diagnosing mental disorders.

The DSM II, published in 1968, was similar to the DSM I, and neither publication contained Selective Mutism (formerly Elective Mutism).

In 1980, when the DSM III (third edition) was published, it included “Elective Mutism” (now renamed Selective Mutism), and a more defined system for diagnosis.  The DSM III was developed in part, by gathering documented experiments, while attempting to remain neutral to theories, to form a consensus for validation of the diagnostic system.  In time, however, it became apparent that the DSM III system contained discrepancies, and that some of the criteria was lacking in clarity.  The discrepancies motivated research that led to further clarification for criteria and diagnosis.  A “Work Group” was assigned by the American Psychiatric Association (DSM publisher) to revise the DSM III for corrections and improvements.  This resulted in the 1987 publication of the DSM III-R (revised).  In effect, the DSM IV, published in 1994, was substantially improved, due to the analysis and inclusion of relevant, credible progressive research studies, reanalysis of previous findings, and the evaluations of thousands of subjects at more than 70 sites throughout the US.  This huge task was accomplished through the DSM IV Task Force and it’s Work Groups.  The 3 step unified effort resulted in a more comprehensive version of the diagnostic manual. 

The DSM IV-TR (Text Revision) was published in 2000 in an effort to improve diagnostic criteria for mental disorders, justified by additional legitimate findings.  The DSM-IV TR is our current manual, and the diagnostic contents for Selective Mutism, since our input for the DSM IV, display only 2 subtle, but positive changes.  There is certainly a need for improvement to the diagnostic criteria for Selective Mutism, however credible unbiased published studies are necessary to influence further changes. The more recent DSM’s contain approximately 17 classification sections, or headings.  Each heading provides a list of categories and/or disorders with official diagnostic codes.  The official codes are used to distinguish each specific mental disorder or condition.  The official diagnostic codes are also mandatory to be reported by health care professionals on patient’s health insurance forms for reimbursement, under “reason for visit”, or “principal diagnosis”.  In addition, the official coding system is used for collecting diagnostic data to produce statistical information for governmental agencies, private insurance companies and for the World Health Organization. The DSM code for Selective Mutism is 313.23.  It has been coordinated with Mental and Behavioral Disorders section of the International Classification of Diseases (ICD) for a future reporting system for the U.S. Department of Health.  The official code for Selective Mutism in the ICD is F94.0. It is important to note that the DSM intent is to act as the first step for a comprehensive evaluation, followed by additional sources of information.  It provides guidelines for sound clinical judgment, and includes ethnic and cultural considerations to avoid misdiagnosing.

DSM IMPACT ON SELECTIVE MUTISM:

Selective Mutism, (previously Elective Mutism) until the inception of our organization in 1991, was virtually ignored, and regarded as a rare and low public interest disorder.  As such, input for the DSM III and DSM III-R had to be drawn from available literature.  There were no comprehensive research studies prior to the development of the Selective Mutism Foundation, Inc., only a few compromised studies and single case studies, based upon theories.  The available literature presented conflicting theories, with most describing Elective Mutism’s essential feature as a “refusal” to speak along with characteristics of willful, controlling, and manipulative behaviors, caused by maternal over protection, abuse, trauma, or family dysfunction.  Even the name, Elective Mutism, was indicative of a deliberate refusal to speak to EVERYONE and in ALL environments.  There was no distinction between sudden mutism possibly caused by a traumatic event, and shyness or social anxiety.  There was also no distinction between a speech or language communication disorder and social phobia.  All of these characteristics, and more, were summed together within the diagnostic and associated features of Elective Mutism in the DSM III and III-R. The Selective Mutism Foundation’s input, in 1991, was the major source in eliminating theories and replacing them with sound facts, including renaming the disorder to Selective Mutism, for the DSM IV, 1994.

The DSM is the most widely used mental disorders manual in the U.S. and is utilized by a diverse group of mental health professionals.  As such, the characteristics of Selective Mutism published prior to 1994 had a devastating impact on most families seeking professional help for their children.  Especially alarming, was the demoralized manner in which many Selective Mutism students were treated, due to perception of school personnel, influenced by DSM misconceptions that were derived from available literature.  Some parents were reported for, or suspected of child abuse.  Others were told that they had caused the mutism by having too many children, not enough children, working fulltime, not bonding with or breast-feeding the child during infancy.  Yet others were told that their child was keeping family secrets of dysfunction, the child was spoiled, angry, seeking attention, stubborn, and on and on. The domino effect of misdiagnosis that began with documented theories trickled down to many school psychologist and other school personnel who unknowingly misdiagnosed Selective Mutism students.  This resulted in inappropriate classifications and placements into Speech/Language therapy, segregated programs for the Emotionally Disturbed, Resource Room, Specific Learning Disability classes, Occupational Therapy or Physical Therapy, etc.  Some students were reprimanded, ridiculed, or denied extracurricular activities due to their “refusal to speak”; while others were easily ignored as they were not disruptful in class. 

There were, indeed, some professionals who were intuitive and recognized social anxiety, however, for the most part, many parents were blamed for their child’s silence.  Parents were blamed, and felt guilty, for something that they themselves did not understand.  Many parents reported previously having mutism themselves, however they were confused by the theories.  They were not yet equipped with evidence, or specifically, credible published research studies to defend their children or themselves.  The Selective Mutism Foundation’s efforts, through research encouragement and participation, since 1991, have been and continue to be the only major source acknowledged nationally to positively effect Selective Mutism criteria for the DSM.

Unfortunately, there are still healthcare professionals who are either resistant to progressive research, or who do not keep up with published studies or current DSM criteria.  However, due to the foundation’s diligent efforts, there are published systematic scientific studies to support the relation of social anxiety to Selective Mutism. 

In addition, our book, Characteristics of Selective Mutism: Evidence for An Anxiety Related Etiology © 2002 Research Collaboration between S. Coiffman-Yohros, Ph.D and the Selective Mutism Foundation, Inc. is scheduled for further publications.  The collected data and statistical contents of more than 400 families will undoubtedly, positively, affect Selective Mutism in the next DSM.  To eliminate confusion, it is also important to clarify that, through our efforts, the name “Elective Mutism” has been obsolete since 1994, eliminating the deliberate connotation.

IMPORTANT ISSUES IN DIAGNOSING Selective Mutism AND INAPPROPRIATE REMEDIAL TREATMENT:

It is important to clarify 2 crucial issues of confusion that are not visible in the DSM.  The 2 areas of ongoing confusion pertain to why Selective Mutism was not classified as an Anxiety Disorder, or under “Communication Disorders”, within “Disorders Usually First Diagnosed In Infancy, Childhood, or Adolescence”.  The DSM Children’s Anxiety Disorders section was discontinued prior to recognition of Elective Mutism in the DSM, in an effort to prevent misdiagnosis.  As children may not recognize or be able to express their fears or symptoms, assumptions or uncertainty was thereby eliminated.  The DSM does have an Anxiety Disorders section for diagnosing adults, with inferences to those under 18 years of age.  In addition, the listed conditions under “Anxiety Disorders” (e.g. social phobia, specific phobia) obviously cannot imply the essential feature to be a failure to speak in specific situations.  Within the Associated Features and Disorders for Selective Mutism, it is however indicted, that the additional diagnosis of Anxiety Disorder, especially Social Phobia is usually given (DSM-IV TR)

The placement of Selective Mutism under “Communication Disorders” was prior to the inception of our organization, a controversial issue.  Current published studies, some that include research participants from our organization confirm that Selective Mutism is not a language impairment.  Published studies and statistics also reveal that Speech/Language therapy  including within school systems is inappropriate for the Selective Mutism population.  It has been established, for over a decade, that children experiencing Selective Mutism have the ability to comprehend and to speak normally in comfortable settings. 

The DSM IV and DSM IV-TR, as you can see, under Selective Mutism's Diagnostic Features and Differential Diagnosis, clearly indicate that Selective Mutism should be distinguished from speech impairments, and that Selective Mutism should be diagnosed if the child’s failure to speak is not considered a language impairment.  It is further clarified that communication disorders are not restricted to certain settings in contrast to Selective Mutism.

The DSM IV and DSM IV-TR reflect that language impairments, an an Associated Disorder, may occasionally coexist with Selective Mutism, although not an essential feature and confirms, in Diagnostic Criterion E that Selective Mutism is not better accounted for by a Communication Disorder. As a result, Selective Mutism remains classified in “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”, under “Other Disorders”, rather than under "Communication Disorders".

ESSENTIAL DIFFERENCES BETWEEN THE DSM III’s and the DSM IV’s

Prior to viewing the information about Selective Mutism, reproduced from all 4 DSM’s, please see the graph below.  The graph highlight’s only the significant changes generated by the Selective Mutism Foundation’s exposure of Selective Mutism through education, the media, and research motivation. 

The DSM-IV TR supercedes all previous DSM’s, and was published to correct facts, and to include new information.  The DSM V will be published, at the very earliest, in 2006.  DSM revisions are an ongoing process, to insure that new information about mental disorders are recorded and/or updated. 

It is evident that more research is imperative to a cure, the development of expertise, and to develop meaningful treatment interventions.  We urge qualified researchers and participants to continue to contact us.  Among the hundreds of our accessible participants are numerous sets of twins to assist in determining a genetic predisposition, or basis for Selective Mutism.

DSM III 1980

Diagnostic and Statistical Manual of Mental Disorders

313.23 Elective Mutism

The essential feature is continuous refusal to speak in almost all social situations, including at school, despite ability to comprehend spoken language and to speak. These children may communicate via gestures, by nodding or shaking the head, or, in some cases, by monosyllabic or short, monotone utterances.

Children with this disorder generally have normal language skills, though some have delayed language development and abnormalities of articulation. The refusal to speak is not, however, due to a language insufficiency or another mental disorder.

Associated features. Excessive shyness, social isolation and withdrawal, clinging, school refusal, Functional Encopresis, Functional Enuresis, compulsive traits, negativism, tempter tantrums, or other controlling, or oppositional behavior, particularly in the home, may be observed.

Age at onset. Although onset is usually before age five, the disturbances may come to clinical attention only with entry into school.

Course. In most cases the disturbance lasts only a few weeks or months, although in a few it continues for several years.

Impairment. There may be severe impairment in social and school functioning.         

Complications.  School failure and teasing or scapegoating by peers are common complications. 

Predisposing factors. Maternal overprotection, speech disorders. Mental Retardation, immigration, hospitalization or trauma before age three, and entering school may be predisposing factors. 

Prevalence.  The disorder is apparently rare: it is found in less than 1% of child-guidance, clinical, and school-social-casework referrals.

Sex ratio. The disorder is slightly more common in girls than in boys.

Familial pattern. No information.

Differential diagnosis. In Severe or Profound Mental Retardation.  Pervasive Developmental Disorder, or Developmental Language Disorder, there may be general inability to speak.  In Major Depression, Avoidant Disorder of Childhood or Adolescence, Overanxious Disorder, Oppositional Disorder, and Social Phobia, there may be a general refusal to speak.  However, in none of these disorders is the lack of speaking the predominant disturbance. 

Children in families who have emigrated to a country of a different language may refuse to speak the new language.  When comprehension of the new language is adequate but the refusal to speak persists, Elective Mutism should be diagnosed. 

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders.
Copyright 1980, American Psychiatric Association.

DSM III-R 1987

Diagnostic Statistical Manual of Mental Disorders

OTHER DISORDERS OF INFANCY, CHILDHOOD, OR ADOLESCENCE

313.23 Elective Mutism

The essential feature of this disorder is persistent refusal to talk in one or more major social situations, including school, despite ability to comprehend spoken language and to speak.  The refusal to talk is not a symptom of Social Phobia, Major Depression, or a psychotic disorder, such as Schizophrenia.

The child with Elective Mutism may communicate via gestures, by nodding or shaking the head, or, in some cases, by monosyllabic or short, monotone utterances.  Most commonly the child will not speak at school, but will talk normally within the home. Less commonly the child refuses to speak in nearly all social situations. 

Children with this disorder generally have normal language skills, though some have delayed language development and abnormalities of articulation.

 Associated features. Speech disorders may be present, such as Developmental Articulation Disorder, Developmental Expressive or Receptive Language Disorder, or a physical disorder that causes abnormalities of articulation.  Excessive shyness, social isolation and withdrawal, clinging, school refusal, compulsive traits, negativism, temper tantrums, or other controlling or oppositional behavior, particularly at home, may be observed.

Age at onset. Although onset is usually before age five, the disturbance may come to clinical attention only with entry into school.

Course. In most cases the disturbance lasts only a few weeks or months; in a few, it continues for several years.

Impairment. There may be severe impairment in social and school functioning.

Complications. School failure and teasing or scapegoating by peers are common complications.

Predisposing factors.  Maternal overprotection. Language and Speech Disorders, Mental Retardation, immigration, and hospitalization or trauma before age three may predispose to Elective Mutism.

Prevalence.  The disorder is apparently rare: it is found in fewer than 1% of child guidance, clinical, and school-social-casework referrals.

Sex ratio.  The disorder is slightly more common in females than in males. 

Familial pattern. No information.

Differential diagnosis.  In Severe or Profound Mental Retardation, Pervasive Developmental Disorder, and Developmental Expressive Language Disorder, there may be inability to speak, but not a refusal to do so.

Children in families who have emigrated to a country of a different language may refuse to speak the new language. When comprehension of the new language is adequate but the refusal to speak persists, Elective Mutism should be diagnosed. 

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders
Copyright 1987, American Psychiatric Association.

DSM IV 1994

Diagnostic and Statistical Manual of Mental Disorders

 USUALLY FIRST DIAGNOSED IN INFANCY, CHILDHOOD, OR ADOLESCENCE

 313.23 Selective Mutism
(formerly Elective Mutism)

Diagnostic Features
The essential feature of Selective Mutism is the persistent failure to speak in specific social situations (e.g., school, with playmates) where speaking is expected, despite speaking in other situations (Criterion A).  The disturbance interferes with education or occupational achievement or with social communication (Criterion B). The disturbance must last for at least 1 month and is not limited to the first month of school (during which many children may be shy and reluctant to speak) (Criterion C).  Selective Mutism should not be diagnosed if the individual’s failure to speak is due solely to a lack of knowledge of, or comfort with, the spoken language required in the social situation (Criterion D).  It is also not diagnosed if the disturbance is better accounted for by embarrassment related to having a Communication Disorder (e.g., Stuttering) or if it occurs exclusively during a Pervasive Development Disorder, Schizophrenia, or other Psychotic Disorder (Criterion E). Instead of communicating by standard verbalization, children with this disorder may communicate by gestures, nodding or shaking the head, or pulling or pushing, or, in some cases, by monosyllabic, short, or monotone utterances, or in an altered voice. 

Associated Features and Disorders
Associated features of Selective Mutism may include excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling or oppositional behavior, particularly at home.  There may be severe impairment in social and school functioning.  Teasing or scapegoating by peers is common.  Although children with this disorder generally have normal language skills, there may occasionally be an associated Communication Disorder (e.g., Phonological Disorder, Expressive Language Disorder, or Mixed Receptive-Expressive Language Disorder) or a general medical condition that causes abnormalities of articulation. Anxiety Disorders (especially Social Phobia), Mental Retardation, hospitalization, or extreme psychosocial stressors may be associated with the disorder. 

Specific Culture and Gender Features
Immigrant children who are unfamiliar with or uncomfortable in the official language of their new host country may refuse to speak to strangers in their new  environment.  This behavior should not be diagnosed as Selective Mutism. Selective Mutism is slightly more common in females than in males.

Prevalence
Selective Mutism is apparently rare and is found in fewer than 1% of individuals seen in mental health settings. 

Course
Onset of Selective Mutism is usually before age 5 years, but the disturbance may not come to clinical attention until entry into school.  Although the disturbance usually lasts for only a few months, it may sometimes persist longer and may even continue for several years. 

Differential Diagnosis
Selective Mutism should be distinguished from speech disturbances that are better accounted for by a Communication Disorder, such as Phonological Disorder, Expressive Language Disorder, Mixed Receptive-Expressive Language Disorder, or Stuttering.  Unlike Selective Mutism, the speech disturbance in these conditions is not restricted to a specific social situation.  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.  Individuals with a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder, or severe Mental Retardation may have problems in social communications and be unable to speak appropriately in social situations.  In contrast, Selective Mutism should only be diagnosed in a child who has an established capacity to speak in some social situations (e.g., typically at home).  The social anxiety and social avoidance in Social Phobia may be associated with Selective Mutism.  In such cases, both diagnoses may be given. 

776 Appendix D  Annotated Listing of Changes in DSM-IV

Selective Mutism.   Several provisions have been added to reduce false-positive identification: a duration criterion of 1 month, the exclusion of children who are quiet only during the first month of school, a criterion requiring clinically significant impairment, and a criterion requiring that the lack of speech is not better accounted for by a Communication Disorder or by lack of knowledge of the spoken language required in a social situation.  In addition, the name has been changed from DSM-III-R Elective Mutism, which was less descriptive and implied motivation.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders.
Copyright 1994, American Psychiatric Association.

DSM IV-TR 2000
Diagnostic and Statistical Manual of Mental Disorders

USUALLY FIRST DIAGNOSED IN INFANCY, CHILDHOOD, OR ADOLESCENCE

 313.23 Selective Mutism
(formerly Elective Mutism)

Diagnostic Features
The essential feature of Selective Mutism is the persistent failure to speak in specific social situations (e.g., school, with playmates) where speaking is expected, despite speaking in other situations (Criterion A).  The disturbance interferes with educational or occupational achievement or with social communication (Criterion B).  The disturbance must last for at least 1 month and is not limited to the first month of school (during which many children may be shy and reluctant to speak) (Criterion C).  Selective Mutism should not be diagnosed if the individual’s failure to speak is due solely to a lack of knowledge of, or comfort with, the spoken language required in the social situation (Criterion D).  It is also not diagnosed if the disturbance is better accounted for by embarrassment related to having a Communication Disorder (e.g., Stuttering) or if it occurs exclusively during a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder (Criterion E).  Instead of communicating by standard verbalization, children with this disorder may communicate by gestures, nodding or shaking the head, or pulling or pushing, or, in some cases, by monosyllabic, short, or monotone utterances, or in an altered voice.

Associated Features and Disorders
Associated features of Selective Mutism may include excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling or oppositional behavior, particularly at home. There may be severe impairment in social and school functioning.  Teasing or scapegoating by peers is common.  Although children with this disorder generally have normal language skills, there may occasionally be an associated Communication Disorder (e.g., Phonological Disorder, Expressive Language Disorder, or Mixed Receptive-Expressive Language Disorder) or a general medical condition that causes abnormalities of articulation.  Mental Retardation, hospitalization, or extreme psychosocial stressors may be associated with the disorder.  In addition, in clinical settings, children with Selective Mutism are almost always given an additional diagnosis of an Anxiety Disorder (especially Social Phobia).

Specific Culture and Gender Features
Immigrant children who are unfamiliar with or uncomfortable in the official language of their new host country may refuse to speak to strangers in their new environment.  This behavior should not be diagnosed as Selective Mutism.  Selective Mutism is slightly more common in females than in males. 

Prevalence
Selective Mutism is apparently rare and is found in fewer than 1% of individuals seen in mental health settings.

Course
Onset of Selective Mutism is usually before age 5 years, but the disturbance may not come to clinical attention until entry into school.  The degree of persistence of the disorder is variable.  It may persist for only a few months or may continue for several years.  In some cases, particularly in those with severe Social Phobia, anxiety symptoms may become chronic.

Differential Diagnosis
Selective Mutism should be distinguished from speech disturbances that are better accounted for by a Communication Disorder, such as Phonological Disorder, Expressive Language Disorder, Mixed Receptive-Expressive Language Disorder, or Stuttering. Unlike Selective Mutism, the speech disturbance in these conditions is not restricted to a specific social situation.  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.  Individuals with a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder, or severe Mental Retardation may have problems in social communication and be unable to speak appropriately in social situations.  In contrast, Selective Mutism should only be diagnosed in a child who has an established capacity to speak in some social situations (e.g., typically at home).  The social anxiety and social avoidance in Social Phobia may be associated with Selective Mutism.  In such cases, both diagnoses may be given.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders.
Copyright 2000, American Psychiatric Association.