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E.
Steven Dummit,
III
,
MD
Advisory Board Member, Selective Mutism Foundation, Inc.
The
Therapy
Center
333 Adams Street
Bedford Hills
,
NY
10507
914-241-0758
In
the course of my experience evaluating and treating children with Selective
Mutism, both in
research and clinical practice, the following concepts have evolved in my
thinking as the answers to questions that I have often been asked, both by the
families of my patients and by professionals. In talking to parents and
teachers, as well as in assessments of children, I have found that
misconceptions are widespread about what Selective Mutism is and how children
develop this problem. These misconceptions are prevalent even in professional
educators, physicians and mental health providers. I believe they reflect both
confusion in the professional community and a general misunderstanding of the
problem in our culture. Because these misconceptions are so widespread, I
refer to them as “common myths”.
“The child is just being stubborn and controlling
by not talking.” This belief is so
pervasive that the disorder was called “Elective mutism” for
over 50 years, as if these children made a conscious decision, or
“elected” at some point, to quit talking. It is assumed that
such “controlling” behavior is a result of conflicts in the
parent-child relationship, with the child attempting to win the
struggle by resorting to mutism. In this view of the problem,
parents, usually the mother, are assumed to lack parenting skills,
or character strength or such, and are thus blamed for the
child’s disorder. Fortunately, modern child psychiatry is moving
away from such outmoded theories. Most of the reports of Selective
Mutism published in the past decade recognize the disorder as stemming
from severe social anxiety and excessive inhibition, not from bad
parenting. The developmental history of children with Selective
Mutism is
usually that they always had a problem with the shyness and fear
of talking to strangers, even before they entered school, with
parents describing an insidious onset of the mutism, rather than a
sudden change in behavior where a child decides to act in a
certain way. Behavior that was described in the past as
“controlling” may now be seen as trying to avoid very
anxiety-provoking and distressing situations, driven by fear
rather than by anger.
“Children
who are mute must have been traumatized.”
This is what I call the
Hollywood
version of mutism. It makes for good drama, such as in the rock
opera Tommy and the
movie The Piano, but it
does not correspond to the usual reality of the children I have
seen. While cases of mutism have occurred as a result of a child
being abused or emotionally or physically traumatized, it seems to
be very rare. I have not yet seen such a case, where a child spoke
normally until a traumatic incident and then stopped speaking.
Such cases are documented in the medical literature case reports,
but in the two systematic studies, including 50 children evaluated
by our group at
Columbia
and 30 evaluated by Drs. Black and Uhde at NIMH, no children were
found to have such a history. A report in 1980 by Hayden described
“traumatic mutism” as a subgroup of cases reported in a chart
review study, but in the paper it is stated that where police or
social service reports could be found to document child abuse, the
reports always indicated that a child was abused because they were
not speaking, not the other way around. Why the author considered
this “traumatic mutism” is a mystery. Like so many other
psychiatric disorders, it seems that being excessively shy and
mute makes a child vulnerable to being taken advantage of or
abused. This is a general problem in the mental health field and
in our society, confusing cause and effect between bad experiences
and mental disorders. Many parents have reported to me that they
were suspected of child abuse, some even have been investigated by
child welfare agencies, because their child did not talk in
school. It is assumed that such children “must be hiding some
deep, dark secret” about the family, or an abusive situation, as
the reason for mutism.
“Don’t worry, it’s just shyness that
they will outgrow.” Many
parents have told me that they hear this often from doctors and
educators. While there are undoubtedly many normally shy children
who may talk little or none when they first enter a new social
situation, it is not normal to remain silent in a classroom
indefinitely. We do not have good estimates for the prevalence of
Selective Mutism in this country, as the few epidemiological studies that have
been done on childhood mental disorders in community-based
populations have not included Selective Mutism as a disorder to be studied. A
school survey in Britain 30 years ago found a rate of about 7 per
1000 children entering an urban school system, at age 5, were not
speaking in the classroom. When surveyed again after a year in
school, that number had dropped by a factor of 10, to slightly
less than 1 per 1000. The study was confounded by including high
rates of immigrant children who may not have learned English yet
at the time of the first survey, and thus might not have met
modern diagnostic criteria for Selective Mutism. However, the second figure, of
about 1 per 1000, is likely to be a truer estimate of the
prevalence of Selective Mutism and matches the finding of a similar survey in
Canada
done soon after. It would appear that some children do “outgrow
it” soon after entering school. However, the consensus now
amongst professionals who have seen many children with this
disorder is that, if it lasts beyond the first few weeks of
entering school, it tends to be persistent. I have also come to
believe, based on review of the professional literature and
personal experience with patients and their parents’
descriptions of previous treatments, that children with Selective
Mutism do not
improve quickly with conventional psychodynamic psychotherapy
aimed at uncovering and working through emotional conflicts.
Current
thinking is that social anxiety disorders are more of a
biologically-based abnormality than a neurotic problem based on an
emotional conflict. Further, our studies and my clinical
experience indicate that older children, who have suffered longer
with Selective Mutism, are more resistant to all forms of treatment, taking a
much longer time and more intensive combination of behavioral and
pharmacologic treatment to get improvement. Therefore, I recommend
starting treatment as soon as one sees impairment in school that
lasts more than the first few weeks. Begin treatment when the
child is young and the disorder is easier to treat. Do not wait to
see if a child will outgrow it when it has persisted beyond the
first few weeks of school.
“If
the child does not speak, they must have a language or speech
delay.” Many
parents report that schools and professionals recommend speech
therapy for mute children. While about 10% of the children seen in
our research program did appear to have a language or learning
delay, or speech articulation problem, needing special educational
or speech treatment, most had normal or above average speech and
verbal skills when carefully evaluated. However, it is rather
difficult to evaluate a child’s verbal skills when they do not
speak to teachers, professionals and other unfamiliar adults.
Social anxiety causes people to be reluctant to guess or respond
if even a little bit unsure of the answer, from fear of
embarrassment at making a mistake. Even when children respond
non-vocally to tests of receptive language, which measure the
ability to understand language, rather than the ability to express
oneself, the test result can be an underestimate of true ability
because of fear of guessing wrongly. Hence, socially-anxious
children tend to do less well with such assessments performed by
strangers than they would when speaking with family, resulting in
test scores which could be an underestimate of a child’s true verbal
skills. I have seen this effect in children I examined before and
after pharmacologic treatment of the social anxiety, their
performance on verbal measures often improved.
However,
there are a small minority of children who have both a language or
speech problem and social anxiety, and all children deserve very
careful assessment of verbal and academic skills before
educational or treatment recommendations are made. Unfortunately,
educators are often frustrated and bewildered by children who do
not speak to them, and special educational placement or speech
therapy are their main forms of help to offer, so they often
recommend such even when it is not clear that it can help. I
believe that smaller classrooms with specially trained teachers
can help some children with Selective Mutism to be less anxious and more likely
to begin speaking. But when such classrooms are composed
predominantly of aggressive and disruptive children, as is often
the case, it is unlikely to be an environment in which a child
will conquer their anxiety and shyness and probably should not be
recommended in the absence of clear evidence of learning delay.
What
Can Be Done to Help Children with Selective Mutism
Seeking
help from a clinician who has experience treating children with
this uncommon disorder is important, since most therapists and
psychiatrists have little or no experience with it and many are
not aware of recent research which has improved our understanding
of the problem.
I
have seen a large number of children who suffer from Selective
Mutism, both during my work as a research fellow, and since, in
practice and clinical teaching settings. Recent research,
including the program at
Columbia
University
in which I managed the systematic evaluation and treatment of more
than 50 such children, has shed important new light on the
disorder (Dummit et al, May 1997, J Am Acad Child Adol
Psychiatry). Essentially all selectively mute children our team
studied clearly suffer from an excessive and impairing degree of
social anxiety, far beyond normal shyness, which affects not only
their ability to converse in public, but also interferes with
academic and social development. We call this Social Phobia, and
studies of socially phobic adults suggest that some medications
can be very helpful to reduce social anxiety and excessive social
inhibition, leading to change of avoidant behavior. A core feature
of Social Phobia is an irrational fear of embarrassment or
humiliation in the presence of unfamiliar people. Our current view
of Selective Mutism is that it usually represents a form of
avoidant behavior that is a consequence of social anxiety. In
these children, an overwhelming irrational fear of speaking to
strangers has become generalized to most non-family settings
during early childhood.
Prozac
(fluoxetine), a selective serotonin reuptake inhibitor, is useful
for socially anxious adults. Based on this new understanding of
mutism as a consequence of social anxiety, Prozac has been used in
three studies with selectively mute children: an uncontrolled
trial (Dummit et al, May 1996, J Am Acad Child Adol Psych), a
small placebo-controlled trial (Black & Uhde, 1994, J Am Acad
Child Adol Psych), and a crossover-discontinuation
placebo-controlled study (Dummit et al, reported as New Research,
AACAP Annual Meeting, 10/96). All three studies support efficacy
and safety in this use. This is the only treatment with
scientifically proven efficacy for this disorder, although a small
literature of uncontrolled case reports (lacking the experimental
methodology needed to prove effectiveness scientifically) of
various behavioral treatments suggests they may also benefit some
children. Unfortunately, the methodology of case reports precludes
comparison to medication trials, as there is no systematic means
of ascertaining which
children,
and how many, respond to which treatment. It is exceedingly rare
that someone publishes a “negative” case report of treatment,
where the treatment failed. Case reports are only the treatment
successes; whereas, systematic medication trials report how many
patients were treatment successes and how many were failures.
Systematic medication trials with placebo controls can also
provide further scientific analysis of what characteristics
predict good or poor response to medications and the probability
of response. No case report series can provide that level of
scientific analysis.
There
is no evidence to date that play psychotherapy, family therapy or
other forms of insight-oriented therapy are effective for
improving either the social anxiety or the mutism. Indeed, in my
clinical experience, many families report having tried these forms
of therapy, sometimes for years, without success. Granted, I would
likely never see the children who did get cured with such a
treatment, but it is my impression clinically, as well as from
reviewing the world literature, that success rates are extremely
low with these forms of treatment for Selective Mutism.
The
typical picture of the selectively mute children I have seen (well
over 100 cases now), includes clear features of Social Phobia and
social avoidance, often with other anxiety problems and diagnoses
also present, and otherwise normal language development. True
language delays, speech pathology or learning problems are only
present in about 10% of cases.
However, because their language and academic skills are
hard to evaluate due to the mutism and schools have no other help
to offer, such children are frequently placed in speech and
special educational services, aimed at improving language or
speech skills, without needing or benefiting from them. Selective
Mutism has erroneously in the past often been classified as a
speech or communication disorder, but it is clear now that this is
inaccurate. While language disorders can exacerbate the anxiety
problem in some children, they should be viewed as a separate
clinical problem when present.
My
recommendation has generally been against speech or language
remediation in the absence of clearly documented (i.e. by formal
testing) language or speech abnormalities. However, there are
times in which a special educational classroom with a lower
student to teacher ratio might be of help to a child with anxiety,
and classification for special education based on emotional
disorder might be of benefit. However, if such classification
would place a shy and anxious child in a classroom composed
primarily of disruptive and aggressive children, I doubt it would
be of benefit to the child and would not recommend it. Of most
benefit in the school, in my experience, would be a teacher who
is sympathetic to the anxiety-based nature of the disorder and can
apply behavioral principles in the classroom in a way which
promotes increased speech and social interaction, but does not
exacerbate the child’s social anxiety by exposing them to
greater public scrutiny in a way the child would perceive as
embarrassing.
Regarding
clinical treatment, I have had much success using Prozac (fluoxetine)
with these children. The other Selective Serotonin Reuptake
Inhibitors (Zoloft, Paxil, Luvox, Celexa, Lexapro) also all appear
to benefit people with social anxiety, but Prozac is the one with
the most research studies in children to demonstrate effectiveness
and safety. It generally takes 3 to 6 months to see the full
benefit of this treatment on both social anxiety and speech
behavior in children who have persistent mutism. Children aged 10
and older, who have typically been mute for many years, may take
even longer to respond, and often need additional behavioral
treatment to overcome the mutism. My success rate with adequate
medication treatment in young children is around 80-90%, but the
rate drops considerably in older children and adolescents.
Therefore, I recommend early intervention, in kindergarten or
first grade if the problem has been persistently present for at
least a year. I believe it is not a good plan to wait to see if a
child will “outgrow it” before trying medication, if other
approaches (e.g., behavioral treatment) have failed to alleviate
the mutism in the first year or two of school. I have yet to hear
of a case with this typical presentation (preschool onset and
persistence past the first few months of school) where the
disorder remitted spontaneously, i.e. the child “outgrew it”
without treatment.
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