E. Steven Dummit, III , MD
Former Advisory Board Member, Selective Mutism Foundation, Inc.
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, 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 about 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 a 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 child was 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 always stated in police or social service reports found to document child abuse 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 findings 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 their 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 for their social anxiety, their performance on verbal measures often improved.
However, there are a 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 can 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 during my work as a research fellow, in practice, and in 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 their 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 of them respond to which treatment. It is exceedingly rare that someone publishes a “negative” case report of this 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 been classified as a speech or communication disorder often in the past, 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 I would not recommend it. What would benefit the school, from my experience, would be a teacher who is sympathetic to the anxiety-based nature of the disorder and who can apply behavioral principles in the classroom in a way that 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 their 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 and 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.