Psychological mutism

There are two forms of psychological mutism—traumatic and selective/3 32) Both are dramatic and rare.

Traumatic mutism has an acute onset following a psychological shock or injury. Some consider it to be a hysterical phenomenon as it is not associated with any disorder of the structures subserving speech functioning (lips, tongue, palate, or vocal cords). Furthermore, the patient is able to cough normally. The literature suggests that it is common, but a wide clinical survey has attested to its considerable rarity. (32) Selective mutism is a fascinating disorder, where talking is confined to familiar situations, usually the home, and to a small group of intimates. The earliest manifestations are in the preschool years, with the parents being unaware of significant abnormality because there has been a period of relative competence in spoken language. Commonly, recognizable shyness is present from the early years of life and only in a small percentage are there indications that it emerges for the first time at a later stage in development. (31.) It needs to be distinguished from inordinate shyness, which occurs relatively frequently in school reception classes, by its severity and persistence. (33)

Assessment

Enlisting the co-operation of the child for the purpose of psychological and psychiatric assessment usually constitutes a challenge, the bases of which are the complex emotional and attitudinal expressions accompanying the refusal to talk. Co-operation is best facilitated by adopting a style of communication that avoids expectation of the child to talk. In contrast, pressure is likely to intensify the child's resistance. Unobtrusive observations are invaluable sources of information about behavioural interactions and communication within the family, and can be achieved using one-way screens or family videotaped vignettes. For younger children, the provision of drawing and play materials as a medium for preliminary interaction is often helpful. Subsequently, standardized non-verbal measures are the main source of assessment, particularly among the older children.

Epidemiology

A rate of 0.8 per 1000 'core' selective-mute children was reported(1) in a total city cohort of 3300 7-year-olds, which is as common as broadly defined autism. In contrast, a rate of 7.2 per 1000 of children who do not speak at school soon after entry at the age of 5 was reported, (32) but a year later the rate had fallen to 0.7 per 1000. This 'persistent shyness' of the latter group is closely comparable to core selective mutism. (32) Even higher rates are recorded when broader criteria are used and where there is no associated clinical assessment.(34)

Diagnosis and differential diagnosis

Inordinate shyness and the reluctance to talk at school entry have proved to be transient phenomena, (33) which are likely to reflect normal separation anxiety compounded by transient adaptation reactions to the usual stresses and unfamiliarity of the new school situations. With exposure this anxiety diminishes and the child may begin to talk/19 Thus a distinction needs to be made between such transient states of inordinate shyness and pathological behaviours by applying more rigorous criteria when defining selective mutism as being persistent, severe, and showing pathological shyness beyond the home situation. (32> ICD-10 captures the essential criteria well: 'characterised by a marked emotionally determined selectively in speaking...With language competence demonstrated in some situations but not in others...with a normal or near normal language comprehension...with demonstrable evidence that the child can speak normally in some situations...the failure to speak is persistent over time'. A further issue concerns children who speak rather little in all circumstances, with the view that they should not be assigned the diagnosis of selective mutism, nor should those children who display 'reluctant speech', i.e. they do not speak spontaneously but may answer questions.

Developmental and biological factors

There is a consistent pattern of an excess of girls to boys, which is unusual for childhood disorders. (3 35) Kolvin and Fundudis(32) included a control group drawn from a general population sample. They reported an excess of birth complications and also found evidence of slow or uneven development compared with the controls, which included delayed onset of speech, excessive developmental mispronunciations, and associated problems of speech. Underlying speech or language delay or problem are reported to range from 20 per cent(35) to 50 per cent.(32) Recently Steinhausen and Judi(36) reported similar features, namely being more common in girls and seen in all social strata. Early developmental risk factors were also quite common as was a background of migration. School and unfamiliar people were common social concerns and comorbid psychiatric diagnoses were common.

Personality temperament and behaviour

Insidious development of shyness has been reported in over 80 per cent of cases, and even where it appeared acute the essential abnormality became dramatically obvious only when the child started school.(32) In addition, a wide variety of complex personality patterns often occur, such as oppositional behaviour and poor manageability both at school and at home.(32) A common personality pattern was of sulkiness combined with aggressiveness, with a child presenting as sulky to strangers and aggressive within the home. Many of these children are described as having powerful personalities, with 'wills of steel'. About a quarter showed a combination of shyness in social situations with submissiveness at home. Another quarter seemed to be rather sensitive children. In addition, there was an important trend for such children to be more withdrawn in relation to peers than to adults. Problem behaviours were described in over two-thirds of the children. (32)

Black and Uhdek7 studied 30 5- to 12-year-olds using parent- and teacher-rating scales and structured diagnostic interviews. They report that mutism varied according to the psychological setting. The majority of their subjects were diagnosed as social phobic or avoidant disorders (97 per cent) and simple phobic disorders (30 per cent). The severity of social anxiety correlated with the severity of the mutism, and they argue that selective mutism may be a symptom of social anxiety.

Cognitive aspects

The evidence available shows that although selectively mute children as a group cover most ranges of non-verbal intellectual ability, there is a distinct shift to the left. In general terms, when selectively mute children do speak—within the confines of their own homes—their vocabulary, verbal conceptualization of ideas, and grammatical structure of sentences are commonly normal.

Family and social factors

The families of selective mutes are represented at all socio-economic levels.(32) Of importance is the nature of the operant psychological dynamics. The literature abounds with examples of parents with unusual personalities and psychiatric problems, which are often offered as explanations for the selective mutism of their children/38) The confidence placed in these findings must be limited by the lack of controls and small sample size of the studies upon which the theories are based. Some of the factors which were presumed causative include maternal rejection, maternal anxiety, fearfulness, and overprotectiveness, the influence of 'family secrets' and the child's fear of parental retaliation, and the effects of a symbiotic relationship between a parent and the child. Most of these notions derive from older publications.

In one controlled study,(32) one-third of the parents of selectively mute children were reported to have personalities characterized by serious or marked reserve and shyness or oddness; neurotic disorder was present in one of the parents in about one-sixth of the families, and depression was present in one of the parents, again in one-sixth of the families. Considerations of psychiatric disorder and major personality problems, in combination with serious marital disharmony, occurred in about 60 per cent of the families. However the disturbance in families is defined, the available evidence points to an excess of psychological morbidity compared with families of normal control children/32) On balance, the origins appear multifactorial.

Another study reported a 75 per cent rate of parental psychological disturbance. (36) This higher rate was probably due to the use of a much broader definition of disturbance. Shyness in parents of selectively mute children appears to be fairly common,(32) and raises the interesting possibility of a familial or even a genetic link between shyness of the parents and selective mutism of the child. The latter possibility is enhanced by the finding of a number of affected siblings (35) or twins(39 in different series of selectively mute children. On the other hand, the influence of learning and modelling cannot be discounted.

More recent research exploring the parental perceptions of selective mutes as adults suggests important negative parental influences, with the compounding of poor affection and care with overcontrolling behaviour (S. Baharaki et al., personal communication). Others imply that it is a learned pattern of behaviour. Yet others implicate temperamental or personality factors which have a familial basis. Or it may be a secondary psychological reaction to some biologically based symptoms—for instance, some children may avoid speaking because they are teased when they mispronounce words; others implicate an important maturational component.

Finally, Kolvin et al.,(49 following the conceptualization of Stevenson-Hinde and Shouldice, (4D refer to the mother's poor sensitivity followed by child dysfunction in each of three behavioural systems—reflecting wary and fearful behaviour; inhibition in social situations; and insecure attachments. Another theme is stranger anxiety(42) represented by either avoidant freezing reactions in social situations or oppositional, silent, and quiet reactions. The notion of severe anxiety has been taken up by Dummit et al.(43) and by J. Morgan et al. (personal communication) who argue for an early onset of a social phobic condition. This diversity of presumed aetiological factors suggests that the origins are multiple and the condition heterogeneous.

Intervention and outcome

Selective mutism continues to be a challenge to psychodynamically and behaviourally oriented psychotherapists. Success rates are variable. It is difficult to offer general conclusions from major studies because of the differences in diagnostic criteria used, the severity of the mutism, and the criteria of improvement. For example, Wright(35) reported that almost 80 per cent of children achieve an 'excellent' or 'good' adjustment, whereas Kolvin and Fundudis (32) report an adjustment rate of 46 per cent. The literature emphasizes the intractability of selective mutism to psychotherapy, in that, although degrees of improvement are usually reported, the spontaneity of interpersonal communication of the selectively mute child is seldom fully shifted. Some now suggest that psychodynamic approaches have to vary according to the mutism subtype under scrutiny. For example, those who are more compliant will respond to longer psychodynamically oriented approaches; and those who are non-compliant are more likely to respond to group therapy.(42)

The emphasis of psychodynamic approaches has given way to behavioural strategies. In keeping with the more pragmatic stance of the behaviourists it has been argued that intervention should be directed not only at 'mutism' but more broadly at 'social skills. {44» Consistent with the above is the proposal of a multidimensional management approach(45) consisting of the following:

• avoidance of strategies likely to put pressure on the child to talk

• inclusion of the child in small peer-group activities

• use of reading, story-telling, and other verbal activities which do not make the child feel especially uncomfortable

• parental encouragement for relatives and peers to visit the selectively mute child at home to create a natural social context of conversation without putting pressure on the child to talk

• encouragement of the child, within the classroom situation, to engage in non-verbal and non-threatening interpersonal relationships

• a gradual process of encouragement and involvement of the child in one-to-one situations, where appropriate stimuli are used as a means of creating the potential for verbal communication and then drawing one or two other children into the activity

• encouragement to engage in joint activities outside the home.

This broad-based behavioural approach seems attractive, but it merits more careful evaluation.

Inevitably, some clinicians have turned to pharmacotherapy spurred by notions of origins in anxiety and social phobia. Most studies are single case or have small sample sizes, without controls, with fluoxetine being favoured. One open trial, using a repeated measure design, treated 21 selectively mute children with a combination of behaviour therapy and fluoxetine.There was a reduction of anxiety and improved ability to speak in 13, no change in 4, and the fluoxetine was discontinued in 4 because of an increase in oppositional behaviour. However, there was no control group. The efficacy of fluoxetine has been evaluated in a double-blind placebo-controlled study. (47) Here, 15 placebo non-responders were assigned to double-blind treatment with fluoxetine—significant improvement was reported in mutism, anxiety, and social anxiety. However, most subjects remained very symptomatic at the end of the study. Overall, the fluoxetine findings must be viewed as interesting rather than definitive, with improvement linked to the duration of the treatment and where the selective mutism is more widely defined.

Chapter References

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Funny Wiring Autism

Funny Wiring Autism

Autism is a developmental disorder that manifests itself in early childhood and affects the functioning of the brain, primarily in the areas of social interaction and communication. Children with autism look like other children but do not play or behave like other children. They must struggle daily to cope and connect with the world around them.

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