Psychology
Abstract
Selective mutism affect many children and can get worst if it is left mis-diagnozed. It is important for parents to know the signs and act early to prevent their child from suffering from this disorder later on in their life. The early diagnosis of the disorder is important, so too is the treatment options that are available for the child. If it is caught early on in the child’s life, it is easier for them to be treated and enabled to live a normal life. If it is not treated, the child may become an adult who is a recluse, because they are not aware that they have a disorder or that it can be treated. Identifying the treatments that are necessary to treat this disorder can be of great help to a child who suffers from selective mutism.
Selective mutism in early childhood is characterized as a disorder that affects mostly children. It is an anxiety disorder that results in a child’s inability to speak or communicate effectively. The disorder normally begins at childhood and, if it goes unrecognized or undiagnosed, can present a problem for the sufferer later on. They are most shy at social gatherings or in school. They are only able to communicate in familiar surroundings where they feel comfortable and secure.
Over 90% of the children who suffer from selective mutism are also sufferers of other conditions, such as social phobias or anxiety. The disorder can be debilitating and stressful for the child. Children and adolescents who suffer from selective mutism experience fear when they speak or have social interactions in which they are required to speak to others. Many of the children who suffer from this disorder experience difficulty with responding to, or the initiation of communication in which they are supposed to respond, so social interaction can become strained if the child is expected to interact.
If they get a sense of anticipation or expectation, they can draw into their shell. Children are different and experience anxieties in different ways. Many become mute and refuse to speak if there are too many people around, while others may be able to speak or whisper to some people. Some children become immobilized with fear as they confront people socially. They can also isolate themselves for fear of being expected to speak or interact. Children who are not affected or less severely affected take on the appearance of carefree, relaxed individuals who are confident in themselves.
They have the ability to communicate and socialize with one to a few other children, but are unable to speak effectively with teachers or peers. Children develop selective mutism because they were genetically predisposed to feelings of anxiety. What this means is that they tend to experience anxiety from one family member or more than one. Many times, they inherit this tendency to be anxious from a family member.
They will also display signs of being anxious, this can be separation anxiety, throwing tantrums, crying, being moody, problems falling and staying asleep and being shy from as early as infancy. The children who suffer from selective mutism experience subdued temperaments. Based on studies conducted, these type of children who have subdued temperaments get anxious quicker than those who have a normal temperament. Most of the sufferers, if not all of them display those distinctive characteristics (DSI) as those who suffer from the disorder.
It is easily explained by the hypothesis that those who have a subdued personality, experience a decreased amount of excitability in their amygdala (area of the brain that is shaped like an almond). When they are confronted with fear the amygdala gets signals of danger approaching from the nervous system and sets off series of reactions as a defense mechanism.
- For children with selective mutism, their fear is based on social gatherings such as parties, family groups or even school. Some of the children who suffer from selective mutism also suffer from a sensory processing disorder. This means they will experience processing some form of sensory information. They can experience a sensitivity to lights, taste, touch and smells. Some have a difficulty in modulating sensory inputs, which can affect their abilities to respond emotionally.
- DSI can cause the child to misconstrue social and environmental cues. These cues can cause the child to be inflexible, experience anxiety and frustration. It may cause them to shut down, have tantrums, act out or display negative behaviors. Between 20 and 30% of children who have selective mutism also have minor speech and language defects. They experience receptive and expressive language defects or delays.
- Others can display disorders with heir auditory sensors. In many cases, the children are also prone to anxiety attacks or shyness. The stress that comes with the other disorders, speech, learning, listening or language, may result in the child experiencing discomfort or insecurity if he is required to speak. More studies would then be required to assess the other problems that the child experience. It is of importance to note that many children suffer from selective mutism and still meet their developmental milestones as other, normal children do.
- Research conducted by the SMART (Selective Mutism Anxiety Research and Treatment Center) indicates that a percentage of children who suffer from selective mutism are members of bilingual families, have been residents of a foreign country, or have learned another language later in their lives. These same children possess a subdued temperament, but experience anxiety and withdrawal because of the stress of speaking other languages.
According to DSM-IV-TR, 1 in 1000 children who were referred for mental health assessment and treatment suffer from selective mutism (APA, 2000). Other researchers are of the opinion that the prevalence of the sufferers are more, as many are yet undiagnosed. Recently conducted studies indicate that selective mutism is no longer a rare disorder and can be compared to other childhood disorders that are more widely recognized. A study targeted a specific amount of children who suffer from the disorder in a Californian school who were identified by those who met the criteria for diagnosis of the disorder. A rate of prevalence in children who have the disorder was found to be approximately 7.1 in every 1000 children (Camposano, 2011). A follow-up study to that conducted by another source found that the prevalence rate was almost the same. These findings are suggestive of the fact that there is a higher rate of prevalence for selective mutism, than there is for autism, which is .5 in every 1000 children.
The statistics for other depressive disorders are also lower at .4 to 3 in every 1000. Those who suffer from Tourette’s Syndrome were also .5 in every 1000, OCD was .5 to 1 in every 1000. When compared to other studies, which accounted for only those cases that were diagnosed, the evidence that was uncovered was that many cases of selective mutism were either mis-diagnosed or went undiagnosed. Parents who had children with selective mutism who went for treatment reported that their child/children were misdiagnosed and said to be suffering from autism or another pervasive disorder that would affect their development.
Many are advised by uniformed officials that the child is perfectly normal and will outgrow the behavior that they now display. A lack of awareness from educators and professionals who treat the disorder can cause delays and missed treatment opportunities as the disorder was not appropriately diagnosed. Selective mutism is found to be more prevalent in females than males. Even though the duration of the disorder can be prolonged for several months, if it goes untreated, it can persist even longer and continue for many years.
The average onset age is 5 years, but can begin earlier. The children who showed long term mutism continued being silent in higher grades and even into adulthood.
While there are scarcely any reports of adults who suffer with selective mutism, based on collective effort by clinicians, it was found that sufferers who choose to get treatment later in life can become depressed or suffer from other types of disorders with their selective mutism, but their treatment can cure the selective mutism before they get older. Several children who are diagnosed with selective mutism are not in any way shy. Some of them are able to perform or do any other actions to get the attention that they want.
They are also described as professional mimes. The reason for the disorder has not been proven, but follow-up reports from SMART has shown that they may suffer from the disorder for other reasons. An example is if they were mute before and somehow ingrained that behavior pattern into their personality without displaying other symptoms or developmental problems. These children are said to be stuck in a nonverbal stage of the communication process. One symptom being the selective mutism.
It is rare that children are found to be just “mute”, so the emphasis will have to be placed on the causes and propagating factors of selective mutism. No study has uncovered the fact that selective mutism is a contributing factor of neglect, abuse or trauma. Some children who have the disorder can begin displaying signs of mutism in school or other social gathering. Because their mutism was negatively reinforced or others around them misunderstood the disorder, or other heightened stressors in their environment, they can develop mutism (Viana, Beidel & Rabian, 2009).
The mutism that these children suffer from, can be progressive and include those living at home, parents or siblings. Children who have selective mutism can be normal and act socially appropriate like normal children if they are in comfortable surroundings. Parents sometimes lament about their children being boisterous, funny, inquisitive, verbal, stubborn and bossy, especially in the home setting. The thing that differentiate most of the children who have selective mutism is the inhibitive behavior that they display. They are unable to speak or communicate in many social setting. Some, on the other hand, will act as if they are being judged in a contest.
Both negative behaviors and physical symptoms are displayed before they get to school or go in a social setting. Parents of children with selective mutism and teachers need to understand that both behavioral and physical symptoms are because of their anxiety and as such, their treatment should be focused on assisting the child to learn effective coping skills that can be used to combat their anxiety.
Some children have a blank expression on their face and refuse to smile. Some are stiff, show an awkward disposition or seem unhappy or uncomfortable when they are in crowd. Some of them will turn their head, chew on, or twirl their plait, avoid to make eye contact or stay in a corner by their self and play alone. Others show less discomfort and avoid people less. They are able to play with children and participate in a group activity. Even so, they are still mute and can barely interact with teachers and classmates (Sharp, Sherman & Gross, 2007).
When they develop social relationships, they will begin to communicate an speak or whisper to some children in school. After a while, these children are known to cope when they are presented with certain situations. It becomes harder for the children who suffer from this disorder to maintain social relationships. When it comes to dating, children with selective mutism may become isolated. The characteristics of the sufferers of selective mutism are a subdued temperament, they are timid, cautious or restrained in unfamiliar territory (Bernstein, DO, 2014).
They may or may not have suffered from separation anxiety as an infant or child. In excess of 90% of them suffer from social anxiety and experience discomfort when they are introduced to other people. They do not like to be criticized, teased or to be the center of attention. They are commonly seen as perfectionists and have Paruresis or what is known as shy bladder syndrome and are afraid to have a meal if others are looking.
- Many of the children who are sufferers of selective mutism need to, or want to have friends. This minor fact can be used to differentiate selective mutism from other types of disorders, such as those in the autistic spectrum. Most of the sufferers have social skills, although some do not. Here is where a need to develop those skills arise. Some sufferers experience mutism, nausea, joint pains, vomiting, stomach aches, headaches, shortness of breath, diarrhea, feelings of being scared and other symptoms attributed to anxiety attacks.
- They display an expressionless face and awkward bodily movements. They are afraid to make eye contact with others when they experience anxiety. For younger children, at the start of the school year, or when they are approached by people who are unfamiliar to them. In older children, it is highly unlikely that they will exhibit the stiffness that the younger ones do. A popular hypothesis is that when sympathetic response is heightened, it can cause tension in the muscles and paralyze one’s vocal chord (Giddan, Ross, Sechler & Becker, 1997). For the younger child they will not get upset about their condition, because their peers accept them more than when they get older.
- When these children get older they often develop an inner turmoil and negative feelings if their anxiety is left untreated. They sometimes experience delays in their development, some do not, but others experience multiple delays. Delayed development can be in their motor, social or communication skills. They may also experience difficulties in processing information.
- Sensory processing problems are sometimes the underlying reason for their mutism. If the environment is bigger, or more crowded, with multiple stimuli and the child feels expectant, then they can develop sensory defensiveness. When anxiety is experienced, the child reverts to what is known as free mode and this is the mutism. Sufferers are picky eaters who have issues with their bladders and bowels, are sensitive in a crowd, afraid of bright lights and loud noise or being touched. Their sensitive and perceptive senses are heightened and they become harder to manage (boisterous, stubborn, etc.).
- In a classroom setting the child with sensory problems becomes withdrawn and plays by himself. He is distracted, non-verbal and refuses to follow directions. These difficulties may or may not be a problem for their learning ability. Children who are highly intelligent usually compensate with their academics and end up doing very well. Some choose to focus on their studies and forget about the social interaction aspect of it. They possess, in addition to behavioral problems, co-morbid anxieties, communication, social engagement, OCD and other issues.
- Some of these symptoms are not present while they are at home. Most children are diagnosed with selective mutism between the ages of 3 and 8 years. Children who are subdued and severely anxious as children are normally perceived as just being shy as adults. Most children experience separation anxiety and warm up to people at a slower pace than others. The disorder often becomes evident when the child is at school and is unable to interact or perform socially (Cohan, Chavira & Stein, 2006).
- Because of the scarcity of the diagnosis of selective mutism, many teachers, physicians and therapists lack understanding of the disorder. Most of the researches that were done were based on a small sample amount. Textbooks are not able to define the disorder, or there is a limited amount of information available. Because of this, it is only a few people who understand what is selective mutism.
- It is important to have the child assessed when he is young because the earlier it is diagnosed, the earlier it can be treated. The Surgeon General of the United States states that the country is in an emergency state where the mental health of children is concerned. Mental disorders affect approximately 10%, while fewer than 5% are being treated. The most common illness that affects children and adolescents is anxiety disorders. Getting therapy for the child is not all that is needed. It just assists in preparing the child for the real world and for school. It helps them to develop strategies to condition the child in order to reverse his childhood behavior.
- These intervention and strategies are based on the child’s social skills or communication problem. Programs that include techniques to lower anxiety and methods that can be used to build their self esteem can assist with the progression of their communication. This includes going from total shut down to whispering, or non-verbal communication before transitioning to spoken words with a verbal intermediary, such as a Ritual Sound Approach. If possible, devices that augment sounds can also be employed. Children who suffer from selective mutism should be made to feel like they are in control, understand and have the ability to choose their treatment based on their age (Carlson, Mitchell & Segool, 2008).
- Goals and games that are targeted to the child’s age can be used for bridging the communication gap. They can develop social and communicative skills. Controlled and ritualistic methods and strategy charts can help them to be socially comfortable and to develop speech mechanisms. Changes to their environment coupled with silent and active goals that are child-directed and based on their control and choice can also be used with the selected program. Each child is different, so treatment plans should be individualized and include the home setting. The needs of the child, and modification to his school should also be considered. In lowering the child’s anxiety level, his self esteem will be increased and therefore his ability to communicate will also improve. His confidence level should also increase, enabling him to interact with others without fear of being rejected.
- A professional who is trained to diagnose and treat selective mutism should be consulted. They should place emphasis on the child’s ability to communicate and interact socially as these are two key skills that enable them to live a normal life leading up to adulthood.
References
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Camposano, L. (2011). Silent Suffering: Children with Selective Mutism. TPC, 1(1), 46-56. doi:10.15241/lc.1.1.46
Carlson, J., Mitchell, A., & Segool, N. (2008). The current state of empirical support for the pharmacological treatment of selective mutism. School Psychology Quarterly, 23(3), 354-372. doi:10.1037/1045-3830.23.3.354
Cohan, S., Chavira, D., & Stein, M. (2006). Practitioner Review: Psychosocial interventions for children with selective mutism: a critical evaluation of the literature from 1990?2005. Journal Of Child Psychology And Psychiatry, 47(11), 1085-1097. doi:10.1111/j.1469-7610.2006.01662.x
Giddan, J., Ross, G., Sechler, L., & Becker, B. (1997). Selective Mutism in Elementary School. Lang Speech Hear Serv Sch, 28(2), 127. doi:10.1044/0161-1461.2802.127
Kehle, T., Madaus, M., Baratta, V., & Bray, M. (1998). Augmented Self-Modeling as a Treatment for Children with Selective Mutism. Journal Of School Psychology, 36(3), 247-260. doi:10.1016/s0022-4405(98)00013-2
Sharp, W., Sherman, C., & Gross, A. (2007). Selective mutism and anxiety: A review of the current conceptualization of the disorder. Journal Of Anxiety Disorders, 21(4), 568-579. doi:10.1016/j.janxdis.2006.07.002
Viana, A., Beidel, D., & Rabian, B. (2009). Selective mutism: A review and integration of the last 15 years. Clinical Psychology Review, 29(1), 57-67. doi:10.1016/j.cpr.2008.09.009
