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*E. The disturbance is not better explained by a communication disorder (e.g., [[childhood onset fluency disorder]]) and does not occur exclusively during the course of autism
*E. The disturbance is not better explained by a communication disorder (e.g., [[childhood onset fluency disorder]]) and does not occur exclusively during the course of autism spectrum disorder, [[schizophrenia]], or another psychotic disorder.
spectrum disorder, [[schizophrenia]], or another psychotic disorder.
}}
}}


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Selective mutism is usually characterised by the following:
Selective mutism is usually characterised by the following:
*Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.
*Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.
*The disturbance interferes with educational or occupational achievement or with social communication.
*Interference with educational or occupational achievement or with social communication.
*The duration of the disturbance is at least 1 month (not limited to the first month of school).
*Disturbance lasting at least 1 month (not limited to the first month of school).
*The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
*Failure to speak not due to a lack of knowledge of, or comfort with, the spoken language required by the social situation.
*The disturbance is not better accounted for by a Communication Disorder (e.g. stuttering) and does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder.
*Lack of better cause explained by a Communication Disorder (e.g. stuttering) and disturbance lasting longer than a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder.
 


Typical sufferers have some of the following traits when anxious, some of which are often perceived as rudeness:
Typical sufferers have some of the following traits when anxious, some of which are often perceived as rudeness:
 
*Find it difficult to maintain eye contact.
*They find it difficult to maintain eye contact.
*Often don't smile and have blank expressions.
*Often don't smile and have blank expressions.
*They move stiffly and awkwardly.
*Move stiffly and awkwardly.
*They find situations where talk is normally expected particularly hard to handle. (answering school registers, saying hello, goodbye, thank-you, etc.)
*Find situations where talking is normally expected particularly hard to handle (answering school registers, saying hello, goodbye, thank you, etc.).
*They tend to worry about things more than others
*Tend to worry about things more than others.
*They can be very sensitive to noise and crowds
*Can be very sensitive to noise and crowds.
*Find it difficult to talk about themselves or express their feelings
*Find it difficult to talk about themselves or express their feelings.


==Treatment==
==Treatment==


Contrary to popular belief, people suffering from selective mutism don't necessarily improve with age, or just ''grow out of it''. Consequently, treatment at an early age is important. If not addressed, selective mutism tends to be self-reinforcing; those around such a person may eventually expect him or her not to speak, and stop attempting to initiate verbal contact, making the prospect of talking seem even more difficult or foreign. Sometimes in this situation, a change of environment (such as changing schools) to a place where the condition is not proven make the difference, but in some cases; with psychological help the sufferer's condition can improve.
Contrary to popular belief, people suffering from selective mutism don't necessarily improve with age, or ''grow out of it''. Consequently, treatment at an early age is important. If it is not addressed, selective mutism tends to be self-reinforcing: the expectation that one suffering from selective mutism will not speak causes those around them to stop trying to initiate verbal contact, thus making the prospect of talking seem increasingly difficult or foreign. In such a situation, a change of environment (such as changing schools) can decrease the severity of one's selective mutism by eliminating such expectations.  
 
Occasionally, treatment in teenage years becomes more difficult, though not necessarily.  


Forceful attempts to make the child talk are not productive, usually resulting in higher anxiety levels and so reinforcing the condition. The behaviour is often viewed externally as willful, or controlling, as the child usually shuts down all communication and body language in such situations, which is perceived as rudeness.
Psychological treatment has also been shown to help the counteract this condition, though treatment in teenage years is sometimes more difficult. Specific courses of treatment differ based on the subject, and must take factors such as age into account.  


The exact treatment depends a lot on the subject, their age and other factors. Typically, stimulus fading is used with younger children.
Attempts to force a child to talk are typically ineffective and often result in higher anxiety levels, consequently worsening the condition.


Some in the psychiatric community believe that anxiety medication may be effective in extremely low dosages and that higher doses may just make the problem worse. Others in the field believe that the side-effects of psychiatric medications- in any dose and on any child- are so dangerous as to negate any temporary benefit, preferring behavioral and psychological interventions.  
Some in the psychiatric community believe that anti-anxiety medications may be effective in extremely low dosages while higher doses may worsen the condition. Others in the field advocate that the side-effects of psychiatric medications- in any dose and on any child- are so dangerous that they negate any temporary benefits, preferring behavioral and psychological interventions.


===Stimulus Fading===
===Stimulus Fading===
In this technique the sufferer is brought into a controlled environment with someone who they are at ease with and can communicate. Gradually another person is introduced into the situation involving a number of small steps.
Stimulus fading is a common treatment for younger children suffering from selective mutism. This ''sliding-in'' technique consists of the subject being brought into a controlled environment with someone who they are at ease with and can communicate with. Gradually, another person is introduced into the situation, often in several distinct stages. This process can be relatively long as the first few people are slid (or faded) into the environment and the conversation.
 
These steps are often done in separate stages in which case it is called the ''sliding-in'' technique, where a new person is slid into the talking group.
This can take a relatively long time for the first one or two faded in people.


===Desensitization===
===Desensitization===
The subject is allowed to communicate via non-direct means to prepare them mentally for the next step. This might include email, phone, taped recordings, webchat, until they are in a position to try more direct communication.
The subject is prompted to communicate via indirect means in order to prepare them mentally for direct communication. Methods of indirect communication include email, phone, voice recordings, and conversations on the internet.


===Medical Therapy===
===Medical Therapy===
Some practitioners believe that there is evidence indicating that antidepressants such as [[fluoxetine]] (prozac) may be effective in treating children with selective mutism. Though many in the medical community believe that psychiatric medications decrease the anxiety levels enough to allow communication to take place in cases of selective mutism, other practitioners and activists (see articles on [[Peter Breggin]] and [[David Healy (psychiatrist)]]) stringently decry any use of psychiatric medications on children and note the lack of medical proof of genetic links to behavioral disorders. The denunciation of psychotropic intervention on children with behavioral anxiety disorders has intensified particularly since lawsuits against several drug companies—current to 2005—have exposed previously unseen internal research documents linking fluoxetine and other SSRI antidepressants with increased risk of suicide, psychosis and—ironically enough—damage to areas of the brain which could affect language production and normal social development.
Some practitioners advocate the use of antidepressants such as [[fluoxetine]] (prozac) as treatment for children with selective mutism. While many in the medical community believe that psychiatric medications can decrease anxiety levels enough to allow patients with selective mutism to communicate, others (see articles on [[Peter Breggin]] and [[David Healy (psychiatrist)]]) stringently decry the use of psychiatric medications on children. These practitioners and activists note the lack of medical evidence that behavioral disorders have genetic bases. The denunciation of psychotropic intervention on children with behavioral anxiety disorders intensified as lawsuits against several drug companies exposed previously unseen internal research documents linking fluoxetine and other SSRI antidepressants with increased risk of suicide, psychosis and damage to areas of the brain which could affect language production and normal social development.


==References==
==References==

Latest revision as of 12:48, 24 June 2015

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Overview

Selective mutism is a social anxiety disorder in which a person who is normally capable of speech is unable to speak in given situations.

Causes

No single cause has been established, but there is some evidence that there is a hereditary component.

Differential Diagnosis

Epidemiology and Demographics

Prevalence

The prevalence of selective mutism is 30-1,000 per 100,000 (0.03%-1%) of the overall population.[1]

Risk Factors

  • Behavioral inhibition
  • Genetic predisposition
  • Negative affectivity (neuroticism)
  • Parental history of shyness
  • Social anxiety
  • Social isolation[1]

Natural History, Complications, and Prognosis

Children (and adults) with the disorder are fully capable of speech and understanding language, but fail to speak in certain social situations when it is expected of them. They function normally in other areas of behavior and learning, though appear severely withdrawn and some are unable to participate in group activities due to their extreme anxiety. It is like an extreme form of shyness, but the intensity and duration distinguish it. As an example, a child may be completely silent at school, for years at a time, but speak quite freely or even excessively at home.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Selective Mutism[1]

  • A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations.

AND

  • B. The disturbance interferes with educational or occupational achievement or with social communication.

AND

  • C. The duration of the disturbance is at least 1 month (not limited to the first month of school).

AND

  • D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

AND

  • E. The disturbance is not better explained by a communication disorder (e.g., childhood onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

Symptoms

Selective mutism is usually characterised by the following:

  • Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.
  • Interference with educational or occupational achievement or with social communication.
  • Disturbance lasting at least 1 month (not limited to the first month of school).
  • Failure to speak not due to a lack of knowledge of, or comfort with, the spoken language required by the social situation.
  • Lack of better cause explained by a Communication Disorder (e.g. stuttering) and disturbance lasting longer than a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder.


Typical sufferers have some of the following traits when anxious, some of which are often perceived as rudeness:

  • Find it difficult to maintain eye contact.
  • Often don't smile and have blank expressions.
  • Move stiffly and awkwardly.
  • Find situations where talking is normally expected particularly hard to handle (answering school registers, saying hello, goodbye, thank you, etc.).
  • Tend to worry about things more than others.
  • Can be very sensitive to noise and crowds.
  • Find it difficult to talk about themselves or express their feelings.

Treatment

Contrary to popular belief, people suffering from selective mutism don't necessarily improve with age, or grow out of it. Consequently, treatment at an early age is important. If it is not addressed, selective mutism tends to be self-reinforcing: the expectation that one suffering from selective mutism will not speak causes those around them to stop trying to initiate verbal contact, thus making the prospect of talking seem increasingly difficult or foreign. In such a situation, a change of environment (such as changing schools) can decrease the severity of one's selective mutism by eliminating such expectations.

Psychological treatment has also been shown to help the counteract this condition, though treatment in teenage years is sometimes more difficult. Specific courses of treatment differ based on the subject, and must take factors such as age into account.

Attempts to force a child to talk are typically ineffective and often result in higher anxiety levels, consequently worsening the condition.

Some in the psychiatric community believe that anti-anxiety medications may be effective in extremely low dosages while higher doses may worsen the condition. Others in the field advocate that the side-effects of psychiatric medications- in any dose and on any child- are so dangerous that they negate any temporary benefits, preferring behavioral and psychological interventions.

Stimulus Fading

Stimulus fading is a common treatment for younger children suffering from selective mutism. This sliding-in technique consists of the subject being brought into a controlled environment with someone who they are at ease with and can communicate with. Gradually, another person is introduced into the situation, often in several distinct stages. This process can be relatively long as the first few people are slid (or faded) into the environment and the conversation.

Desensitization

The subject is prompted to communicate via indirect means in order to prepare them mentally for direct communication. Methods of indirect communication include email, phone, voice recordings, and conversations on the internet.

Medical Therapy

Some practitioners advocate the use of antidepressants such as fluoxetine (prozac) as treatment for children with selective mutism. While many in the medical community believe that psychiatric medications can decrease anxiety levels enough to allow patients with selective mutism to communicate, others (see articles on Peter Breggin and David Healy (psychiatrist)) stringently decry the use of psychiatric medications on children. These practitioners and activists note the lack of medical evidence that behavioral disorders have genetic bases. The denunciation of psychotropic intervention on children with behavioral anxiety disorders intensified as lawsuits against several drug companies exposed previously unseen internal research documents linking fluoxetine and other SSRI antidepressants with increased risk of suicide, psychosis and damage to areas of the brain which could affect language production and normal social development.

References

  1. 1.0 1.1 1.2 1.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.

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