Selective Mutism in Children: Comparison to Youths With and Without Anxiety Disorders

Fifteen children with selective mutism (SM), 15 children with anxiety disorders (AD) without selective mutism, and 15 children without anxiety disorders or selective mutism (CN) were compared to examine the relationship between selective mutism and anxiety. Data were collected from children (age 4–10 years), parents, teachers, and clinicians. Results indicated that children with SM closely resemble children with AD. All children with SM received a diagnosis of social anxiety disorder and 53% received a diagnosis for an additional anxiety disorder. In addition, the SM and AD groups differed substantially from controls with respect to parent- and teacher-rated internalizing behavior problems. No differences among the groups were found with respect to parent-and teacher-reported externalizing behavior problems. The results are consistent with prior research emphasizing the association between selective mutism and anxiety disorders, and suggest that selective mutism may be conceptualized, assessed, and treated as an anxiety-related problem.     

MCMI-II personality traits and symptom traits in parents of children with selective mutism: a case-control study.

The etiology of selective mutism (SM) in children is unknown but is regarded as multifactorial. SM is frequently associated with social anxiety and language disorder or delay. The present study addresses SM and social anxiety as a familial phenomenon by comparing self-reported personality traits and symptom traits (Millon Clinical Multiaxial Inventory) in parents of 50 SM children with control parents. Personality and symptom traits reflecting social anxiety are also explored separately in the parents of SM children with and without a comorbid communication disorder. The results confirm SM and social anxiety as a familial phenomenon. Assessment and treatment planning should take this into account. The family data also suggest different family transmissions of SM and social anxiety in the SM group with and without a comorbid communication disorder.     

Selective mutism in children: A structural family therapy approach to treatment

When children refuse to speak in some social settings, but can understand and speak in other settings, the diagnosis of selective mutism must be considered. A review of the literature describes the disorder, the various types of mutism, and related family dynamics. A family systems approach to treatment using structural family therapy is suggested. The case history presented illustrates one type of mutism as well as the family rules and hierarchy which appeared to be maintaining it. Structural and strategic family systems theory techniques that were used to move the family toward resolution of this problem are discussed.Diane Wolf Tatem, MA, MS, completed graduate work in marriage and family therapy at New Mexico State University, Las Cruces, NM. She is employed at Life Management Center of El Paso's Child Development Services and also has a private practice in marriage and family therapy in El Paso, Texas. Robert L. DelCampo, PhD is a professor of family science at New Mexico State University and maintains a private practice with Associates for Marriage and Family Therapy in Las Cruces, NM. Please address all correspondence to Dr. DelCampo at Box 3470, New Mexico State University, Las Cruces, NM, 88003-3470.Appreciation is expressed to Dr. Charles Huber, New Mexico State University in Las Cruces, for his insightful critique of the final draft of this paper. This paper was presented at the Texas Association for Marriage and Family Therapy Annual Conference, January 25–29, 1995 in Dallas, TX.     

Anxious Solitude and Clinical Disorder in Middle Childhood: Bridging Developmental and Clinical Approaches to Childhood Social Anxiety

It was hypothesized that children identified by their peers at school as anxious solitary would report more symptoms of social anxiety disorder on a self report questionnaire and, on the basis of child and parent clinical interviews, receive more diagnoses of social anxiety disorder and additional anxiety and mood disorders. Participants were 192 children drawn from a community sample of 688 children attending public elementary schools. Half of these children were selected because they were identified as anxious solitary by peers and the other half were demographically-matched controls. 192 children provided self reports of social anxiety disorder symptoms on a questionnaire, and 76 of these children and their parent participated in clinical interviews. Results indicate that children identified by their peers as anxious solitary in the fall of 4th grade, compared to control children, were significantly more likely to receive diagnoses of social anxiety disorder, specific phobia, and selective mutism based on parent clinical interviews. Additionally, there was a tendency for these children to be diagnosed with generalized anxiety disorder and post traumatic stress disorder based on parent clinical interviews. Furthermore, children who had been identified as anxious solitary at any time in the 3rd or 4th grades were more likely than control children to report symptoms of social anxiety disorder that fell in the clinical range and to receive diagnoses of social anxiety disorder and dysthymia (both trends) and major depression (a significant effect) according to parental clinical interview.     

The neural circuitry of conversion disorder and its recovery

Little is understood about neural networks associated with conversion disorders. This case study reports the first investigation of the neural circuitry associated with the recovery of chronic conversion disorder. A patient with a four year history of hysterical mutism was assessed with functional MRI (fMRI) during a vocalization task, and then provided psychotherapy that attempted to reduce motivational factors that maintained mutism. The patient resumed full speech, and was readministered the fMRI vocalization task. Vocalization during mutism and following recovery of speech resulted in increases in speech-related networks, including the inferior frontal gyrus (IFG), middle frontal, and supplementary motor area of the frontal cortex, temporal and parietal cortices, and also in the primary and sensory motor regions. Following speech recovery but not during mutism, the IFG was correlated positively with the anterior cingulate cortex and negatively with the amygdala. This pattern suggests that during the conversion disorder there was impaired connectivity between speech networks and networks that regulate anxiety.     

Selective Mutism and Its Relations to Social Anxiety Disorder and Autism Spectrum Disorder

In current classification systems, selective mutism (SM) is included in the broad anxiety disorders category. Indeed, there is abundant evidence showing that anxiety, and social anxiety in particular, is a prominent feature of SM. In this article, we point out that autism spectrum problems in addition to anxiety problems are sometimes also implicated in SM. To build our case, we summarize evidence showing that SM, social anxiety disorder (SAD), and autism spectrum disorder (ASD) are allied clinical conditions and share communalities in the realm of social difficulties. Following this, we address the role of a prototypical class of ASD symptoms, restricted and repetitive behaviors and interests (RRBIs), which are hypothesized to play a special role in the preservation and exacerbation of social difficulties. We then substantiate our point that SM is sometimes more than an anxiety disorder by addressing its special link with ASD in more detail. Finally, we close by noting that the possible involvement of ASD in SM has a number of consequences for clinical practice with regard to its classification, assessment, and treatment of children with SM and highlight a number of directions for future research.

     

Behavioral and Socio-emotional Functioning in Children with Selective Mutism: A Comparison with Anxious and Typically Developing Children Across Multiple Informants

We examined differences among 158 children, 44 with selective mutism (SM; M = 8.2 years, SD = 3.4 years), 65 with mixed anxiety (MA; M = 8.9 years, SD = 3.2 years), and 49 community controls (M = 7.7 years, SD = 2.6 years) on primary caregiver, teacher, and child reports of behavioral and socio-emotional functioning. Children with SM were rated lower than controls on a range of social skills, but the SM and MA groups did not significantly differ on many of the social skills and anxiety measures. However, children with SM were rated higher than children with MA and controls on social anxiety. Findings suggest that SM may be conceptualized as an anxiety disorder, with primary deficits in social functioning and social anxiety. This interpretation supports a more specific classification of SM as an anxiety disorder for future diagnostic manuals than is currently described in the literature. The present findings also have implications for clinical practice, whereby social skills training merits inclusion in intervention for children with anxiety disorders as well as children with SM.     

Treating Youths With Selective Mutism With an Alternating Design of Exposure-Based Practice and Contingency Management

Selective mutism is a severe childhood disorder involving failure to speak in public situations in which speaking is expected. The present study examined 9 youths with selective mutism treated with child-focused, exposure-based practices and parent-focused contingency management via an alternating treatments design. Broadband measures of functioning were employed, but particular focus was made on behavioral assessment of words spoken audibly and daily in public situations. Treatment ranged from 8 to 32 sessions and resulted in positive end-state functioning for 8 of 9 participants. Broader analyses indicated greater effectiveness for exposure-based practice than contingency management. The results support recent case reports of behavioral treatment for this population but in more rigorous fashion. Clinical and research challenges are discussed, including caveats about length and intensity of treatment for this population and need to develop standardized daily measures.     

Finding One’s Voice: Psychotherapy for Dissociative Motor Disorders in the Indian Context

Dissociation is a prevalent disorder in India, however there is a lack of evidence-based psychological interventions worldwide. The present paper includes two case studies of dissociative motor disorder with onset in the perinatal period, seeking treatment in the Indian tertiary mental health set-up. Both cases presented with disabling symptoms of paraparesis, and mutism in one. The case series discusses similarities in presentation, socio-cultural contexts, and the psychotherapeutic approach. The psychotherapy process is discussed in detail, with a focus on challenges encountered, therapist reflections and supervision. Insights from treatment are presented, including the melding of approaches, and sensitivity of interventions to the larger socio-cultural framework.

     

A Controlled Single-Case Treatment of Severe Long-Term Selective Mutism in a Child With Mental Retardation

The aim of the present study was to demonstrate the efficacy of combining two operant learning procedures—shaping and fading—for treating selective mutism. The participant was a 12-year-old boy with mental retardation presenting a severe long-term selective mutism. The treatment was aimed at increasing the loudness of his vocalizations in an increasingly social milieu. The treatment was conducted over the course of about 20 weeks, with four 15-minute sessions per week. A gradual increase in speech loudness was observed. Data indicated a close correspondence between the changes in speech loudness and the criteria for reinforcement successively applied by the therapist, thereby confirming the causal link between the child's progress and the changes in reinforcement contingencies. In addition, good generalization was noted during the stimulus fading phase. Six-month follow up showed that loudness of verbalizations was still satisfactory in the classroom despite a change of school and peer group. The impressive improvement of the child's verbal behavior shows that the implementation of a treatment package including both shaping and stimulus fading is a worthwhile therapeutic option, even in the case of severe long-term selective mutism associated with mental retardation.     

Pure mutism due to simultaneous bilateral lenticulostriate artery territory infarction

A case of pure mutism without pseudobulbar palsy and other neurological findings resulting from simultaneous bilateral lenticulostriate artery territory infarction is presented. A 45-year-old woman suffered a transient ischemic attack with nonfluent aphasia and right hemiparesis. Six months later, she developed pure mutism without oral apraxia, pseudobulbar signs, and motor deficits. Magnetic resonance imaging revealed bilateral infarction in the lentiform nucleus regions. In the available data, there is only one report of simultaneous bilateral lenticulostriate infarction. To date, in all reported cases of mutism of subcortical vascular origin there are also various degrees of pseudobulbar signs and motor deficits and the responsible lesions are mostly consecutive. The case presented here is the first to show pure vascular mutism without other neurological findings.     

Progressive catatonia

We present the case of a young man with a diagnosis of a childhood-onset pervasive developmental disorder who developed a progressive neurologic deterioration with persistent catatonia and right hemiparesis. On his initial evaluation approximately three years after the onset of mutism, he manifested right hemiparesis and catalepsy. Two years later, although catalepsy had subsided, motor function had deteriorated so that he could not use his hands to feed or dress himself. Oral-facialbuccal dyskinesia manifested by blepharospasm and grimacing were present constantly during waking hours. Quantitative electroencephalography demonstrated markedly decreased amplitude, a finding associated with catatonia. Left sural nerve biopsy indicated large axon cylinder degeneration. Left deltoid biopsy demonstrated perimysial fibrosis and type II fiber predominance. Although magnetic resonance imaging of the head without contrast was normal, positron emission tomography indicated hypometabolism of the right cerebral and the right cerebellar hemispheres. The patient continues to deteriorate despite a course of 25 electroconvulsive treatments. He continues to manifest criteria for catatonia including motoric immobility, mutism, and peculiarities of voluntary movement such as prominent grimacing. We suspect an inherited neurodegenerative disorder. Since catatonia is a treatable condition frequently associated with medical and neurological diseases, examination for the features of catatonia must be included in the assessment of patients with progressive brain degeneration. This report is an attempt to clarify the traits of a serious variant of progressive brain degeneration.     

Elective mutism in children: A family systems approach

Abstract

Elective mutism in children is a relatively rare symptom which is more prevalent in the kindergarten population and has a higher incidence among immigrant families. Treatment strategies for this silent symptom include speech therapy, behavior modification, psychoanalytic, psychotherapeutic, family systems and a combination of these approaches. This paper reviews the types of elective mutism and proposes common characteristics of elective mutists' families. The potential for a redefinition of the term “elective mutism” is examined. It is concluded that family dynamics are an integral part of the elective mutism problem and need to be considered in a comprehensive treatment plan.     

Satisfaction with social support and depressive symptoms: a panel analysis

The literature suggests that persons who are dissatisfied with the amount of social support that has been provided to them may subsequently suffer from psychological disorder. At the same time, there is evidence that individuals who initially suffer from emotional disorder may consequently be less satisfied with their social support systems than may persons who enjoy better mental health. The purpose of this study was to test these competing hypotheses with panel data from a community survey of older adults. The findings indicate that changes in satisfaction with support tend to precede changes in depressive symptoms. A number of issues in the analysis of longitudinal data are discussed.     

The Social Phobia Inventory: validity and reliability in an adolescent community sample

Social anxiety disorder and social anxiety are highly prevalent psychological conditions in youth. Because of the known risks associated with the spectrum of social anxiety in youth, early detection with valid and reliable assessment measures is imperative. Self-report measures have become the most widely used method of assessment for child and adolescent social anxiety. Because research to date on self-report measures of social anxiety disorder in adolescents is limited, the primary objective of the present study was to contribute to the literature by examining the validity and reliability of a new self-report measure, the Social Phobia Inventory (SPIN), in a community sample of adolescents. The SPIN is a 17-item measure purported to assess the full spectrum of social anxiety disorder symptomatology. Previously, psychometric research on the SPIN in adult populations has demonstrated its validity and reliability. In the current psychometric examination, results revealed strong support for the temporal stability, internal consistency, and construct validity of the SPIN, suggesting it is an appropriate screening measure for the assessment of social anxiety disorder in adolescents.     

The communication disorder in dialysis dementia: A case report

The communication disorder in dialysis dementia is an integral feature of the syndrome. This report describes the communication disorder in a 67-year-old man over a period of 4 months from his admission to the hospital to his death. In the early stage of the syndrome, the most prominent feature was a speech problem, the characteristics of which may vary among cases. In the middle stage, it was difficult to distinguish among aphemia, aphasia, or a combination of dysarthria and confusional state. The severity of the problems in these stages was temporally related to the dialysis treatments. The final stage was characterized by constant mutism and was unrelated to the dialysis treatments. Death occurred 10 months after the communication problems emerged. Communication studies of dialysis dementia patients may offer a systematic method to monitor the course of the syndrome, its response to therapeutic trials, and a clinical model for the study of communication disorders in general.     

Cerebellar mutism

Cerebellar mutism occurs in about 25% of children following posterior fossa tumor surgery. It is usually accompanied by other neurological and behavioral disturbances. Mutism is transient in nature lasting several days to months and is frequently followed by dysarthria. In addition, impairment of language and other neuropsychological functions can be found after long term follow up in the majority of patients. The pathophysiological background of mutism may be higher speech dysfunction mediated by crossed cerebello-cerebral diaschisis which is frequently found during the mute period. Foremost injury to the bilateral dentatothalamocortical tract appears to be critical for the development of cerebello-cerebral diaschisis and subsequent mutism. Direct cerebellar injury is the likely reason for persisting deficits after the mute period. Minimization of injury to the dentatothalamocortical tract during surgery may be promising in the prevention of mutism. While there is no established treatment of mutism, early speech and rehabilitation therapy is recommended.     

Two sets of twins with selective mutism: neuropsychological findings.

Neuropsychological data are reviewed from two sets of dizygotic twins presenting with selective mutism characterized by situation specific anxiety, extreme passive behavior, lack of responsivity, lack of peer interaction, and a chronic course of selective mutism. Both sets of twins had a history of prematurity and delayed speech development. One set of twins presented with normal intelligence and normal receptive language skills but with expressive language and oral motor sequencing difficulties. The second set of twins presented with Verbal IQ deficits and significant receptive and expressive language deficits. A summary of current conceptualizations regarding etiology and treatment of selective mutism is provided.     

Mutism as permanent catatonic condition]

The history of a case of mutism, where the patient had been silent for more than twenty-five years, caused by the author to study and discuss this relatively infrequent catatonic symptom which is a type of schizophrenia, with frequent references being made to the results of psychiatric studies made by authors ranging from Kahlbaum to Leonhard. Permanent mutism as a possible phenomenal form was logically classified, by Leonhard, as a type of mannered catatonia.