Selective Mutism: Understanding and Management

Selective Mutism: Understanding and Management

Charu Kriti (National University of Study and Research in Law, India)
DOI: 10.4018/978-1-5225-4955-0.ch019

Abstract

Selective mutism is a disorder that is characterized by a failure to speak in certain social settings, like the school, while speaking normally in other settings, like home. The settings in which the failure to speak occur are those where speech is expected from the individual. It is a disorder that onsets in childhood, and if left untreated, may go well into adolescence. For a very long time, this disorder has been overlooked and understudied. Though rare, the disorder may pose a potential threat to the social and academic development of a child suffering from it. The DSM-5 has classified selective mutism as an anxiety disorder. The present chapter intends to cover the psychosocial approach to the disorder, the diagnostic criteria, the etiology, the treatment of the disorder, and the management by respective caregivers. An analysis of case studies has also been given in the chapter.
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Introduction

Burson (2006) stated, “At home, Grace was outgoing, funny and bossy to her little sisters. It was just the opposite at school: She was withdrawn, her face a blank stare. She didn’t utter a single word to anyone.

Colborn (2017) reported, “At home, Nola is a talkative, high energy child, even as a toddler she would always be making noises. Lately, she would become quiet in public situations and her parents think she is just being shy.

There have been many more stories like these. Parents have reported that their usually talkative children have suddenly shown signs of absolute mutism in certain situations. The entire demeanor of the child changes and she or he shows a drastically different set of behavior patterns in such situations. Quoting a parent, “she went to school that day and came back a different kid” (Burson, 2006). These are instances of what has been called Selective Mutism by the DSM-5 (APA/American Psychiatric Association, 2013).

Selective Mutism is a psychological disorder which has gone unnoticed, misdiagnosed and overlooked for a long time. It is only in the last decade that this particular condition has been talked of at length. It is strange that though the initial reference of selective mutism goes back to over 125 years ago, it is as late as 2006, after the publication of an article called "Behind the wall of silence" by Newsday, that streamlined discussions started (Burson, 2006).

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Defining And Understanding Selective Mutism

History of Selective Mutism

It was back in 1877 that a German physician called Adolph Kussmaul used the term ‘aphasia voluntaria’ to describe children who ‘refused’ to speak though they could speak normally. Kussmaul used the term after he reported three clinical cases with similar symptoms (Jainer, Quasim, & Davis, 2001). In 1934, a child psychologist from Switzerland called Mortis Tramer used the term ‘elective mutism’ for the first time to describe “a fascinating group of children, whose talking is confined to familiar situations” (Kolvin, Trowell, Le Couteur, Baharaki, & Morgan, 1997). Going by both the terms, it can be seen that the understanding was of a voluntary act of refusing to speak, which would mean it was an oppositional behavior (Noelle, 2017).

The same understanding is reflected in the diagnostic criteria given by the earlier versions of the Diagnostic and Statistical Manual (DSM). The third editions of the Diagnostic and Statistical Manual (DSM-III and DSM-III-R) explained elective mutism in terms of “refusal to speak”. This was changed in the fourth edition of DSM, where it was recognized as an inability to speak (Noelle, 2107). The diagnostic criteria given in DSM-III (APA, 1980) talks of “continuous refusal to speak in almost all social settings”, while the diagnostic criteria given in DSM-III-R (APA, 1987) updated it to “persistent refusal to speak in one or more social settings”. In contrast, after the publication of DSM-IV in 1994, the diagnostic criterion read “failure to speak in specific social situations”.

There are other differences between the elective mutism as described in the third editions (DSM-III and DSM-III-R) of the Diagnostic and Statistical Manuals (APA, 1980, 1987) and the selective mutism as described in the subsequent editions, i.e., DSM-IV (APA, 1994), DSM-IV-TR (APA, 2000) and DSM 5 (APA, 2013). Some instances would be the predisposing factors and differential diagnosis.

According to both the third editions of the DSM (APA, 1980; 1987), maternal overprotection, speech disorders, mental retardation and trauma were possible predisposing factors for the onset of selective mutism. These factors were, however, removed in the subsequent editions of the DSM (DSM-IV, DSM-IV-TR & DSM-5). Similarly, the third editions stated that the ‘refusal’ to speak could be differentially diagnosed as developmental disorders, while the later editions (DSM-IV & DSM-IV-TR) list speech abnormalities and social anxiety disorder as differential diagnosis for selective mutism. DSM-5 (APA, 2013) lists a differential diagnosis of communication disorders, social anxiety and psychotic disorders like schizophrenia and autism spectrum disorders.

Key Terms in this Chapter

Systematic Desensitization: This technique is used in behavior modification. The individual is presented with anxiety-inducing stimuli and the presentation is combined with relaxation, thereby leading to a pairing of relaxation and the anxiety-arousing stimuli.

Stimulus Generalization: The desired behavior is reinforced in the presence of different stimuli and different situations.

Contingency Management: A technique where the individual is positively reinforced for indulging in the desired behavior instead of the behavior substitute that the individual has created for himself or herself.

Selective Mutism: A form of communication disorder where the individual fails to speak in a social setting, where speech is expected. The individual is capable of speech and speaks normally in the presence of close family members.

Escape-Avoidance Procedure: A technique where, when the individual is not willing to go through the modification process in its entirety, he or she is allowed to leave only after making at least one display of the desired behavior.

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