If you’ve ever worked with a student identified as being diagnosed with Selective Mutism, you might see how easy it is to understand why many assume that the student is willfully avoiding eye contact, conversation, or compliance. How can it be that the same child, who speaks so clearly and animatedly in one setting, does not speak in another? Why is it that an individual who is described by family and acquaintances as sweet, compliant and sensitive, can seem so obstinate and manipulative in school? We assume that if a child is able to speak, then when he refuses, the decision must be conscious. Having encountered Selective Mutes in my professional life and having witnessed the parents speaking for the child before he even had a chance to respond, I, too, fell into the erroneous belief that such behaviors were intentional and controlled.
Selective Mutism (SM) is described as a psychiatric disorder characterized by a persistent failure to speak in specific social situations, which continues for more than a month. It is most commonly found in children and appears to be related to severe anxiety, shyness and social anxiety. The exact cause of SM is still unknown and was first reported by the German physician Kussmaul in 1877, who called the condition “Aphasia Voluntaria” meaning voluntary autism. The term “Elective Mutism” was later coined by English physician Tramer in 1934 who used this term to describe children who spoke only to certain people. In 1994, the Selective Mutism Foundation (www.selectivemutismfoundation.org) was instrumental in changing the name in the DSM IV to Selective Mutism as the feeling was that the word “elective” suggested a preference, implying a deliberate decision not to speak, and “selective” implies a less willful component. Another important change brought about by the foundation was replacing the term “refusal to speak” with “failure to speak.”
The first symptoms of SM usually appear between the ages of one and three and apart from a reluctance to speak (with the exclusion of populations including immigrants who speak another language, experience SM for a short period of time, and those who temporarily stop speaking due to a traumatic event) can include shyness, little eye contact, social isolation, fear of social embarrassment, withdrawal, clinging behavior, compulsive traits, negativism, oppositional behavior when trying to avoid social situations, temper tantrums and a fear of people. Seventy-one percent of children in a study conducted by Fundutis et. al. (1979), displayed difficulty in performing motor activities and had bowel and bladder problems. Some people with social anxiety symptoms may experience pauresis, a fear of using public restrooms, perhaps to avoid the sounds of urinating that others may hear (Stein & Walker, 2001).
Current research has discarded the theory that SM is caused by abuse, which in the past has caused devastation to families suspected or accused of parental child abuse and has deterred many families from seeking help for their children. It should also be noted that there is no relationship between SM and Autism, with the difference being that Autistic individuals have limited language ability while people with SM can speak, and normally will do so in comfortable situations. True language delays, speech pathologies or learning problems are only present in about 10 percent of cases, but because their language and academic abilities are hard to evaluate due to the mutism, children are often placed in speech and special educational services, aimed at improving language or speech skills, without needing or benefiting from them. Selective Mutism has mistakenly been classified as a speech or communication disorder, but it has been shown that this is inaccurate.
There are varying degrees of the disorder and not all those with SM require treatment, and it is difficult to know if intervention is necessary. For those who experience severe forms of SM, treatment is recommended as symptoms can increase, and generally the younger the child is when treatment begins, the better the chance of recovery. Treatments consisting of behavioral management programs that deal with phobias and medications used for anxiety and/or social anxiety, have been beneficial for many, usually in conjunction with behavioral treatment. Prozac (fluoxetine), a selective serotonin reuptake inhibitor, is useful for socially anxious adults. Based on this new understanding of mutism as a consequence of social anxiety, Prozac has been used in three studies with selectively mute children: an uncontrolled trial (Dummit et al, May 1996, Journal American Academy Child Adolescent Psychiatry), a small placebo-controlled trial (Black & Uhde, 1994, Journal American Academy Child Adolescent Psychiatry), and a crossover-discontinuation placebo-controlled study (Dummit et al, reported as New Research, AACAP Annual Meeting, 10/96). All three studies support efficacy and safety in this use. Treatment needs to be consistent with positive reinforcement and rewards used to motivate the child to speak. Punishment, negative consequences and bribery have been shown to be harmful.
While certainly not the norm, there have been cases of un-treated or ill-treated individuals that have turned violent. In April of 2007, Cho Seung-hui, a Korean immigrant, murdered 32 students at Virginia Tech before killing himself. Cho was diagnosed with Selective Mutism in his early academic years, and was placed in special education under the classification of “emotional disturbance.” He was excused from oral presentation and answering questions in class. Aided by these efforts to compensate for his disability, he was able to garner A’s and B’s in regular and Advanced Placement classes and was admitted to Virginia Tech. Mr. Cho’s, and others’ experiences in special education may suggest that schools might be placing too much emphasis on academic advancement of bright but troubled students and not enough to their emotional or other disorders. As the individual enters adolescence, depression is more common and can lead to more severe anxiety, social isolation, lower performance in school, suicidal thoughts and self-medication with drugs and alcohol.
In order to have any success with individuals with SM, it is important for teacher training addressing the nature of SM and use of classroom strategies with on-going support for all those who work with the student. Understanding that the failure to communicate is due to an anxiety condition and not pressuring the student to speak, with no teasing, threatening or punishment for failure to participate is imperative. Written work, non-verbal communication, audio or videotaping, collaboration with friends, use of a computer or use of another person as a verbal go-between can be used as alternative forms of assessment and participation. Waiting for the student to speak is anxiety-provoking, and making a big deal of any vocalization that does occur might make the student pull away, as that is turning attention toward the student. Clear, specific assignments and expectations can also reduce the student’s anxiety, as well as hands-on activities which has the student more engaged and less distracted by worries. Social support outside of the classroom and at unstructured times is another tool that can help the older student with SM develop social relationships and realize academic success.
Sheree Incorvaia is the Director or Recruitment for New York Institute of Technology’s Vocational Independence Program and has worked with special needs students for the past 20 years.
