Selective Mutism DSM-5 312.23 (F94.0)
DSM-5 Category: Anxiety Disorders
Introduction
According to the DSM-V, Selective Mutism is a childhood disorder typified by an inability to speak in certain circumstances. Specifically, it is a consistent failure to speak in certain social situations where there is a natural expectation of speaking (American Psychiatric Association, 2013). For instance, a child may be verbal at home but unable to speak in a classroom environment. Researchers believe the behavior is a form of social phobia; often not recognized before the age of 5 when a child enters school.
Symptoms of Selective Mutism
Manifestations of Selective Mutism are varied. An early warning sign may be if a child who is normally talkative in the home resorts to monosyllabic utterances or gestures to communicate (Wasssom, 2010). A medical professional would rule out the possibility is not the result of an inability to speak the language or a simple lack of knowledge regarding a topic the child is asked to address. Too, Selective Mutism must be in evidence for more than the time span of one month; and it will be determined to have a detrimental impact on school or work. There must also be no evidence of associated communication disorders such as stuttering; or occurrence during other psychotic disorders. However, additional behavioral correlates indicative of Selective Mutism include clinginess, temper tantrums, excessive shyness and social isolation (McKay & Storch, 2011).
Diagnosis
The diagnosis of Selective Mutism may begin when parents recognize out-of-the ordinary behavior such as a child who chatters at home but consistently refuses to speak in public such as church or other social situations. An unwillingness to speak may even occur at family gatherings such as holiday get-togethers. Otherwise, a teacher may express concern after the child has been in a classroom for a month or more. Parents should begin by getting a complete physical exam for the child including standardized testing and psycho-educational testing. A comprehensive developmental screening is advised as well as a thorough speech and language evaluation.
Seeking the expertise of a professional in the diagnosis of communication disorders is advisable as the diagnosis of selective mutism is a painstaking and time consuming process. This begins by making an appointment with a trained professional who is familiar with Selective Mutism. In a parental interview the physician will compile a complete dossier of the child’s medical history, development, social interactions, manifestation of anxiety, behavioral characteristics, and home life description. The professional will schedule a follow-up interview with the child; aware he or she will likely be uncommunicative. But an expert can expect assess interpersonal communication skills and build rapport that will determine if Selective Mutism can ruled in or out as a diagnosis.
Psychologist Based Treatment of Selective Mutism
After a diagnosis of Selective Mutism has been made the parents should seek the counsel and support of professional child therapists to ensure a coordinated treatment approach is designed and implemented. Any of the following psychotherapeutic approaches may be used in treatment. Behavioral therapy strategies include contingency management, social skills, stimulus fading and modeling have all been successful for treating Selective Mutism (Dombrowski; Gischlar; & Mrazik, 2011). Each is intended to help the child gradually adopt speaking-type behaviors, and includes positive reinforcement when the child is successful.
Cognitive-behavioral (CBT) strategies involve the identification of anxious thoughts that may contribute to the mute behavior and teaches the child to identify negative thoughts and coach the children to replace thee with positive thoughts instead. A host of other therapies may also be introduced and include (but are not limited to) emotional reinforcement, self-esteem strengthening and more (Viana, Beidel & Rabian, 2009).
Pharmacological Treatment of Selective Mutism
Research has been conducted on the use of pharmaceuticals as intervention for Selective Mutism. This has included such prescription medications as antidepressants or antianxiety medication. However, these studies have been limited in scope. As this disorder has been designated to be related to social anxiety disorder or social phobia; the use of medication is not totally unexpected however. Increasingly, these anxieties have been traced to a chemical imbalance in the brain; specifically the neurotransmitter named serotonin. Pharmaceuticals for treatment are known as serotonin reuptake inhibitors (SSRI's). These include Prozac, Paxil, Celexa, and Zoloft. Other medications are Buspar Serzone, and Remeron.
Parents should note that these drugs have not been approved by the food and drug administration (FDA) for the treatment of SM in children. The side effects are normally quite minimal and can it may be possible to avoid them altogether by beginning with a very low dosage level and adjusting as recommended. However, medication alone will not resolve the problem. Appropriate behavioral or cognitive-behavioral therapy is strongly recommended. Also, the pharmaceutical component of a treatment plan may call for the child to remain on the medication for up to twelve months. There is research to support the notion that this time period is sufficient for a child’s anxiety to decrease and confidence increase. Discontinuing the medication will require physician oversight to ensure there are no adverse side effects. Finally, it should be noted that these medications do not target the mutism itself – but the associated anxiety. Psychotherapists and parents should be working in collaboration to determine the appropriateness of medication for a young child who suffers from Selective Mutism.
Prognosis
Certainly, the earlier a child is diagnosed and engages in a treatment plan for Selective Mutism then the faster they will be able to response and the better the overall prognosis. It is evident that the longer a child remains mute the more conditioned the child becomes to this response. In short, prognosis for this disorder is excellent; many children overcome it completely with proper treatment.
Functioning with Selective Mutism
Families of children with Selective Mutism must first admit their child may be exhibiting an unusual level of social anxiety. Next, the parents will want to seek medical attention for a proper diagnosis and development of a treatment plan. Most importantly, though, is for families to embrace the therapy and play a proactive role in their child’s treatment.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Dombrowski, S.; Gischlar K.; & Mrazik, M. (2011). Assessing and Treating Low Incidence/High Severity Psychological Disorders of Childhood. Springer, New York.
McKay, D.:& Storch, E.(eds) (2011). Handbook of Child and Adolescent Anxiety Disorders.Springer: N.Y.
Viana, A.; Beidel, D. & Rabian, B. (2009). Selective Mutism: A review and integration of the last 15 years. Clinical Psychology Review: Vol. 29; Iss. 1,
Wassom,M (2010).“Selective Mutism”. Journal of Developmental and Behavioral Pediatric.Vol. 31, Iss. 8.
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