Selective Mutism in Childhood: Clinical Presentation, Evaluation, and Treatment

Regarding a clinical case: comorbidity with oppositional defiant disorder

Joaquín Díaz Atienza¹Marina Díaz Blanquez²

This post is an update of a work previously published in the Journal of Child and Adolescent Psychiatry and Psychology.³

INTRODUCTION

El selective mutism It is defined as a childhood and/or adult disorder (DSM-5) characterized by a persistent inability to speak in social situations, affecting school performance or social communication, lasting at least one month, and not explained by any other organic or child psychiatric cause. Depending on the researchers' approach, it is usually classified either within language/communication problems or anxiety/phobia disorders, although in the latest edition of the DSM-5⁴It has been included within anxiety disorders and is no longer considered a disorder specific to childhood and adolescence (Table 1). Here, I will simply present it semiologically as it usually manifests in childhood. 

CLINIC

Table 1. DSM-5 Criteria

DSM-5 DIAGNOSTIC CRITERIA FOR SELECTIVE MUTISM: 313.23

A. Consistent failure to speak in specific social situations where there is an expectation to speak despite doing so in other situations. B. The impairment interferes with educational or occupational achievements or social communication. C. The duration of the disturbances is at least one month (not limited to the first month of school). D. It cannot be attributed to a lack of knowledge or comfort with the spoken language required in the social situation. E. The disturbance is not better explained by a communication disorder with onset in childhood, autism spectrum disorder, schizophrenia, or another psychotic disorder.

The only one The pathognomonic symptom is the absence of speech by the patient in certain environments or with certain people, usually strangers. When the absence of speech is generalized, it is called global or progressive mustishness.

In an attempt to clarify this surprising clinical problem as much as possible, empirical research (based on large samples and statistical procedures) and other research based on the clinical method have been conducted. A comprehensive review in the PubMed Database This highlights how cumbersome it is to define exactly what selective mutism is, as well as the wide variation in its clinical expression. As an example, we will present some bibliographic findings that, as mentioned earlier, demonstrate the lack of a unified definition.

In Spain, the monograph on Olivares Rodríguez published in 1996⁵This author proposes a classification of childhood mutism, based on two fundamental aspects: the context in which it occurs and its extent. He distinguishes between the aversion to speaking (it would only happen in front of people in one's inner circle); selective mutism(only speaks to people in their inner circle) and progressive mutism (doesn't talk to anyone). The clinical reality is that, quite frequently, the aversion to speaking evolves into progressive or global mutism if early intervention is not implemented.

A) Empirical (statistical) studies

We will cite two studies that I believe summarize quite well what we find in the literature as a whole. The first is the research conducted by Cohan et al. (2008)⁶They study a sample of 130 children with selective mutism following the criteria of DMS.-IV-R44 boys and 86 girls, aged between 5 and 12 years (M= 6,98; SD=1,98). As a criticism of the sample, I consider it excessively heterogeneous, since it includes children with a history of or presence of delays in communication and the quality of expressive and receptive language; all of whom, according to section D of the DSM-IV-R, would be Exclusion criteria.

The objective is to study the presence of:

• • Communication delays

• • Quality of expressive and receptive language.

• • Functional disability.

• • Internalizing and externalizing symptoms.

• • Social and behavioral problems.

1. 1. Slightly Anxious Oppositionist

1. 1. Delayed anxious communication

1. 1. Exclusively anxious

1. 1. Slightly Anxious Oppositionist

They represent the 44,6% of the sample studiedBehavioral and syntactic language construction problems are observed. Social anxiety scores are clinically significant. Behavioral problems consist of stubbornness and behavioral control in situations that provoke anxiety.

2. Delayed anxious communication

They represent the 43,1%Notable problems include receptive and expressive language; clinically significant social anxiety; greater severity of mutism; and a greater number of behavioral problems than in the anxious group.

3. Exclusively anxious

They represent the 12,13%They exhibit lower levels of anxiety and better skills in receptive and expressive language than those in the first group.

The authors conclude that, overall, the positive association between behavioral problems and language difficulties is evident.

Another prominent and more recent empirical investigation is that of Mulligan et al. (2015) (cited by Kearney and Rede, 2021)⁷These authors describe five clusters after analyzing their sample. They are:

1. 1. Global silence: It was present in 50% of the sample. They generally presented with less disability. The female/male ratio was 2:1.

1. 1. Low-functioning mutismThey represented 16,2% of the sample. They were particularly characterized by greater academic difficulties, sensory and executive function problems, and family psychopathology. They received special education.

1. 1. Mutism with sensory pathology. They represent 15,5%. A higher number of cases present with bilingualism, motor difficulties, oppositional behavior, sensory integration problems, and separation anxiety.

1. 1. Mutimo anxiousThey represented 10,6% of the sample. It is characterized by difficulties in executive functions and oppositional defiant behavior.

Empirical research presents a significant methodological challenge: the heterogeneity of the sample and the disregard for established diagnostic criteria. Therefore, its explanatory power beyond the studied sample is highly questionable. This primary bias cannot be corrected by statistical methods.

Hence the importance of clinical studies, which complement them.

B) Clinical studies

Just as they collect Kearney and Rede (2021In their literature review, a wide variety of situations have been described in children who have presented with selective mutism. Thus, a group of patients is described who are characterized by: traits of behavioral inhibition; those who, in situations that demand spoken language, are especially affected by specific fears; inhibitions due to previous traumas; and those who manifest selective mutism only in school settings. Others report that it occurs in 30% of children with an oppositional and defiant temperament. The current tendency to associate it with... Autism Spectrum Disorders, at least as a comorbidity, contributing to diagnostic confusion and hindering the development of conveniently standardized treatment guidelines.

ETIOLOGY

Regarding etiology, in Figure 1, we present the multifactorial view presented by Rozenek et al (2020)⁸ Figure 1   Although by definition there should be no organic cause to justify it, studies continue to appear linking mutism to other psychiatric and medical disorders in general. The first to appear were the posterior fossa alterations, specifically due to tumorous or other causes affecting the cerebellum.

Some have also been described genetic abnormalities related to selective mutism: 7q11.23 duplication syndrome (Mervis et al., 2021)⁹; disease VPS13A, Peikerty et al (2023)¹⁰), as well as the CNTNAP2 polymorphism (rs2710102)¹¹ We consider these circumstances as coincidental facts and whose "selective mutism" does not clinically or etiologically correspond to the disorder listed in the DSM-5 as selective mutism.

On the contrary, we are closer to other explanatory modelssuch as the psychodynamic model and the one derived from the psychology of learning.

The psychodynamic: Their etiopathogenic explanation is based on the existence of a series of factors that would give rise to a neurotic reaction. Namely: a) hypersensitivity to instinctual impulses, b) the existence of a psychological trauma during the critical period of language development, c) lack of sufficient security in the child's environment, d) the persistence of mutism as a fear-reducing mechanism, and e) a family environment based on dependence and permissiveness.

Learning theory: The explanation is based on the following assumptions:

a) Selective mutism is a learned behavioral response.

b) Discriminative stimulus situations are fundamental to maintaining the disorder. Hence, treatments are based on stimulus control.

According to AMARI (1999)¹² Selective mutism is based on the loss of generalization of a type of operant response across environmental contexts. Contingent reinforcement would increase behaviors that did not previously exist, basing its interpretation on the presence of discriminative stimuli and stimulus generalization. Some authors, such as Anstending (1999),¹³They assert, through an exhaustive literature review, that selective mutism is an anxiety disorder or a symptom of separation anxiety, social phobia, or post-traumatic stress disorder, even going so far as to propose a change in future revisions of the current DSM-IV.

EVALUATION

There are protocols that thoroughly evaluate the social behavior and family environment of individuals with selective mutism. However, in my view, the evaluation is quite simple: using some anxiety scale (we used the Spence Children's Anxiety Scale, Spanish version), the neurodevelopmental assessment through the WISC or the WPPSI, depending on age, together with von videos or recordingsThis is more than enough to give us a sufficient clinical understanding of the importance of mutism. However, there is a situation that often goes unnoticed and that it is imperative to rule out in all evaluations for this reason. I am referring to the possibility that mustiness is often related to the existence of abuse and/or sexual assault .

The reports should be obtained primarily through family and school interviews. Observation of the patient during the interventions is equally essential.

TREATMENT

While a wide variety of techniques are described, as we will see in the clinical case, none stands out as being more efficient or effective than another. We list those that are commonly recommended in the literature:

• • Exposure techniques.

• • Family therapy.

• • group therapy.

• • Contingency management with parents.

• • Self-modeling.

• • Social skills and verbal training.

• • Gradual dissipation of the stimulus.

• • Pharmacotherapy.

CLINICAL CASE

The clinical case we present has already been previously published in the Journal of Child and Adolescent Psychiatry and Psychology.

AG is a five-year-old girl who is seen at our unit. The reason is selective mutism that began at age three. Its onset coincides with a visit to her parents' home by relatives and the start of the school year, although her mother insists that the trigger seems to have been something that happened during the dance classes she attended when she was three.

She tends to choose the people she speaks to, regardless of whether they are familiar to her or not, depending on how well she connects with them and, almost always, on how they address her. She is a clearly seductive girl with her interlocutor, showing no resistance to being alone with the therapist and clearly giving the impression that she displays "her problem" with a certain gratification. She smiles, gestures, approaches, and interacts without difficulty; she enjoys physical contact. She gives the impression that she might start talking at any moment. This leads to repeated attempts to get her to communicate verbally, resulting in a complete blockage in all aspects of communication, including gestures.

If she is threatened with discontinuing psychotherapy, she becomes aggressive, as she does when the therapist mirrors her behavior, communicating with her in the same way she communicates: through gestures. Sometimes, in conjunction with her distress, she even exhibits physical aggression towards the therapist.

His general behavior does not give the impression that the underlying mechanism of his mutism is phobic in nature, with defiant and negativistic behaviors predominating.

The difficulties arising from his mutism are social in nature, with a clear deficiency in social relationships. He uses his sister to communicate with his schoolmates.

Regarding her personal medical history, she has celiac disease but no coexisting eating disorders and is very compliant with the dietary restrictions related to her condition. She sleeps normally and has no other psychological symptoms.

Additional tests:

The WPPSI was administered through the mother, who is a psychologist, yielding the following results: Verbal IQ: 93, Performance IQ: 107, Performance IQ: 100. We observed a 14-point difference between the verbal and performance scores, explained by low scores in general knowledge, abstract thinking, and auditory sequential memory. The Spence Children's Anxiety Scale (Spanish version) was also administered.

Recordings were made during typical family life situations where no deficits in language production or articulation were observed. A record was also kept of situations in which AG refused to speak and with whom.

Treatment and evolution

Medication was prescribed, first pimozide and, when treatment failed, clomipramine. At the same time, an intervention program focused on stimulus control was attempted but yielded no results. AG spoke to whomever she wanted, whenever she wanted, and wherever she wanted, making intervention planning difficult.

Given that he was starting primary school and one of the places where he refused to speak was at school (with almost all his classmates and teachers), an attempt was made to develop a Classroom Intervention Program that would be modified based on the results obtained. The points on which it was based were the following:

1. 1. Give the impression that the problem is not significant to the teacher. To do this:

• • She will address her normally, without paying attention to her silences or showing concern. For the teacher, whether or not AG is mentioned will be irrelevant, both for completing school assignments and because of its complete lack of emotional resonance.

• • Situations requiring a verbal response will be avoided. When this is not possible, and if AG does not respond, the turn will be passed to another student as if nothing had happened, without making any comments, positive or negative, or expressing concern.

• • If necessary, the evaluation of the teaching objectives would have to be adapted to the handicap presented by AG, since it was not in our interest for this eventuality to cause distress to the teacher and the parents and for it to be observed by AG.

• • Comments regarding AG's progress, both regarding his disorder and the difficulties arising from his problem in the school setting, would not be made in his presence.

• • At home, his parents would not ask him any school-related questions that had to do with his mutism.

• • The instruction was given to view the situation as if AG had no problem, as if she spoke normally; daily behavior toward her should be as if "THE PROBLEM DOESN'T EXIST." Therefore, neither our gestures, nor our speech, nor our attitudes should show the slightest concern in her eyes.

EVOLUTION

During the implementation of the aforementioned guidelines, some symptoms of anxiety appeared. Given that his classmates were progressing in their literacy development, AG began speaking with two classmates, hoping they would help him with his schoolwork, but threatening to never speak to them again if they mentioned him talking to them. One day, for no other reason than his falling behind his classmates and the teacher's change in attitude, he told his mother that he would begin speaking to the teacher on a specific date, and he did so. First in a low voice (whispering), and shortly after, normally.

During follow-up psychotherapy sessions, he challenged me to talk if I went to his country house for a weekend. He let me know this through his mother. I promised I would. We started talking in therapy at the next session. Two sessions later, follow-up began via telephone.

In the telephone follow-up we have carried out at 3 and 9 months, AG continues to speak normally with the teacher and has generalized to the classmates.

REFERENCES