“The child is just being stubborn and controlling by not talking.”
This belief is so pervasive that the disorder was called “Elective mutism” for over 50 years, as if these children made a conscious decision, or “elected” at some point, to quit talking. It is assumed that such “controlling” behavior is a result of conflicts in the parent-child relationship, with the child
attempting to win the struggle by resorting to mutism. In this view of the problem, parents, usually the mother, are assumed to lack parenting skills, or character strength or such, and are thus blamed for the child’s disorder. Fortunately, modern child psychiatry is moving away from such outmoded theories. Most of thereports of Selective Mutism published in the past decade recognize the disorder as stemming from severe social anxiety and excessive inhibition, not from bad parenting. The developmental history of children with Selective Mutism is usually that they always had a problem with the shyness and fear of talking to strangers, even before they entered school, with parents describing an insidious onset ofthe mutism, rather than a sudden change in behavior where a child decides to
act in a certain way. Behavior that was described in the past as “controlling” may now be seen as trying to avoid very anxiety-provoking and distressing situations, driven by fear rather than by anger.
“Children who are mute must have been traumatized.”
This is what I call the Hollywood version of mutism. It makes for good drama, such as in the rock opera Tommy and the movie The Piano, but it does not correspond to the usual reality of the children I have seen. While cases of mutism have occurred as a result of a child being abused or emotionally or physically traumatized, it seems to be very rare. I have not yet seen such a case, where a child spoke normally until a traumatic incident and then stopped speaking. Such cases are documented in the medical literature case reports, but in the two systematic studies, including 50 children evaluated by our group at Columbia and 30 evaluated by Drs. Black and Uhde at NIMH, no children were found to have such a history. A report in 1980 by Hayden described “traumatic mutism” as a subgroup of cases reported in a chart review study, but in the paper it is stated that where police or social service reports could be found to document child abuse, the reports always indicated that a child was abused because they were not speaking, not the other way around. Why the author considered this “traumatic mutism” is a mystery. Like so many other psychiatric disorders, it seems that being excessively shy and mute makes a child vulnerable to being taken advantage of or abused. This is a general problem in the mental health field and in our society, confusing cause and effect between bad experiences and mental disorders. Many parents have reported to me that they were suspected of child abuse, some even have been investigated by child welfare agencies, because their child did not talk in school. It is assumed that such children “must be hiding some deep, dark secret” about the family, or an abusive situation, as the reason for mutism.
“Don’t worry, it’s
just shyness that they will outgrow.”
Many parents have told me that they hear this often from doctors and educators. While there are undoubtedly many normally shy children who may talk little or none when they first enter a new social situation, it is not normal to remain silent in a classroom indefinitely. We do not have good estimates for the prevalence of Selective Mutism in this country, as the few epidemiological studies that have been done on childhood mental disorders in community-based populations have not included Selective Mutism as a disorder to be studied. A school survey in Britain 30 years ago found a rate of about 7 per 1000 children entering an urban school system, at age 5, were not speaking in the classroom. When surveyed again after a year in school, that number had dropped by a factor of 10, to slightly less than 1 per 1000. The study was confounded by including high rates of immigrant children who may not have learned English yet at the time of the first survey, and thus might not have met modern diagnostic criteria for Selective Mutism. However, the second figure, of about 1 per 1000, is likely to be a truer estimate of the prevalence of Selective Mutism and matches the finding of a similar survey in Canada done soon after. It would appear that some children do “outgrow it” soon after entering school. However, the consensus now amongst professionals who have seen many children with this disorder is that, if it lasts beyond the first few weeks of entering school, it tends to be persistent. I have also come to believe, based on review of the professional literature and personal experience with patients and their parents’ descriptions of previous treatments, that children with Selective Mutism do not improve quickly with conventional psychodynamic psychotherapy aimed at uncovering and working through emotional conflicts.
Current thinking is that social anxiety disorders are more of a biologically-based abnormality than a neurotic problem based on an emotional conflict. Further, our studies and my clinical experience indicate that older children, who have suffered longer with Selective Mutism, are more resistant to all forms of treatment, taking a much longer time and more intensive combination of behavioral and pharmacologic treatment to get improvement. Therefore, I recommend starting treatment as soon as one sees impairment in school that lasts more than the first few weeks. Begin treatment when the child is young and the disorder is easier to treat. Do not wait to see if a child will outgrow it when it has persisted beyond the first few weeks of school.
“If the child does not speak, they must have a language or speech delay.”
Many parents report that schools and professionals recommend speech therapy for mute children. While about 10% of the children seen in our research program did appear to have a language or learning delay, or speech articulation problem, needing special educational or speech treatment, most had normal or above average speech and verbal skills when carefully evaluated. However, it is rather difficult to evaluate a child’s verbal skills when they do not speak to teachers, professionals and other unfamiliar adults. Social anxiety causespeople to be reluctant to guess or respond if even a little bit unsure of theanswer, from fear of embarrassment at making a mistake. Even when children respond non-vocally to tests of receptive language, which measure the ability to understand language, rather than the ability to express oneself, the test resultcan be an underestimate of true ability because of fear of guessing wrongly. Hence, socially-anxious children tend to do less well with such assessments performed by strangers than they would when speaking with family, resulting in test scores which could be an underestimate of a child’s true verbal skills. I have seen this effect in children I examined before and after pharmacologic treatment of the social anxiety, their performance on verbal measures often improved.
However, there are a small minority of children who have both a language or speech problem and social anxiety, and all children deserve very careful assessment of verbal and academic skills before educational or treatment recommendations are made. Unfortunately, educators are often frustrated and bewildered by children who do not speak to them, and special educational placement or speech therapy are their main forms of help to offer, so they often recommend such even when it is not clear that it can help. I believe that smaller classrooms with specially trained teachers can help some children with Selective Mutism to be less anxious and more likely to begin speaking. But when such classrooms are composed predominantly of aggressive and disruptive children, as is often the case, it is unlikely to be an environment in which a child will conquer their anxiety and shyness and probably should not be recommended in the absence of clear evidence of learning delay.
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