Elective Mutism

Elective mutism many researchers call a syndrome-disease. Insufficient knowledge and complexity of this developmental anomaly often lead to diagnostic errors (for example, diagnosing schizophrenia or mental retardation) or assessing the state of both stubbornness and simulation and, as a consequence, choosing inadequate medical, psychological and pedagogical approaches. In many cases, the violation of speech contact in certain social situations is regarded as temporary and spontaneously docked. In the case of a protracted or chronic elective mutism, improper treatment or lack of it often leads to severe forms of school as well as social disadaptation, including when a person reaches adulthood. In this regard, the timely establishment of an accurate diagnosis by a psychiatrist is of particular importance for the appointment of a full-fledged treatment. The clinical manifestations of this pathology and the dangers of its social outcome should be aware of the psychologists of children's institutions, educators and teachers, who are the first instance on the path of a "silent" child.

Synonyms

• Selective mutism.
• Selective mutism.
• Partial mutism.
• Voluntary mutism.
• Psychogenic mutism.
• Situationally caused by mutism.
• Characterological mutism.
• Speech phobia.
•  Nemota with hearing preserved.

[1], [2], [3], [4], [5], [6], [7], [8]

Epidemiology

Elective mutism is regarded as a relatively rare phenomenon, the prevalence of which among children and adolescents, according to official data, is 0.02-0.2%. There is evidence that in children who started schooling, a short elective mutism appears much more often (0.72%).

[9], [10], [11], [12], [13], [14], [15], [16]

What causes elective mutism?

Elective mutism, as a rule, has a psychogenic origin, is associated with an overvalued attitude towards a particular situation and is expressed in a regressive reaction to separation from relatives, resentment, a sense of own insolvency, which is more often a form of passive protest. For such deviation, a hysterical mechanism can be characteristic that allows reactions such as "imaginary death" to develop. Elective mutism is also able to take the form of an obsessive fear of discovering one's verbal or intellectual insufficiency.

The mechanism of development

Signs of elective dumbness appear even at preschool age, but are not regarded by relatives as a painful phenomenon, since the child spends most of his time in the family, and his silence with outsiders and outside the home is interpreted as excessive shyness. Manifestations of elective mutism become apparent at the beginning of schooling, when silence in certain situations quickly creates the prerequisites for maladaptation. Elective mutism tends to a long flow, lasting from several months to several years. The spontaneous disappearance of elective mutism is a very rare phenomenon. In most cases, in the absence of targeted treatment, painful manifestations are stretched throughout the school years, accompanied by fear of interpersonal contacts, logo and social phobia, and disappear completely or partially, when the social situation changes, most often with a favorable psychological climate in the team (at work, in professional educational institution). Meanwhile, most authors note in the cataclysm of people affected by this syndrome, the difficulties of social adaptation associated with uncertainty and social fears. With many years of elective mutism, secondary psychogenic reactions to their condition often occur, which leads over the years to the pathological formation of the personality, mainly in a retarded and pseudo-schizoid type.

Classification of elective mutism

Depending on the etiological factor, the following variants of elective mutism are distinguished.

• Elective mutism of supervalued behavior associated with the negative attitude of the child towards a certain significant person (for example, teacher, educator, stepfather, stepmother, doctor) or an unpleasant place (kindergarten, school, polyclinic).
• Sociophobic elective mutism, caused by the fear of the child to discover its intellectual and verbal inconsistency or associated with constitutional hypersensitivity, including intolerance of the new environment and unusual surroundings.
• Hysterical elective mutism, based on the unconscious desire of the child to attract attention to himself, to achieve his desires and release from excessive mental stress.
• Depressive elective mutism, expressed in a decrease in the vital tone, retardation in the ideatorial and motor spheres.
• Elective mutism with mixed mechanisms.

For various reasons, elective mutism is classified as situational, permanent, elective and total, and in duration - transitory and continuum.

It is also worth mentioning the selection of the following variants of elective mutism.

• Symbiotic elective mutism, in which case the child is characterized by a symbiotic relationship with a certain person and subordinate manipulative relationships with other participants in the social environment.
• Speech phobic elective mutism with fear to hear your own voice and ritual behavior.
• Reactive elective mutism with withdrawal into itself due to reactive depression.
• Passive-aggressive elective mutism, which can be described as the enemy's use of dumbness as a psychological weapon.

The clinical picture of elective mutism is characterized by the absence of speech contact in a certain situation, most often in conditions of educational institutions (at school, kindergarten, boarding school). Total dumbness is observed in the school as a whole, or is limited only to a classroom, when the child does not speak with teachers or with classmates. Sometimes the child is silent only in the presence of some teachers or one teacher / educator, talking freely and loudly with the children. Verification of the quality of knowledge in these cases is conducted in writing through homework, answers to questions, abstracts. Often children with elective mutism, avoiding verbal contact, willingly use to communicate facial expressions and pantomime. In other cases, children freeze in the presence of certain people or all strangers, do not allow themselves to touch, do not look into the eyes of the interlocutor, keep tight, sit, lowering their head and pulling it into the shoulders. There are cases when the child refuses to speak in the presence of strangers, as he sees his own voice as "funny", "strange", "unpleasant." Significantly less elective mutism spreads not to educational institutions, but, on the contrary, to the family: easily communicating with each other, as well as with adults in the street and at school, children do not speak at home with any of the family members (with stepfather, stepmother, father, grandfather).

The behavior of a deviant child in comparison with that of normal peers is so unusual and absurd that others begin to suspect a mental disorder or intellectual inconsistency. However, the results of psychological, defectological and medical examinations indicate normal intelligence and the absence of mental illness in a child prone to speech phobia. However, in the history of many children with a similar deviation, a delay in speech development, violation of articulation or dysarthria is detected. Children can show shyness, anxiety, passivity, excessive stubbornness, the desire to manipulate others. They are, as a rule, overly attached to the mother and feel unhappy when separated from her. In a family environment and in a children's collective, some of these children are shy and taciturn, others, on the contrary, are very sociable, talkative, noisy.

Elective mutism is often supplemented by distinct neurotic disorders (enuresis, encopresis, phobias, tics), as well as signs of depression of predominantly astheno-dynamic type.

[17], [18], [19]

How to recognize an elective mutism?

The diagnosis of elective mutism can be established under the following conditions:

• normal understanding of speech;
• sufficient for social communication level of expressive speech:
• The ability of a child to normally speak in some situations and use this ability.

Elective mutism should be distinguished from early childhood autism, early childhood schizophrenia with regressive-catatonic disorders and schizophrenia with a later onset (in prepubertal and adolescence) with predominantly catatonic, manic and hallucinatory-delirious symptoms, depressive states of the psychotic level, organic brain diseases , reactive and hysterical mutism.

Unlike early childhood autism, for which there is a lack of verbal contact with others, elective mutism is characterized by a violation of verbal communication after a period of normal speech communication, a selective character associated with a particular situation, placement or person. In the case of elective mutism, there are no profound introverted and disharmonious mental development, and such typical for autism symptoms as stereotypes, ridiculous supervaluations and games, fanciful fears, total behavioral disorders, facial expressions and motor skills are excluded.

It should be noted that in some cases, in the early manifestation of the schizophrenic process, the child disappears speech within the framework of regressive or catatonic regressive noises after a period of normal psychophysical development. In this case, unlike the elective mutism, there is a bright polymorphic productive psychopathological symptomatology, and regressive disorders are represented not only by the complete or partial loss of speech, its delayed and unusual development after the end of the attack, but also by other regressive disorders: loss of self-service skills, neatness, extreme simplification and stereotyping of the game, the emergence of archaic symptoms.

With the later onset of schizophrenia and severe depressive attacks, the absence or partial loss of speech is not an obligatory sign, but only accompanies a pronounced productive psychopathological symptomatology, which in the overwhelming majority of cases does not allow confusing the endogenous disease with neurotic dumbness.

Loss of speech in neurological diseases is due to organic damage to the basal ganglia, frontal lobes or limbic system of the brain, is gradually growing, accompanied by typical for the organic process symptoms and does not present difficulties for differential diagnosis.

Within the framework of the affective-shock reaction, the specificity of the mutism is its acute emergence immediately after the psychotrauma, totality, relative short-term, as well as the absence of selectivity, severity of panic fear, motor retardation and somatovegetative disorders.

The most difficult is the delimitation of electrifying from the hysterical. Common signs for these two options are the mechanisms of emergence, based on the principle of "conditional desirability", mental infantilism, demonstrative behavior, education by type of hyperope. Differences consist in the features of personality. A child with an elective mutism tries to be inconspicuous, it is characterized by indecision, difficulties of interpersonal contacts, shyness, low self-esteem, primitive imagination. Children with hysterical mutism, on the contrary, tend to be in the center of attention, inclined to lush fantasies, have inadequately increased self-esteem, seek to manipulate others. With a hysterical neurosis, mutism is generally total, but it is quickly reduced if a correct psychotherapeutic approach is applied.

Differential diagnostics

Diagnosis is based primarily on clinical manifestations of the condition, mainly does not require additional physical examination, laboratory and instrumental studies, with the exception of suspicions of organic brain disease and hearing loss. In such cases, an in-depth examination is necessary:

• pediatrician;
• neurologist; 
• psychologist;
• speech therapist;
• psychotherapist;
• oculist;
• an otolaryngologist;
• neuropsychologist;
• a surdologist;
• a neurosurgeon.

The following studies are also conducted:

• craniography;
• ECG;
• radiography (copy) of the chest;
• EEG;
• Echo;
• REG;
• MRI.

[20], [21], [22]

Treatment of elective mutism

Treatment is outpatient. The exceptions are cases requiring observation and laboratory-instrumental studies in a psychiatric hospital to identify specific differences between elective mutism and endogenous or current organic disease. It is equally important to distinguish children from deep school disadaptation, who need sparing training in the semi-permanent department of a psychiatric hospital.

Methods of treatment of elective mutism

Psychotherapy: family, individual, communication trainings, igroterapiya, art-therapy, integrative (cognitive-analytical, suggestive-behavioral) psychotherapy.

Drug treatment (if necessary, it is not mandatory and is prescribed taking into account the severity of the clinical picture and the depth of school and social adaptation):

• tranquilizers - chlordiazepoxide, diazepam, oxazepam and in small doses of phenazepam;
• nootropics: pyracetam, gopantenic acid, acetylaminosuccinic acid, aminophenylbutyric acid, pyrithinol, cortex brain cortex polypeptides, etc .;
• timoanaleptics: sulpiride up to 100 mg / day, alimamazine up to 10 mg / day;
• mild anti-anxiety antipsychotics: thioridazine up to 20 mg / day;
• antidepressants: pypofezin up to 50 mg / day, amitriptyline up to 37.5 mg / day, pyrlindole up to 37.5 mg / day, maprotiline up to 50 mg / day, clomipramine up to 30 mg / day, imipramine up to 50 mg / day.

Objectives of treatment

Coping of neurotic and depressive disorders, improving interpersonal contacts.

Are excluded

• General developmental disorders (B84).
• Schizophrenia (P20).
• Specific disorders of speech development (P80).
• Transient elective mutism as part of anxiety disorder due to fear of separation in young children (P93.0).