Elective mutism

Many researchers call elective mutism a syndrome-disease. Insufficient study and complexity of this developmental anomaly often lead to diagnostic errors (for example, diagnosing schizophrenia or mental retardation) or assessing the condition as stubbornness and simulation and, as a consequence, to choosing inadequate treatment, psychological and pedagogical approaches. In many cases, a violation of speech contact in certain social situations is assessed as temporary and spontaneously relieved. In the case of prolonged or chronic elective mutism, improper treatment or its absence often lead to severe forms of school and social maladjustment, including when a person reaches adulthood. In this regard, in order to prescribe a full-fledged treatment, it is especially important for a psychiatrist to establish an accurate diagnosis in a timely manner. Psychologists of children's institutions, educators and teachers, who are the first point of contact on the path of a "silent" child, should be aware of the clinical manifestations of this pathology and the dangers of its social outcome.

Synonyms

• Selective mutism.
• Selective mutism.
• Partial mutism.
• Voluntary mutism.
• Psychogenic mutism.
• Situationally determined mutism.
• Characterological mutism.
• Speech phobia.
• Dumbness with intact hearing.

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Epidemiology

Elective mutism is considered a relatively rare phenomenon, the prevalence of which among children and adolescents, according to official data, is 0.02-0.2%. There is information that in children who have started school, short-term elective mutism occurs significantly more often (0.72%).

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What causes elective mutism?

Elective mutism, as a rule, has a psychogenic origin, is associated with an overvalued attitude to a certain situation and is expressed in a regressive reaction to separation from relatives, resentment, a feeling of one's own failure, which most often takes the form of passive protest. Such a deviation may be characterized by a hysterical mechanism, allowing the development of a reaction such as "imaginary death". Elective mutism can also take the form of an obsessive fear of discovering one's speech or intellectual insufficiency.

Mechanism of development

Signs of selective muteness appear already in 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 strangers and outside the home is interpreted as excessive shyness. Manifestations of elective mutism become obvious at the beginning of school education, when silence in certain situations quickly creates the preconditions for maladaptation. Elective mutism tends to be long-term, lasting from several months to several years. Spontaneous disappearance of elective mutism is an extremely rare phenomenon. In most cases, in the absence of targeted treatment, painful manifestations stretch out over all school years, are accompanied by fear of interpersonal contacts, logo- and sociophobia and disappear - completely or partially - when the social situation changes, most often in a favorable psychological climate in the team (at work, in a professional educational institution). Meanwhile, most authors note in the follow-up of people susceptible to the said syndrome, difficulties in social adaptation associated with insecurity and social fears. With long-term elective mutism, secondary psychogenic reactions to one's condition often arise, which leads over the years to pathological formation of personality, mainly of the inhibited and pseudo-schizoid type.

Classification of elective mutism

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

• Elective mutism of overvalued behavior associated with a child’s negative attitude toward a certain significant person (for example, a teacher, caregiver, stepfather, stepmother, doctor) or an unpleasant place (kindergarten, school, clinic).
• Sociophobic elective mutism, caused by the child's fear of discovering his intellectual and speech inadequacy or associated with constitutional hypersensitivity, including intolerance of new situations and unfamiliar surroundings.
• Hysterical elective mutism, based on the child’s unconscious desire to attract attention to himself, to achieve the fulfillment of his desires and liberation from excessive mental stress.
• Depressive elective mutism, expressed in a decrease in vital tone, inhibition in the ideational and motor spheres.
• Elective mutism with mixed mechanisms.

Based on various characteristics, elective mutism is classified as situational, permanent, elective and total, and based on duration - transient and continuous.

It is also worth noting the following variants of elective mutism.

• Symbiotic elective mutism, in which 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 of hearing one's own voice and ritualistic behavior.
• Reactive elective mutism with withdrawal due to reactive depression.
• Passive-aggressive elective mutism, which can be characterized as the hostile use of muteness 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 the conditions of educational institutions (at school, kindergarten, boarding school). Complete muteness is observed within the school walls as a whole or is limited to the classroom, when the child does not speak with either teachers or classmates. Sometimes the child is silent only in the presence of some teachers or one teacher/educator, freely and loudly talking with children. In these cases, the quality of knowledge is checked in writing through homework, answers to questions, essays. Often, children with elective mutism, avoiding verbal contact, willingly use facial expressions and pantomime for communication. In other cases, children freeze in the presence of certain people or all strangers, do not allow themselves to be touched, do not look into the eyes of the interlocutor, hold themselves tensely, sit with their head down low and pulled into their shoulders. There are cases when a child refuses to speak in the presence of strangers, because he or she considers his or her own voice to be “funny”, “strange”, “unpleasant”. Much less often, elective mutism extends not to educational institutions, but, on the contrary, to the family: easily communicating with each other, as well as with adults on the street and at school, children do not speak at all at home with any of the family members (with a stepfather, stepmother, father, grandfather).

The behavior of a deviant child, compared to that of normal peers, is so unusual and absurd that those around him begin to suspect a mental disorder or intellectual disability. 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. At the same time, the anamnesis of many children with such a deviation reveals a delay in speech development, articulation disorder or dysarthria. Children may exhibit shyness, anxiety, passivity, excessive stubbornness, and a desire to manipulate others. They are usually overly attached to their mother and feel unhappy when separated from her. In a family setting and in a children's group, some of these children are shy and taciturn, while others, on the contrary, are very sociable, talkative and noisy.

Elective mutism is often accompanied by distinct neurotic disorders (enuresis, encopresis, phobias, tics), as well as signs of depression, mainly of the asthenoadynamic type.

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How to recognize elective mutism?

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

• normal understanding of addressed speech;
• a level of expressive speech sufficient for social communication:
• the child's ability to speak normally in some situations and the use of 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 prepuberty and adolescence) with predominantly catatonic, manic and hallucinatory-delusional symptoms, depressive states of a psychotic level, organic diseases of the brain, reactive and hysterical mutism.

Unlike early childhood autism, which is characterized by the absence of speech contact with others, elective mutism is characterized by a violation of speech communication after a period of normal speech communication, selective in nature, associated with a certain situation, room or person. In the case of elective mutism, there is no deep introversion and disharmony of mental development, and such typical autism symptoms as stereotypes, absurd overvalued hobbies and games, fanciful fears, total behavioral disorders, facial expressions and motor skills are also excluded.

It should be noted that in some cases, with the early manifestation of the schizophrenic process in a child, speech disappears within the framework of regressive or catatonic-regressive noises after a period of normal psychophysical development. In this case, in contrast to elective mutism, there is a bright polymorphic productive psychopathological symptomatology, and regressive disorders are represented not only by a complete or partial loss of speech, its slow 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 appearance of archaic symptoms.

In later onset schizophrenia and severe depressive attacks, the absence or partial loss of speech is not an obligatory symptom, but only accompanies pronounced productive psychopathological symptoms, which does not allow in the vast majority of cases to confuse the endogenous disease with neurotic muteness.

Speech loss in neurological diseases is caused by organic damage to the basal ganglia, frontal lobes or limbic system of the brain, increases gradually, is accompanied by symptoms typical of an organic process and does not present difficulties for differential diagnosis.

Within the framework of the affective-shock reaction, the specific features of mutism are its acute occurrence immediately after psychological trauma, totality, relative short duration, as well as the absence of selectivity, severity of panic fear, motor inhibition and somatovegetative disorders.

The greatest difficulty is in distinguishing between elective and hysterical mutism. Common features for these two variants are the mechanisms of occurrence based on the principle of "conditional desirability", mental infantilism, demonstrative behavior, and overprotective upbringing. The differences lie in the personality traits. A child with elective mutism tries to be invisible, is characterized by indecisiveness, difficulties in interpersonal contacts, shyness, low self-esteem, and primitive imagination. Children with hysterical mutism, on the contrary, strive to be the center of attention, are prone to lush fantasies, have inadequately high self-esteem, and strive to manipulate others. In hysterical neurosis, mutism is usually total, but is quickly reduced if the correct psychotherapeutic approach is applied.

Differential diagnostics

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

• pediatrician;
• neurologist; 
• psychologist;
• speech therapist;
• psychotherapist;
• ophthalmologist;
• otolaryngologist;
• neuropsychologist;
• audiologist;
• neurosurgeon.

The following studies are also conducted:

• craniography;
• ECG;
• X-ray (scopy) of the chest organs;
• EEG;
• EchoEG;
• REG;
• MRI.

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Treatment of selective mutism

Treatment is outpatient. The exceptions are cases requiring observation and laboratory and instrumental studies in a psychiatric hospital to identify specific differences between elective mutism and endogenous or ongoing organic disease. It is equally important to distinguish children with profound school maladjustment who require gentle education in a semi-inpatient department of a psychiatric hospital.

Treatment methods for selective mutism

Psychotherapy: family, individual, communication training, play therapy, 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 phenazepam;
• nootropics: piracetam, hopantenic acid, acetylaminosuccinic acid, aminophenylbutyric acid, pyritinol, polypeptides of the cerebral cortex of cattle, etc.;
• thymoanaleptics: sulpiride up to 100 mg/day, alimemazine up to 10 mg/day;
• mild antianxiety neuroleptics: thioridazine up to 20 mg/day;
• antidepressants: pipofezine up to 50 mg/day, amitriptyline up to 37.5 mg/day, pirlindole up to 37.5 mg/day, maprotiline up to 50 mg/day, clomipramine up to 30 mg/day, imipramine up to 50 mg/day.

Treatment goals

Relief of neurotic and depressive disorders, improvement of interpersonal contacts.

Excluded

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