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Children with selective mutism are still, far too often, misdiagnosed. The inability to speak is attributed to shyness, developmental delay, learning disabilities or autism. Worse, children are accused of being defiant, oppositional, manipulative or insolent. They are alternately punished and bribed. Their school life becomes a nightmare as they are made to repeat grades or attend inappropriate special education classes. And their parents undergo suspicion, or sometimes even charges, of child abuse. And, we’ll point out right here and now, that there is absolutely no evidence that the selective mutism is caused by abuse or neglect by parents.
These children appear in the doctor’s office or the principal’s office so anxious that they are unable to speak. Yes, they are children with anxiety disorders – just as the agoraphobic avoids leaving the home to escape feelings of anxiety or the victim of obsessive compulsive disorder responds to anxiety with rituals and compulsions, so the selectively mute child does not speak. Almost all of them have social phobia, the majority have a genetic predisposition to anxiety and they are all unable to interact or communicate in social situations.
Until recently, selective mutism has been considered to be rare and untreatable, but it is becoming increasingly evident that, treated as an anxiety disorder, it can be overcome. Like social phobics, children with selective mutism interact and speak (at age appropriate levels) when in comfortable surroundings, such as their own homes, but, once outside the home, anxiety causes them to withdraw. They freeze, show no emotion and appear completely expressionless... and are unable to speak.
Diagnosing the problem. Newer understanding of selective mutism is enabling many children to participate in school and social activities and live a normal life. The key to this is diagnosis while the children are young – selective mutism is proving to be more responsive to intervention at an early stage. The family doctor’s role is crucial – if a child is cannot speak to the doctor, the doctor must ascertain the extent of the problem in other situations, especially in the classroom, in order to refer the child for evaluation for selective mutism. The diagnostic criteria for Selective Mutism are:
Parents must communicate the symptoms to the doctor if they are evident. In addition to selective mutism, the child will most likely complain of such physical problems as tummy-aches, nausea, vomiting, diarrhea and headaches in attempting to avoid school or social outings. At school, he/she will appear stiff, awkward and expressionless, may avoid eye contact, chew hair, twist clothing or pick at scabs or sores and is unlikely to initiate, or even respond to invitations to, play with other children.
Ultimately the objective in treating selective mutism is to control the anxiety and build self-esteem and self confidence. Children are individuals, however, and various combinations of behavioural and cognitive therapy and, possibly, medication for the anxiety, as well as psychological approaches, need to be included in the program, but chief amongst them is the removal of any obvious expectation or pressure on the child to speak.
New social environments can be introduced in non-threatening ways by making arrangements for parents to familiarise the child with, for example, the school when there is nobody around. Bringing along a friend, then a small group of children will pave the way to introducing the teacher and the other students. This provides a chance for the child to become comfortable in the classroom setting without actually undergoing the sudden anxiety of confronting something new and consequently being unable to speak.
The focus in any kind of therapy should be on letting the child identify with his/her level of fear and know that you understand and are there to help them. Cognitive behavioural therapy will help the child to redirect all the anxious fears and worries into positive thoughts, emphasizing the child’s positive attributes.
Everybody involved is generally reluctant to use medication but, if progress with therapy, it really is necessary to add it to treatment program. Since in most cases of selective mutism, the anxiety is caused by a biochemical imbalance, a serotonin reuptake inhibitor (SSRI) is recommended or one of the newer drugs designed to control specific neurotransmitter action is usually prescribed. The medication lowers the anxiety allowing the therapy to get underway. The hardest part for parents is trying to make other people understand! Often it is they who must educate teachers and school personnel – and health professionals, too! – on selective mutism. Clinical studies and information is limited resulting in doctors and teachers telling a parent that the child is just shy and will outgrow it or – worse – that the child likely has severe learning disabilities or autism. In either case, such misdiagnosis and consequent mistreatment will result in the child growing up neither speaking nor developing social skills. The mute behaviour will become a conditioned response which will get progressively more difficult to change.
Mistreated or left untreated, like any other anxiety disorder, selective mutism will lead to social isolation, underachievement, self-medication with drugs and alcohol, crime or even suicide. Early diagnosis and treatment is imperative but it is only possible through ‘breaking the silence of selective mutism’ by making more information available to school and health professionals, and to parents.
Copyright Jean Jardine Miller.