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DEVELOPMENTAL DELAYS and REGRESSIONS Selective Mutism

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DEVELOPMENTAL DELAYS and REGRESSIONS Selective Mutism CHALLENGING CASE: DEVELOPMENTAL DELAYS AND REGRESSIONS Selective Mutism* CASE Dr. Martin T. Stein Peter’s parents made an appointment with his pe- Selective mutism is an acquired disorder of inter- diatrician because of their increasing concern about personal communication in which a child does not his refusal to speak. After approximately 2 weeks speak in one or more environments where commu- following the start of a new preschool, Peter, 4 years nication typically occurs. These children most often 10 months old, refused to speak to other children or refuse to speak in school and to adults outside the the teacher. During the first week of school, he found home. Some children with selective mutism will not it difficult to separate from his mother or father. He speak to any child; others will use speech with only would cry and cling to them while asking to go a few other children. Parents report normal speech home. This difficult separation experience gradually within the home with at least one parent and some- subsided by the beginning of the third week and times with siblings. The onset of selective mutism is corresponded with the onset of mute behavior. At usually in the preschool or early school age period of home, he spoke only to his mother, with a clear development; often, it is associated with the start of speech pattern and full sentences. He limited his school. responses to his father or two older siblings with Although this disorder is uncommon (1% among body gestures. He appeared to hear well and under- children seen in mental health centers; 0.1% in the stand verbal directions. general population), parents of these children are Peter’s parents described him as a shy child who understandably alarmed when the behavior persists. eventually makes friends and plays interactively. His Normal language production at home and persistent play, both by himself and with others, is filled with mutism outside the home may be baffling. imaginary activities. There have not been any disrup- The etiology and management of selective mutism tive behaviors at home or with friends. Peter’s ges- have undergone a significant change during the past tation and birth were uneventful. Motor milestones three decades. Clinicians from a variety of disciplines were on time. At 18 months, he spoke only five have discovered that most children with selective words; at 24 months, he spoke 10 words. Two mutism have not experienced a major personal, fam- months after his second birthday, he was speaking with clear and elaborate sentences. ily, or environmental trauma as a trigger for this Physical examination revealed a normal office peculiar behavior. Most recent evidence points to a screening audiogram (25-dB threshold from child’s temperament and behavior consistent with 500–3000 Hz) and the absence of dysmorphic facial anxiety as the clue to more effective management features, cleft palate, middle ear fluid, or a neck strategies. mass. Compliance of the tympanic membrane on I have asked two experienced clinicians to com- pneumo-otoscopy was normal; this was confirmed ment on Peter’s presentation to his pediatrician. Dr. by normal peaks on tympanometry. Peter’s orophar- Isabelle Rapin is Professor of Pediatrics and Neurol- ynx, epiglottis, and uvula were easily visualized and ogy at the Albert Einstein College of Medicine, found to be normal. His facial features, body move- where she has taught pediatric neurology for over ments, and responses to his mother’s commands three decades. I can attest that her reputation as a were consistent with intact auditory receptive func- scholar, teacher, and clinician is unmatched. No pe- tion. In the office, he was calm and remained close to diatric resident has left her clinic without equal re- his mother. His family drawing revealed age-appro- spect for the details of the interview process and the priate fine motor and visual-perceptual skills. All nuances of pediatric neurological examination. Dr. members of his family were drawn with distinctive Rapin has written extensively on neurobehavioral differences in size. Peter was at one end of the family aspects of speech and language disorders in children. group, standing next to his mother. During a 20- Diane Yapko, M.A., is a speech and language pa- minute office assessment, the pediatrician was un- thologist with a remarkable ability to unravel lan- able to engage Peter in spoken speech. guage disorders in children with complex neurolog- ical and behavioral disorders. I asked her to Index terms: selective mutism, mutism, acquired aphasia. comment on management strategies for children with selective mutism. Martin T. Stein, MD * Originally published in J Dev Behav Pediatr. 1999;20(1) Professor of Pediatrics PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- University of California, San Diego emy of Pediatrics and Lippincott Williams & Wilkins. San Diego, California 926 PEDIATRICS Vol.Downloaded 107 No. 4from April www.aappublications.org/news 2001 by guest on September 27, 2021 Dr. Isabelle Rapin dren and some 20% of the New York sample had Selective mutism is virtually the only diagnostic delayed or impaired language skills, and some came consideration in this preschooler who was silent in from immigrant homes where another language was school, although he understood what was said to spoken. What characterized both samples was exces- him and was reported to speak normally at home. sive social anxiety and shyness, not acting out be- However, relying on the parents’ report of normal haviors, or depression. There was little or no evi- verbal expression at home is inadequate; pediatri- dence for social or emotional trauma as precipitant. cians must insist that the parents bring in an audio or Counseling and psychotherapy were largely inef- videotape, so that they can substantiate the report. If fective. A short open trial of fluoxetine in a dose of it is verified, and if the child is otherwise entirely some 20 mg/day seemed modestly helpful.4 Few normal, the child can safely be spared neuroimaging, long-term outcome data are available, although fam- EEG, and other neurological tests. ily histories suggest that possibly genetic personality If the child is mute or near mute in any environ- traits like anxiety, social phobia, and avoidance may ment, other diagnoses come under consideration (Ta- predispose children to selective mutism. The best ble 1). A transient (the key word is transient, i.e., ploy for management would seem to be acceptance, lasting at most a few hours or a day) aphasia may be sympathetic encouragement, and patience, possibly a postepileptic deficit (Todd’s aphasia) or the mani- with a trial of medication. festation of a migraine, sometimes without head- ache.1 Besides sudden onset deafness—exceedingly Isabelle Rapin, MD Professor of Pediatrics and Neurology rare unless preceded by bacterial meningitis—the Albert Einstein College of Medicine first consideration is an acquired aphasia, since vir- Bronx, New York tually all acquired aphasias in early childhood are expressive, with or without receptive impairment. REFERENCES Without a history of trauma or signs of an infection, 1. Marchioni E, Galimberti CA, Soragna D, et al: Familial hemiplegic an acute brain lesion producing an isolated aphasia migraine versus migraine with prolonged aura: An uncertain diagnosis. is most likely a stroke, perhaps caused by an embo- Neurology 45:33–37, 1995 lus or sickle cell anemia, although a stroke without 2. Steinhausen H-C, Juzi C: Elective mutism: An analysis of 100 cases. associated sensorimotor or other deficit is unlikely. J Am Acad Child Adolesc Psychiatry 35:606–614, 1996 3. Dummit ES III, Klein RG, Tancer NK, et al: Systematic assessment of 50 Acquired epileptic aphasia (Landau-Kleffner syn- children with selective mutism. J Am Acad Child Adolesc Psychiatry drome), without overt clinical seizure but with an 36:653–660, 1997 epileptiform EEG, requires consideration, since it 4. Dummit ES III, Klein RG, Tancer NK, et al: Fluoxetine treatment of may be sudden. A persistent aphasia with an insid- children with selective mutism: An open trial. J Am Acad Child Adolesc ious onset brings up the possibility of a mass lesion Psychiatry 35:615–621, 1996 or a degenerative disease of the brain. Two large series of children with selective mutism, Diane Yapko, M.A. one describing 100 European children,2 the other 50 Primary care pediatricians are increasingly chal- New York children,3 provide concordant data on this lenged to treat a variety of problems that may not be rare frustrating condition of preschoolers and school found in traditional medical training. The case of age children. Girls outnumbered boys 2 to 1. Mean Peter is a typical example. Peter’s symptoms and age of reported onset was 4 years in one series and history are consistent with a diagnosis of selective 21⁄2 years in the other, with a range of 1 to 7 years mutism, as defined in Diagnostic and Statistical (i.e., virtually from first words) in a small proportion Manual of Mental Disorders, 4th edition (DSM-IV).1 of children. The possibility of an autistic spectrum Historically, children with selective mutism have (pervasive developmental) disorder needs to be con- been treated by mental health professionals or sidered in such early cases. The duration was usually speech-language therapists. My professional experi- 5 or more years after exclusion of children who were ence leads me to recommend that physicians con- mute for less than a month, for example, at the start tinue to refer such patients to therapists with exten- of school. Although strict criteria for selective mut- sive pediatric experience and a background in ism would exclude children with developmental lan- cognitive, behavioral, and play therapy. Beyond guage disorders, almost a third of the European chil- making well-considered referrals, however, primary care physicians can skillfully manage these children with a variety of techniques, some of which can be TABLE 1.
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