Classification of Elective Mutism Torey L. Hayden Abstract. In this study of 68 children displaying elective mutism, four types of mutism are distinguished: (a) symbiotic mutism, characterized by a symbiotic relationship with a caretaker and a submissive but manipulative relationship with others; (b) speech phobic mutism, characterized by fear of hearing one’s own voice and use of ritualistic behaviors; (c) reactive mutism, characterized by withdrawal and depression which apparently resulted from trauma and (d) passive-aggressive mutism, characterized by hostile use of silence as a weapon. The prevalence of physical and sexual child abuse in all four groups was high. The classification of elective mutism into subgroups is clinically relevant for a better understanding of the etiology and for devising appropriate intervention. Journal of the American Academy of Child Psychiatry, 19:118—133,1980 Elective mutism, a term first employed by Trainer (1934), has been used traditionally to describe those children who refuse to speak to all but a small number of intimates. This definition excludes all other nonpsychogenic forms of mutism, including hearing loss, aphasia, schizophrenia, and autism. Although the behavior is a perplexing problem to the families of preschool children, it becomes a seemingly insurmountable problem when the children enter the educational system. Consequently, the elective mutes become candidates for grade retention, special class placement, and frequently residential institutionalization, mounting failure on top of an already complex psychological problem. LITERATURE REVIEW Despite a considerable literature devoted to elective mutism since its identification in 1877 by Kussmaul, no large-scale studies of this specific problem have been undertaken. Hence etiology, dynamics, treatment, and even incidence rates remain uncertain. Several excellent exhaustive reviews of the literature currently exist, Browne et al. (1963), Elson et al. (1965), and Halpern et al. (1971) being among the best. However, detailed systematic observation of a number of cases is lacking. Parker et al. (1960) present the most comprehensive American study with 27 youngsters in the Tacoma school system. Wright (1968) studied 24 cases. Spieler (1941) reviewed 50 European cases described in the literature but did not see these children himself. The rest of the literature deals with a small number of cases, usually 6 or fewer, and very often only a single case. Elective mutism requires further attention because of the difficulty in creating a consistent profile of behavior (Chetnik, 1973; Misch, 1952; Reed, 1963; Waterink and Vedder, 1936; Weber, 1950); its resistance to treatment (Elson et al., 1965; Mora et al., 1962; Pustrom and Speers, 1964); the ungainly amount of time generally required (Chetnik, 1973; Mora et al., 1962; Nolan and Pence, 1970; Sines, 1967; Wassing, 1973); and the great amount of environmental restructuring necessary to produce change (Amman, 1958; Elson et al., 1965; Pangalila-Ratulangie, 1959; Reid et al., 1967; Sines, 1967; Wassing, 1973). The study reported here was undertaken to establish the parameters of elective mutism by investigating a large sample so that the underlying disturbance might be seen more clearly. METHODS Population Criteria for inclusion in the study were: (1) the child must have displayed normal speech and speech patterning in at least one previous circumstance for a period of 6 months or more; (2) the child must have displayed totally mute behavior in at least one major setting for a period of 8 weeks; (3) the child must have an IQ of 70 or more as substantiated by the WISC or Stanford-Binet; (4) the child must have been free of the diagnosis of psychosis, including autism. These criteria were arbitrarily set to assure inclusion of only those children who displayed elective, psychogenic mutism. Along with the 68 children accepted in the study, 270 were rejected for possible contaminating factors. Of these 270 children excluded from the study, 23 (all having speech impairment or retardation) displayed behaviors characteristic of the 68 identified elective mutes and responded to treatment in a manner equivalent to the 68, thus emphasizing the arbitrary nature of some of the inclusion criteria. Table I Demography of Sample Population Girls Boys* Age range 3—9 to 5—6 3 0 6—0 to 7—11 20 7 8—0 to 9—11 17 1 10—0 to 11—11 12 1 12—0 to 14—4 4 1 IQ range 70 to 84 9 3 85 to99 15 4 100 to114 10 2 115 to130 15 3 131+ 7 0 Race Black 2 1 Mexican-American 3 1 Native-American 3 2 White 48 8 Income ** high ($5,573 or more per person) 15 3 middle ($3,829) 23 6 low ($2,396 or less) 18 4 Location Kansas 4 0 Minnesota 36 8 Montana 3 1 Oregon 5 0 Washington 8 3 Community Size *** urban (over 50,000) 14 2 suburban / small town (2,500 to 50,000) 30 6 rural (less than 2,500) 11 4 * The ratio of girls to boys in this segment of the study was approximately 6:1. However, the continued study with 122 children showed it to be closer to two girls to one boy (2:1). ** As established by the Bureau of Labor Statistics, U.S. Dept. of Labor, 1976. *** As established by the U.S. Bureau of Census, 1976. Procedures Data on the children were compiled from direct observation, video-and audiotapes, written reports, questionnaires, and other pertinent written material such as school cumulative folders and psychological, psychiatric, and pediatric reports. The children, who were seen sequentially over a 7-year period, were all referred by school districts. Any later referrals were initiated by mental health clinics and psychiatric facilities; however, almost all observations and interactions were done in the school setting, since there the problem was most acute. Consequently, schools always remained intimately involved and were requested to activate an outside referral from parents or clinical settings by submitting their own referral. The districts also bore primary financial responsibility in 57 (84%) cases. I functioned at first as a special education teacher within the district, and later as a professional affiliated with local universities. I saw all the children directly. (The wide geographical distribution resulted from my frequent moves while pursuing graduate degrees and experience.) Parental permission was gained for access to records and video-and audiotaping privileges. Separate and/or joint conferences were held with parents, teacher, pediatrician, and other individuals who had been involved with the child and his or her problem. Usually included in the last group were psychologists, psychiatrists, speech therapists, school psychologists, social workers, child protection workers, and principals. During the conference questionnaires were filled out by the individuals present and most conferences were audiotaped. Occasionally questionnaires were sent to individuals who could not attend a conference. The return rate on the questionnaires was high since the majority were filled out at the time they were presented. Other questionnaires which were mailed were also usually returned since I followed up unreturned questionnaires with phone calls or in-person pickups. Parent questionnaires dealt with the mutism problem: when it started, how it was handled; the child’s home behavior; family practices: discipline, chores; family attitudes: how the child got along with sibs, how the mother handled misbehavior; child’s past developmental and physical history; perceived school behavior; and general information. Teacher questionnaires dealt with how the teacher saw and interacted with the child, his or her problem and family, and school behavior. Pediatrician questionnaires dealt primarily with developmental and medical history aspects and his or her involvement with the child’s mutism. The general professional questionnaires further covered how the professional perceived the child, his or her mutism, and the child’s interactions with the environment. During conferences the questionnaires generally served as jumping-off points for further discussion and elaboration. All required information was then tallied on a master list in an attempt to ascertain which were and were not salient characteristics of elective mutism. RESULTS Four types of elective mutism were observed: symbiotic mutism, speech phobic mutism, reactive mutism, and passive-aggressive mutism (see table 2). Forty-four characteristics appeared frequently enough in the population to merit mention. Some occurred predominantly in only one or two subgroups. Others occurred frequently in all four groups. These characteristics are summarized in tables 3, 4, 5, and 6. The identifying features of each classification are discussed under the separate subheadings. Table 2 Types of Elective Mutism Girls Boys Symbiotic (S) 24 7 Speech phobic (SP) 6 1 Reactive (R) 13 1 Passive - Aggressive (PA) 13 3 Because the study did not anticipate that four subgroups would be found, the analysis of data was complicated. Thus, results are reported in percentages, and the three control groups (normal, speech-delayed retarded, and neurotic) of 30 children each were dropped because three of the four subgroups became too small for reasonable statistical analysis. Moreover, the last control group, the neurotics, was difficult to compare because of the variety of neuroses, creating the need to subcategorize the control group itself. Symbiotic Mutism This classification embodies Salfield’s (1950) Kretschmerian “sensitives”. The most common type of elective mutism observed (N = 31), symbiotic mutism was characterized by four factors. First, all the children displayed a strong symbiotic relationship with a caretaker, most frequently (84%) the mother. The caretaker was a dominant, verbal individual who consistently met all the child’s needs and was often openly jealous of the child’s other relationships, especially outside the home. Second, the family constellation was always represented by one noticeably dominant, verbal parent and one noticeably passive, nonverbal or absent parent. In all but one instance (97%), the dominant parent was the mother. In no case where both parents were present was the father the dominant member.