Title Concurrent individual and family therapy in a case of electivemutism

In this paper, following a literature review, a family containing a child who had been electively mute for four years is described. A concurrent programme of individual and family therapy and the systemic hypothesis which guided these interventions is then presented in detail. Behavioural and psychometric data are presented to illustrate the dramatic improvement which the identified patient showed over the course of treatment. Finally, the probable mechanisms underpinning the child's improvement, and how these differed from our initial expectations, are discussed. DEFINITION AND INCIDENCE Elective mutism, a condition first described by Tramer in 1934, is characterized by a refusal to speak to anyone except a small group of intimate relatives or peers for a substantial period of time, e.g. six months. The condition is also known as selective mutism. Persistent elective mutism is rare and estimates of incidence range from 0.3-0.8 per 1000 (Brown & Lloyd, 1975; Fundudis et al., 1979). The condition usually develops between the ages of three and five years but is typically noted when the child first enters school and refuses to speak with teachers or classmates (Elson et al., 1965). ____________________ Unlike other language disorders, elective mutism is slightly more common in girls than in boys (Kolvin & Fundudis, 1981; Wilkins, 1985). Elective mutism should be distinguished from mutism secondary to conditions such as mental retardation, developmental language delay, hearing loss, psychosis or hysterical aphonia (Cantwell and Baker, 1985). A distinction should also be made between elective mutism and low-frequency or reluctant speech (Sanok and Ascione, 1979). The condition holds many features in common with other emotional disorders of childhood, but is distinguished from them by a variety of features also. For example, speech difficulties and maternal overprotection are more common among elective mutes (Wilkins, 1985) ETIOLOGICAL THEORIES Theories concerning the etiology and maintenance of elective mutism may be loosely classified as family-oriented, psychodynamic or behavioural. What follows is our synthesis of the more important ideas in each of these conceptual domains. Review papers by Cunningham et al. (1984) and Hesselman (1983) may be consulted for a more detailed appraisal of the theoretical literature and extensive bibliographies . According to family-oriented theories, the elective mute's family is characterized by mother/child enmeshment, a peripheral and passive father, and the presence of one or more shy family members. The identified patient's symptoms are precipitated or exacerbated when a family with this structure is faced with the developmental task of allowing the child to move out of the home and attend school. This transition in the family life-cycle may be more disruptive if the family is physically, socially or culturally isolated, since the extrafamilial environment is viewed as threatening by the family as a whole. The core symptom of the identified patient may be seen as serving a variety of functions within the family. For example, it may allow the parents indirectly to express their aggression or anxiety about their isolated position within the community. Mutism may also indicate that the family have a secret which they do not wish to divulge, e.g. sexual abuse. A variety of psychodynamic formulations have been suggested, many of which attribute a cardinal role to the elective mute's attempts to deal with aggressive impulses. For example, elective mutism has been interpreted as an inhibited or denied oral aggression, or anal retentiveness (i.e. a form of passive aggression) . Hypotheses offered by behavioural theorists tend to focus on reinforcement contingencies which maintain the symptomatic mute behaviour. For example, refusal to speak may lead to anxiety reduction in children who suffer from social anxiety. Where children have conduct disorders, elective mutism may be viewed as a strategy the child uses to manipulate the environment in a coercive fashion to obtain