# Motivation and emotion/Book/2015/Selective mutism and emotional well-being

* Multimedia presentation (3 min)

## Overview

Imagine a world where anyone and any situation outside of the comfort of your home could elicit fear and anxiety so paralysing that you would shut down and were incapable of even speaking.
Daphne was a normal cheerful, talkative and loud four-year-old. But every-day as she entered the school grounds it was as if she transformed. Her teachers and fellow peers viewed her as being shy; and she was never seen speaking whilst in school; a school she had attended for over a year. One of her teachers explained that if she needed to ask a question she would walk up to her and whisper in her ear. During group tasks her comfort levels dropped even further and she would not interact with the other pupils. Even with her closest friend Daphne would only talk to through whispers while in public. The odd thing was, as soon as she was home from school, she was her happy self again; laughing, singing, and telling jokes.
Daphne is one of a number of children who can be classified as facing an anxiety disorder known as selective mutism – a phobia of speaking outside of home or comfortable situations.
Selective mutism is a rare and multi-dimensional childhood disorder that typically affects children at around the time they enter school (Wong, 2010). This disorder is characterised by a persistent failure to speak in certain social situations despite the ability to do so in the comfort of familiar settings.
Despite an increasing awareness of this disorder, selective mutism is under-researched and commonly misdiagnosed. The purpose of this chapter is to inform readers of the psychiatric disorder. This is firstly done through a review of its description, diagnosis criteria, and misconceptions. Secondly, theories and models associated with the childhood disorder and its effect on their well-being are examined. Specific psychological issues that impact the social and emotional well-being of individuals are then described and, lastly, the treatment approaches of behavioural therapy, psychotherapy, and social communication anxiety therapy (SCAT) are addressed.

## Selective mutism

Selective mutism (SM) is a rare condition in which children will speak confidently in certain situations (such as the comfort of their home), but remain silent and incapable of speaking in other situations in which they are expected to speak (such as school or social situations) (APA, 2013; Wong, 2010). SM is a psychiatric condition typically developed in early childhood. However, it usually is not diagnosed until a child begins to enter new environments such as school. The psychiatric condition selective mutism was formerly known as ‘elective mutism’ as it was believed that children with this disorder chose to be silent in certain situations. However, this was recognised as incorrect and the truth was that these children in fact wished to speak but were dealing with an overwhelming anxiety that hindered their ability (Muris, & Ollendick, 2015). To acknowledge the involuntary nature of the disorder, the name was changed in 1994. Despite the change in name from elective to selective, the misconception of these children as being stubborn or defiant remains, which leads to the possibility of the scarce awareness of the disorders significance. Parents are often unaware of this condition since their children tend to function normally at home. Teachers and paediatricians also sometimes mistake SM for severe shyness.
Features of SM include (Selective Mutism Support, 2014):
* clamming up or difficulty maintaining eye contact
* withdrawal
* avoidance of social situations
* communication through gestures such as head nodding and shaking
* blank expression
* stiff and awkward movements
* sensitivity to noise and crowds
* clinging and temper tantrums
Not all mute children manifest their anxiety in the same way. SM can vary along a continuum of severity. Some children may look relaxed and socialise with one or a few close friends but not be able to communicate effectively with others; some may be able to speak to a select few only through whispers; while others may be completely incapable of communicating to anyone in a social setting, or stand motionless with fear when confronted in certain social settings (i.e. they freeze with fear and anxiousness – somewhat similar to that of the flight-or-flight response). In most cases the child is likely to appoint a close friend or family member to be communicator (Bernstein, 2014).
The inability to communicate is most disabling in the schooling years as these children are faced with a major barrier to their academic progress and development of social relationships. Opportunities for social interactions are hindered, and they experience delays in development of appropriate language skills. This in turn can lead to further social, emotional and academic problems for these children. Such issues include additional diagnoses such as learning disabilities, further withdrawal because of performance anxieties, depression, and self-esteem issues. There has also been evidence of high levels of comorbid conditions, especially anxiety disorders such as social phobia, separation anxiety disorder and panic disorder (Manassis, 2009). A study conducted by Dummit et al. (1997) found in 50 selectively mute children, that they all met the criteria for social phobia or avoidant disorder, while 48% had additional anxiety disorders (Dummit, et al. (1997).
While SM is first exhibited in childhood, anxiety levels of these individuals increases, with the persistence of low self-confidence, shyness, and discomfort in social situations and disrupted daily functioning. Studies have further shown that if left untreated and unacknowledged it can continue into an individuals’ adolescent and adult life (Bernstein, 2014), in the form of communication problems, such as fear of public speaking, as-well as higher rates of psychiatric disorders (Remschmidt et al., 2001; Steinhausen et al., 2006).
Most research has found that the prevalence of SM is around 0.07%; that being seven children affected in every 1000, depending on the population studied (SMC, n.d.; Bergman, et al., 2002). The rates of SM have been found to generally be higher in females than males(Bernstein, 2014; Wong, 2010).

### Diagnostic criteria for Selective mutism

As stated in DSM-5, the diagnostic criterion for selective mutism is as follows (APA, 2013; SMC, n.d.):
* Consistent failure to speak in specific social situations in which there is an expectation for speaking (i.e.: at school, with relatives and family friends), despite the occurrence of speaking in other situations (note: the criterion is not met if the child does not speak at all in any situation).
* The disturbance interferes with daily functioning and social communication.
* Absence of speech present for at-least one month (not limited to the first month of school – during which their initial reticence is likely the cause of a normal developmental stage, i.e. general nervousness to entering new surroundings and peers).
* Failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required of them.
* The disturbance is not better accounted for by a communication disorder (e.g. stuttering), and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorders.

### Misconceptions

Studies of selective mutism are scarce, and the research findings thus far have been based on a limited number of children. Information should hence be looked into with caution. Few people truly understand selective mutism, resulting in many misconceptions about the disorder, as well as the misdiagnosis and inadequate therapy set forth for selectively mute children. Professionals and teachers often tell parents that their children will ‘grow out of it’ and that ‘they are just shy’ (Shipon-Blum, n.d.). Unfortunately this is not the case. As a result of the scarce information about the disorder, and the inaccuracy of published information, parents often take this advice and wait with the hope that their children do ‘grow out of’ their mutism (Swinburne, 2013).
The initial name of ‘elective mutism’ was put forth due to the belief that these mute children were just being stubborn and oppositional. Some perceive mutism as a means of defiant or oppositional behaviour. However, research at the SMart Centre has suggested that children who appear ‘oppositional’ often have those around them pressuring them to speak. In cases such as these, mutism is found to not only persist, but is negatively reinforced (SMC, n.d.). Further, research and clinical experience has suggested that without proper recognition and understanding of selective mutism, the problem will persist and increase in intensity. Most children do not ‘out-grow’ the disorder, instead, they go through years without proper interactions, or the development of appropriate social skills[factual?].
The lack of knowledge and misconceptions about SM is seen to be a serious barrier to helping the children of this disorder. Selectively mute children have the best chance of approaching this condition when parents, teachers, and professionals work together in gaining an accurate understanding of the struggles these children are experiencing.

#### Shyness

Selective mutism on many occasions has been misunderstood as a form of severe shyness.The difference between selective mutism and shyness is functionality. Shyness is not a psychiatric disorder like selective mutism or social phobia, both of which are characterised by inhibitions that interfere with daily functioning (Stanley, n.d.). Individuals who are considered to be ‘shy’ are capable of functioning adequately in an uncomfortable situation, whereas an individual characterised as selectively mute will have difficulty socially, emotionally and academically functioning in a situation they perceive to be uncomfortable or anxiety provoking (SMG, n.d.), thus hindering their daily functionality.

### Etiology

The current view is that selective mutism may be produced by a variety of influences, including, genetic, temperamental (Ford, et al., 1998), and environmental (Viana, Beidel, & Rabian, 2009). While no definitive conclusions have been made – predominantly due to under-diagnosis of the disorder and small sample sizes; many etiological theories exist.
The psychodynamic perspective illustrates that the internal conflicts of an individual are believed to be the cause of SM. The behavioural theorists, such as Leonard and Topal (1993) propose SM to be an adaptive response rather than pathological. The traumatic experience factor – in which children exposed to a traumatic event such as physical or emotional abuse are vulnerable to SM is also proposed, however, this theory is less supported (Anderson, & Thomsen, 1998; Black, & Uhde, 1995).
Lastly, a genetic predisposition has come into play more recently, and is viewed among one of the more likely causes of the disorder; suggesting that children with selective mutism have an inherited predisposition to anxiety. These children are often found to have a family member who meets the criteria for an anxiety disorder (Viana, Beidel, & Rabian, 2009; Black, & uhde, 1995).
Some of these perspectives, such as the psychodynamic perspective and the traumatic experience factor, have slowly been losing their support for more empirically evidenced theories such as the behavioural and genetic propositions.
Research has found a large amount of evidence for high rates of anxiety disorders within families of children found to have selective mutism (Remschmidt, et al, 2001; Kristensen, & Torgersen, 2001; Chavria, et al., 2007). All of these findings shed light onto the inferences of a genetic predisposition of SM.

## Emotional well-being

Well-being refers to positive mental health; specifically to the presence of positive emotionality and the absence of negative emotionality (Reeve, 2015). This encompasses the individuals’ consciousness of their own abilities, their capability to deal with normal stressors; and to function productively and effectively (WHO, 2010).
Social and emotional well-being refers to the way a person thinks and feels about themselves and others. It includes the ability to adapt and deal with daily challenges, increased self-esteem and performance, all while leading a fulfilling life. Social and emotional well-being incorporates both the individuals’ characteristics and those of the environments in which they develop; such as the family environment, schooling, and communities (Australian institute of health and welfare, 2012). Implications of decreased emotional well-being are related to mental health concerns such as stress, depression and anxiety.
From this description of social and emotional well-being, the following theories and models have been found to be informative and relevant in the research on the effects selective mutism has on an individuals health and functional life.

## Theories/models related to selective mutism

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### Bronfenbrenner's ecological model

American psychologist Urie Bronfenbenner developed the ‘ecological systems theory’ in order to explain how intrinsic qualities of a child and the external environment in which children interact, influence how they grow and develop.
Bronfenbrenner’s ecological model is based on how the interactions between multiple environments and the child’s inherent characteristics influence their social and emotional wellbeing. The model consists of four main components (Australian institute of health and welfare, 2012):
* The settings in which children actively participate through face-to-face interactions (such as with family, peers, teachers, neighbors) is described as a ‘microsystem’.
* Interrelationships between children’s immediate settings (two or more microsystems), and the extent to which these settings have similar expectations or values is described as a ‘mesosystem’.
* Settings in which children to not actively participate but that may influence the child indirectly is the ‘exosystem’.
* Broader social contexts such as culture, political systems and social values is the ‘macrosystem’.
From an ecological perspective, healthy social and emotional development requires productive and effective interactions between multiple environments and the child’s characteristics.
The child (the centre of the model), is surrounded by their internal characteristics of social and emotional well-being. These characteristics include their emotional regulation, behavioural regulation, resilience, and coping skills, self-esteem and confidence (Australian institute of health and welfare, 2012). The individual characteristics involving relations with others include the ability to identify emotions with others, the capacity to form and maintain relationships and the development of social skills, including empathy, trust, and cooperation (Australian institute of health and welfare, 2012).
This model helps to understand and establish the lack of social and emotional well-being experienced by those confronted by anxiety provoking disorders such as selective mutism.

### Behavioural theory

The behavioural theory describes the failure to communicate as a learned defence mechanism in response to social triggers (Wong, 2010). Behavioural psychologists have argued that selective mutism is an adaptive response rather than pathological (Powell, & Dalley, 1995). Children appear frozen due to behavioural inhibition; especially when exposed to new social situations. This theory describes similarities to those of the flight-or-flight response mechanism (FFM) first described by Walter Bradford Cannon; in which the sympathetic nervous system inhibits behaviour and the ability to speak. As defined in the [[[Wikipedia:Fight-or-flight|response|FFM theory]]] – a physiological reaction occurs in response to perceived threats.
This theory is significant in the distinction between the misconception of selective mutism as an oppositional behaviour, and its acceptance as an anxiety disorder.

## Issues faced by the individual

There are many complications that arise as a result of SM in a selectively mute child's life. Since SM is an established form of social anxiety, the psychological effects it entails on an individual are similar to those of any form of anxiety.
If left untreated, anxiety disorders such as this tend to lead to more severe mental and physical health conditions; effecting their social and emotional well-being. These include (Mayo Clinic, 2014; Health Central, 2006; Shipon-Blum, n.d.; Healthline, 2014):
* Worsening anxiety
* Depression
* Social isolation and avoidance
* Poor self-esteem and self-confidence
* Poor academic performance
* Frequent emotional and/or physical health issues (i.e. headaches, digestive or bowel problems)
* Irritability and in extreme cases:
* substance abuse, and
* suicidal thoughts
The most common conditions and areas associated with complications arising from SM are depression, social isolation and school environment.

#### Depression

The emotional impact of being socially isolated, and the frustration at their own inability to communicate and function as well as their peers, selectively mute individuals are bound toward the starting point of depression. As they age, but continue to lack in development of these skills, into adolescence these individuals are likely to develop deeper levels of depression and anxiousness[factual?]. Depression is quite common among those with anxiety disorders. A combination of depression and anxiety is a major risk factor for more serious conditions such as substance abuse and suicide.

#### Social isolation

All children want friends and to be able to fit in. The issue selective mutism has in a child is that during their schooling years, their mutism prohibits them from developing the social and communicative skills needed in order to engage properly with their peers.

#### School environment

Research has suggested that the school environment is one of the most important determinants of a child’s social and emotional well-being (Weare, & Gray, 2003). Supportive and caring schooling environments can establish positive climates and relationships among those involved. Positive peer relations assist children to develop not only close relations, but to also experience and feel security in the company of others, whilst increasing their confidence and social skills (Australian institute of health and welfare, 2012).
Problematic peer relationships and disturbances to a child’s schooling environment formed by selective mutism can negatively impact the child’s social and emotional well-being. Selectively mute children have inadequate social skills, leading to the likelihood of complicated and unsettling social interactions. Especially in the schooling years, in which bullying occurs most often, this will lead these children to feel isolated, and rejected by their peers. This victimisation and isolation during schooling years has been identified as associated to mental health issues such as depression, self-esteem issues, and furthered anxiety (ACU National & Erebus International, 2008).
These issues have been proven to be significantly associated with lowered well-being; with effects lasting into adulthood (Australian institute of health and welfare, 2012).

## Treatment methods

Selective mutism is usually highly responsive to treatment, and early intervention can avoid a range of residual effects on an individuals emotional well-being.
It is suggested that regardless of the cause, mutism is reinforced if not addressed appropriately. Children left allowed to communicate in ways other than speech, are having their mute behaviour reinforced.
While the long-term effects of selective mutism have not been extensively studied, there is some research to suggest that if mutism is not recognised and addressed appropriately, the individual is likely to develop other problems including depression, avoidant personality disorder, and inadequate social skills (SMG, n.d.). If a child remains mute for many years, their behaviour could become a conditioned response (Shipon-Blum, 2007), in which the child will automatically respond to any feelings of discomfort by remaining silent and avoidant, or even adapting to non-verbalisation communication methods in general.
A number of treatment approaches however, have been developed and utilised in the attempts to treat selective mutism.

#### Behavioural therapy

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http://ccs.sagepub.com.ezproxy.canberra.edu.au/content/12/5/335 - example.
http://zh9bf5sp6t.search.serialssolutions.com/?ctx_ver=Z39.88-2004&ctx_enc=info%3Aofi%2Fenc%3AUTF-8&rfr_id=info:sid/summon.serialssolutions.com&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Practitioner+Review%3A+Psychosocial+interventions+for+children+with+selective+mutism%3A+a+critical+evaluation+of+the+literature+from+1990%3F2005&rft.jtitle=Journal+of+Child+Psychology+and+Psychiatry&rft.au=Cohan%2C+Sharon+L&rft.au=Chavira%2C+Denise+A&rft.au=Stein%2C+Murray+B&rft.date=2006-11-01&rft.issn=0021-9630&rft.eissn=1469-7610&rft.volume=47&rft.issue=11&rft.spage=1085&rft.epage=1097&rft_id=info:doi/10.1111%2Fj.1469-7610.2006.01662.x&rft.externalDBID=n%2Fa&rft.externalDocID=10_1111_j_1469_7610_2006_01662_x&paramdict=en-US
http://ccs.sagepub.com.ezproxy.canberra.edu.au/content/12/4/278
http://onlinelibrary.wiley.com/doi/10.1111/j.1469-7610.2006.01662.x/abstract

#### Psychotherapy

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#### Social communication anxiety therapy (SCAT)

SCAT® is based on the concept that Selective Mutism is a social communication anxiety disorder that is more than just not speaking. http://www.selectivemutismcenter.org/media_library/whatissm.pdf)
Selective mutism is frequently treatable, in that many cases of the disorder are thought to resolve on their own. Sometimes reported cases do resolve with time, although treatment can be very effective. There is little information about the long-term outcome of selective mutism. Researchers have noted that while many children with the disorder do show improvement in speech, their anxiety in social situations persists. http://www.minddisorders.com/Py-Z/Selective-mutism.html

## Conclusion

Selective mutism is quite a rare disorder. Because of this, and that all current data is derived from case studies of small sample sizes, an accurate representation of the disorders characteristics is a challenge to study and thoroughly understand. Even though this is the case, many theories persist in regard to it etiology and its association with other conditions, such as social phobia. Without the raised awareness of selective mutism, many children remain undiagnosed, and misunderstood; causing extended disruptions to their social and emotional well-being.

## See Also

Selective Mutism
Book chapter - Anxiety
Emotional Well-being
Bronfenbrenner Ecological model
Emotional Well-being
Subjective Well-being
Flight or Flight Response
Ecological Systems Theory