Selective Mutism

Selective mutism as it is known today began by being misunderstood as a voluntary condition. German physician Adolph Kussmaul initially coined the condition as “aphasia voluntaria” when he observed children, at a boys’ boarding school, who did not speak at school but had spoken at home. Therefore, Kussmaul concluded that people with aphasia voluntaria were actively deciding not to speak since they had the ability to do so. Nevertheless, Kussmaul recognized that the decision not to speak may have stemmed from experiences of trauma, abuse, or neglect. In 1934, psychiatrist Moritz Tramer renamed the condition to elective mutism, still with the same underlying belief that the person, most often a child, was ‘electing’ not to speak in situations other than their home or amongst immediate family. Elective mutism appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. However, because the elective mutism criteria were not well crafted and contained discrepancies in delineating the diagnosis, a work group was selected by the American Psychiatric Association to revise the criteria. The updated criteria, based on stronger analysis of data and with inclusion of up-to-date research, was included in the DSM III-R (revised) in 1987.

In 1980, Dr. Torey L. Hayden differentiated between four subtypes of elective mutism based on a study he completed with 68 children with this disorder. The first was symbiotic mutism, which was often seen in children with a ‘symbiotic’ relationship with their caregiver, most often their mother. Another characteristic was that there were typically two caregivers, one who was passive and did not speak and another who was more verbal and dominant. In addition, children with this subtype of elective mutism struggled with controlling adults; therefore, their tendency to choose to be quiet was to allow them to control the relationship with the more dominant, more verbal adult caregiver. The second subtype, which Hayden found in his study to be the rarest, was speech phobic mutism, where the child exhibited physiological symptoms of intense fear (e.g. increased heartbeat, sweating) upon hearing their voice. They also displayed ritualistic behaviors, such as saying nonsense words or engaging in physical movements to ‘counter’ anything they said incorrectly. The third subtype, reactive mutism, was most often observed as a reaction to trauma, where the youth showed flat affect and appeared depressed. Finally, the fourth subtype, passive-aggressive mutism, was seen in children with antisocial tendencies, who often remained quiet in order to “us[e] silence as a weapon” and express belligerence by not speaking.

However, in 1994, the term changed to selective mutism in the DSM-IV, to reflect the improved understanding that people with this disorder cannot speak in select scenarios as opposed to voluntarily deciding not to speak. With the most recent edition of the DSM-V, selective mutism was moved to the anxiety disorders section to reflect this newfound discernment that the inability to speak in distinct scenarios stems from anxiety. The formal definition in the DSM-V defines it as a “consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school), despite speaking in other situations."

In modern times, selective mutism impacts less than one percent of children. It is more commonly diagnosed in females and in youth learning a second language. Typically, it begins to be observable between ages two and four, around the time when children typically have greater exposure to people beyond their immediate family. While there is still much that remains unknown about selective mutism, its most updated etiology is that of a severe anxiety disorder where one ‘freezes’ in a particular situation and is rendered unable to talk. Selective mutism can range in severity, from children who may use nonverbal signals to communicate (i.e. gestures, writing on a board) or whisper a few words in select settings to others who may not communicate at all in select settings.

1. ↑ 1.0 1.1 1.2 Wong, P. (2010). Selective mutism: A review of etiology, comorbidities, and treatment. *Psychiatry (Edgemont)*, *7*(3), 23-31.
2. ↑ 2.0 2.1 2.2 2.3 Kotrba, A. (2019, February 27). *Unlocking the mystery of selective mutism*. Continued. https://www.continued.com/early-childhood-education/articles/unlocking-mystery-selective-mutism-23134
3. ↑ 3.0 3.1 Kolvin, I., Trowell, J., Le Couteur, A., Baharaki, S., & Morgan, J. (1997). The origins of selective mutism: Some strategies in attachment and bonding research. *Association for Child Psychology and Psychiatry*, 17-26.
4. ↑ 4.0 4.1 Newman-Mercado, S. (2004). *Selective mutism in the DSM*. Selective Mutism Foundation. https://www.selectivemutismfoundation.org/knowledge-center/articles/view-selective-mutism-in-the-dsm
5. ↑ 5.0 5.1 5.2 5.3 5.4 Hayden, T. L. (1980). Classification of elective mutism. *Journal of the American Academy of Child Psychiatry*, *19*(1), 118-133. https://doi.org/10.1016/S0002-7138(09)60657-9
6. ↑ American Psychiatric Association. (2013). *Diagnostic and statistical manual of mental disorders* (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
7. ↑ 7.0 7.1 7.2 7.3 National Health Service. (2019, August 27). *Selective mutism*. https://www.nhs.uk/mental-health/conditions/selective-mutism/
Further Readings:

1. BERGMAN, R. L. I. N. D. S. E. Y., PIACENTINI, J. O. H. N., & MCCRACKEN, J. A. M. E. S. T. (2002). Prevalence and description of selective mutism in a school-based sample. *Journal of the American Academy of Child & Adolescent Psychiatry*, *41*(8), 938–946. https://doi.org/10.1097/00004583-200208000-00012
2. Sharp, W. G., Sherman, C., & Gross, A. M. (2007). Selective mutism and anxiety: A review of the current conceptualization of the disorder. *Journal of Anxiety Disorders*, *21*(4), 568–579. https://doi.org/10.1016/j.janxdis.2006.07.002
3. Scott, S., & Beidel, D. C. (2011). Selective mutism: An update and suggestions for future research. *Current Psychiatry Reports*, *13*(4), 251–257. https://doi.org/10.1007/s11920-011-0201-7
4. https://www.sciencedirect.com/science/article/abs/pii/S0890856709635930
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861522/
6. https://link.springer.com/article/10.2165/00023210-200216030-00004
7. Krysanski, V. L. (2003). A brief review of selective mutism literature. *The Journal of Psychology*, *137*(1), 29-40.
8. Viana, A. G., Beidal, D. C., & Rabian, B. (2009). Selective mutism: A review and integration of the last 15 years. *Clinical psychology review, 29*(1), 57-67.
9. Steinhausen, H. C., Wachter, M., Laimböck, K., & Metzke, C. W. (2006). A long‐term outcome study of selective mutism in childhood. *Journal of Child Psychology and Psychiatry*, *47*(7), 751-756.