The video below is the section for Selective Mutism from Part 8 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 8, click HERE. To watch earlier lectures in this series, or register for our webinar series on DSM-5 and the EPPP, click HERE.
Transcript of DSM-5 EPPP Lecture Video: Selective Mutism
Selective Mutism is characterized by a child’s failure to speak in specific social situations in which speech is expected, despite the child’s ability and willingness to speak in other situations.
To receive a diagnosis of Selective Mutism, the disturbance must persist for at least a month and interfere with educational achievement or social communication. If a child’s failure to speak is limited to the first month of school, a diagnosis of Selective Mutism is not warranted (because early in the school year, shyness and reluctance to speak are common and do not necessarily signal pathology).
Selective Mutism is not diagnosed if failure to speak is solely due to a lack of knowledge of or comfort with the spoken language required by the specific social environment. For example, newly immigrated children who are in the process of learning English may be timid speaking in front of their American peers, and such children would not be diagnosed with Selective Mutism. In addition, Selective Mutism should not be diagnosed if the failure to speak is better accounted for by a Communication Disorder (e.g., a child who refuses to speak because she is embarrassed by her stuttering) or if it occurs exclusively in the course of a Pervasive Developmental Disorder, Schizophrenia, or another psychotic disorder.
Children with Selective Mutism may employ nonverbal techniques to communicate, using gestures, pointing, nodding or shaking their head, or pushing or pulling objects or people as alternative means of communication.
In some cases, children with Selective Mutism will communicate through monosyllabic, monotone vocalizations or will speak in an altered voice. When they are outside of the specific social situation, these children will communicate normally. Selective Mutism most commonly presents as a failure to speak at school, with uninhibited communication at home.
Although failure to speak may be interpreted as stubbornness or negativism, Selective Mutism is more indicative of anxiety than of oppositional behavior.
The majority of children diagnosed with Selective Mutism also display symptoms of Social Anxiety Disorder. Selective Mutism is associated with excessive shyness, fear of embarrassment, clinging to or difficulty separating from parents, frequent crying or tantrums, and social isolation or withdrawal.
Some children with Selective Mutism may also demonstrate excessive fears or worries, a need to be in control, inflexibility, and heightened sensitivity to sensory stimulation.
As with other Anxiety Disorders, Selective Mutism is commonly treated with behavioral or cognitive-behavioral interventions (e.g., relaxation training, use of positive reinforcement, modeling) and medication, particularly SSRIs. Combinations of behavioral and SSRI treatment are common. In addition to individual therapy, family therapy may prove useful in the treatment of Selective Mutism.
Selective Mutism is a relatively rare disorder, occurring between 0.03% and 1% of various clinic and school samples and does not seem to vary by sex or race/ethnicity. Onset is usually before the age of 5, but symptoms may not reach clinical attention until the child begins school. Contrary to popular belief, Selective Mutism is not associated with abuse, neglect, or other forms of trauma. Parents of children with selective mutism have been discribed, however, as more overprotective or controlling than average. There may be a shared genetic factors between Selective Mutism and social anxiety disoder.
Treatments for Selective Mutism include behavioral and cognitive-behavioral interventions (with encouragement of and reinforcement for speaking, as well as reduction of anxiety) and, sometimes, SSRI medications.
1. Involves a child’s failure to speak in situations in which speech is expected (often presenting as failure to speak in school, despite normal communication at home)
2. Selective Mutism must be distinguished from excessive shyness at beginning of school year, from Communication Disorders (e.g., embarrassment over stuttering), or from immigrant children’s reluctance to speak while learning new language
3. Children may use nonverbal techniques (pointing, pushing/pulling objects, nodding)
4. Indicative of anxiety rather than negativism; not indicative of abuse or trauma
5. Majority of those diagnosed have symptoms of Social Phobia: excessive shyness, fear of embarrassment, clinging to or difficulty separating from parents, frequent crying or tantrums, and social isolation or withdrawal
6. May also demonstrate excessive fears or worries, a need to be in control, inflexibility, and heightened sensitivity to sensory stimulation
7. Occurring in less than 1 percent of individuals seen in mental health settings
8. No gender or enthicity/culture differences
9. Onset is generally generally before 5, but recognized once child starts school
10. Treatment with cognitive-behavior or behavioral strategies, and/or with SSRIs
11. Duration of the disturbance is at least 1 month and not limited to the first month of school
Melissa is a 6-year-old girl who, for the last two months, has not spoken in her kindergarten classroom. When the teacher asks her a question, Melissa responds by gesturing, pointing, or nodding or shaking her head. While she is on the playground at recess, Melissa talks normally with her peers. Melissa’s parents report that she has no trouble communicating at home, but note that she cries frequently and has excessive worries for a child of her age. Based on this information, the most appropriate diagnosis for Melissa would be:
A. Social Anxiety Disorder.
B. Specific Learning Disorder.
C. Selective Mutism.
D. Language Disorder.
C is correct, as Melissa displays the classic symptoms of Selective Mutism. A is incorrect. Although many children with SM also display symptoms of Social Anxiety Disorder, these are not indicative of the condition described. B and D are incorrect, as Specific Learning Disorder focuses on difficulty learning and using academic skill, and Language Disorder relates to persistant difficulties in the acquisition and use of language across modalities (spoken, written, etc.).