CHAPTER 2
Selective Mutism in Children
Changing Perspectives Over Half a Century
Defining the phenomenon
In this chapter, in order to provide a context for the book, I will review how perspectives on Selective Mutism (SM) have changed over the last 50 years. It is a puzzling and unexpected pattern of behaviour. How have professionals and researchers described it and explained it over the years? How have changes in society and changes in the way we think about childhood and mental health and social development affected how we think about SM?
The main characteristics associated with SM appear simple. Here is how a mother, Sharon Longo, describes her son Brian in the Personal Stories section of the Anxiety Disorders Association of America website. Her article, which is called ‘My Silent Child’, begins: ‘My 5-year-old boy has a cherub’s face with a hint of mischief in his beautiful green eyes. Brian dances to silly music and entertains us with his antics. He tells his brother to leave him alone and he teases his sister while she does her homework. The only difference between Brian and most other children is that while he is at school, he is mute.’
Selectively mute children talk readily in some situations but not in others. The characteristics associated with this challenging pattern of behaviour may include:
•social anxiety and social phobia (fearfulness)
•physical symptoms of anxiety
•shy or sad or socially withdrawn demeanour
•oppositional, contrary, manipulative or wilful behaviour
•problems of development of communication (e.g. speech problems)
•concern (which may not be expressed openly) about the negative consequences of speaking (e.g. displaying inefficient or underdeveloped speaking skills)
•skilled compensatory behaviour (e.g. effective non-verbal communication skills)
•successful creation of an environment in which others accept and compensate for the child’s silence.
(Adapted from Kearney 2010, Table 1.3)
Of course, any individual child will show only some of these features. No one will show them all.
How we name a phenomenon reflects what we think it is, and the name may also be influenced by what we think causes it. The terms used to refer to SM have changed over the years for that reason. The earliest term, ‘aphasia voluntaria’, was coined by the German physician Adolph Kussmaul in 1877. The Latin means ‘voluntary lack of speech’. The phrase ‘elective mutism’ was coined in 1934 by a Swiss child psychiatrist, Moritz Tramer. He thought there was an element of choice in his patient’s selection of who he would and would not talk to, even if the basis of that choice was unconscious. There appears to have been no single author who was the first to explain the addition of a letter to the beginning of ‘elective’ to create the term ‘Selective Mutism’. Between 1967 and 1976 several groups of authors in different areas of the USA, starting with John Reid and his colleagues in Oregon (Reid et al. 1967), began to use the new term in the papers that they published. There was no published explanation at the time, but others took up the term and it was decisively adopted by the American Psychiatric Association in 1994. In contrast to the phrases used previously, these words seemed ‘to capture the key features of the phenomenon most clearly: it is selective and it involves a lack of speech where speech is normally found. A particular advantage of this term is that it does not introduce any untested assumptions into the labelling of the behaviour. For example, it does not imply that children elect or choose to remain silent, and it does not automatically associate their pattern of behaviour with a phobic reaction’ (Cline and Baldwin 2004, p.13).
Does SM express some kind of fear or phobia? As early as 1971 a multi-disciplinary team working in Rochester, New York State, used the term ‘speech phobia’ to refer to it (Halpern et al. 1971). This term has not been taken up by others, but the notion that SM may involve some form of phobia has attracted increasing attention. For example, Heidi Omdal of Stavanger in Norway has recently argued that it is best understood as ‘a specific phobia of expressive speech’ (Omdal and Galloway 2008). But perhaps the phobia is not so specific? A more influential idea has been that SM may be a specific symptom of a more general social phobia. In one of the first larger-scale studies of SM, Black and Uhde (1992) reported high levels of social anxiety in a sample of 30 children with SM and argued that it ‘may be a symptom of social anxiety rather than a distinct diagnostic syndrome’ (p.847).
An alternative perspective has been presented by a Canadian psychologist, Norman Hadley. He pointed out that the literature on SM tends to focus on uses and habits of speech. He emphasized the role that silence plays in human communication and was critical of clinicians and researchers who ignored the context of the day-to-day use of silence when treating or studying SM. ‘There are many “sounds of silence” which are a part of day-to-day communication. Elective mutism is only one silence-related communication problem’ (Hadley 1994, p.xxi). So he called children who are selectively mute ‘silence users’. This usage is analogous to calling those whose physical movements are restricted ‘wheelchair users’. It will be seen that such terms are influenced by the late twentieth-century interest in patients and people with disabilities as agents who have (or should have) control over their lives and who are (or should be) active agents in the management of the challenges they face. In some ways the argument for this shift in terminology represents a return to the emphasis on the voluntary or elective nature of the behaviour that characterized the earliest professional accounts of it, but there is a crucial change of perspective: the element of blame has been removed.
The transition from home to school
SM is usually first observed when a child starts at school or nursery. In western societies the contexts of child development up to that point have changed in many ways since the 1960s. The technology of everyday life has been transformed, of course, including the technologies of communication. There has been a shift in buying habits from small, local, family-run shops to large, area-based, impersonal supermarkets and stores. An increasing proportion of purchases are made online. As we move about the cities where most of us live, we use our individual cars much more, and when we go on a bus, we buy a ticket from a machine rather than a conductor. My colleague Sylvia Baldwin has pointed out that the effect of each shift has been that young children are less engaged in family routines that socialize them into confident everyday communication with comparative strangers. There is less communication about everyday transactions with familiar adults who are outside the family circle.
Alongside that important change in children’s pre-school experience there have been developments in their exposure to institutional environments outside the home. An increasing number of children in the UK are now entering their first educational setting at around their third birthday, a stage when many are not yet confident speakers, especially to people outside the home. Nursery staff report that many children speak very little in nursery at first and that it is not uncommon for them to take a term to start talking in a relaxed way with adults. It should be noted that the age of most selectively mute children at referral for help is closely related to the time of starting school. There are no published data on the incidence of SM in nurseries and playgroups. Relatively few referrals are recorded in the literature, but they are not unknown (e.g. Tittnich 1990). At any rate, expectations appear to shift as children approach school age. Some leeway is allowed to a pre-school child. Parents will apologize for a young child who fails to respond to an approach from another adult: ‘He’s not himself today.’ Sylvia Baldwin observed that popular idiom has other similar let-out phrases, such as ‘Has the cat got your tongue then?’ This is not only a defence of the child but a face-saver for the adult who has been rebuffed. Starting school finally takes children away during the day from the group of people with whom they have had most practice in talking. For some, the challenge of separation from their mother and the familiar setting of the home is overwhelming. Most adapt to the new context, but some take a long time to do so.
In the past it was not uncommon for children in remote rural areas to experience many problems on school entry. One region where these were found at one point to include SM was Eastern Kentucky in the USA. The area concerned was in a remote region of the Appalachian Mountains. There were barriers to East–West travel that had affected the area during its colonial history. Even today there are many tiny, isolated communities. In the 1960s a new project brought ‘field clinics’ for children with emotional and behavioural problems to an area of Eastern Kentucky. Analyzing project records, Looff (1971) found a higher number of selectively mute children than expected (2.8% of the clinics’ case load), and he suspected that there were many more who had not been referred. There was therefore a higher prevalence in that region than anywhere else in the USA. He argued that one factor contributing to this phenomenon was a generally low level of verbal communication among many families in the area. There were both silent individuals, known locally as ‘quiet turned’, and silent families where active practical skills were valued more than talk. This was especially true of the men, who, as Looff points out, would be trained from an early age to keep quiet while hunting or fishing.
Obviously, this strong local cultural tradition had a significant influence, but he identified a second important factor relating to the way schools were organized. An acute problem arose for some children when tiny schools with one, two or three rooms in isolated communities were closed and new ‘consolidated elementary schools’ were opened to cater for more than 300 pupils in a whole district. Many children were unused to travelling outside their immediate community. For some, the experience was overwhelming: ‘In the classroom they remained frozen in their seats, would not say a word, and refused to move to go to the bathroom, lunchroom or playground. A few sobbed quietly as they sat. Several furtively nibbled at lunches brought from home, ceasing when noticed. None attempted to read or write’ (Looff 1971, pp.80–81). According to previous school reports all these children had been considered extreme social isolates by their neighbours, but had been able to function in their former schools. The children’s withdrawal, which persisted for two or three months, seemed to be an attempt to cope with the overwhelming anxiety of the unfamiliar situation.
Today in the western world the main factors in the isolation of such families are likely to be psychological, cultural and linguistic rather than physical or geographical. The incidence of SM is greater in children from ethnic and linguistic minorities. SM has been reported more frequently in the recent past in towns and cities. Schools may now face particular challenges in their role as a focus for communal socialization in atomized urban communities, just as they have done in the past in scattered rural communities. One perspective that has had some influence at intervals over the last 50 years has been a systemic approach to understanding SM, a view that it is not produced by factors within an individual or a family alone, but also by the ways that families interact with the society around them and the ways that society facilitates or inhibits that interaction.
The conditions for learning at school
It was already true of many classrooms in the 1960s that the process of learning was based, in part, on group work, shared tasks, social interaction and pooled effort. However, as long as the central goals of the school curriculum were defined in terms of the skills children needed for written examinations, a selectively mute child could get by without taking full advantage of learning strategies that relied on talking and negotiating with a peer group and active collaboration. Thus, writing in 1965, a psychiatric team working in Detroit described a selectively mute seven-year-old girl who ‘did her written work (at school) exceptionally well but refused to read aloud or recite… The teacher reported that she appeared aware of her environment and liked to participate in activities. She actually did communicate by shaking or nodding her head. Because of this non-verbal communication ability, albeit limited, she had not failed in school’ (Elson et al. 1965, p.183).
A few years later a similar team in Seattle reported on a six-year-old girl who they called Emma: ‘Although she lived just across the street from the school and played actively there, she had only to cross the street to become a pliable mannequin. In addition to not speaking, Emma never participated in any motor activities. She carried home the school craft materials, and made at home the things that the others had made in class. She eagerly related to her mother all that went on in school each day and was apparently quite attentive’ (Wulbert et al. 1973). At their university clinic, they tested Emma by observing through a one-way screen while her parents gave her their tests. They found that her intelligence was average, she knew the alphabet, could read several words, including the names of all the members of her family, and could count and write numbers to 100.
Now, however, silent achievement of traditional school skills is not enough. One of the things that has changed since the 1960s is that a social dimension is now a central feature of the school curriculum. Children must not only read and write but also speak. They must learn to work in small co-operative groups and to report back on their group discussions and their own individual work to a whole class. Assessment in school now takes account of these goals. It is no longer enough at any age to be a silent achiever. A full education for selectively mute children, as for all children, ultimately involves working towards relaxed and confident speech in the classroom.
Assessment of SM
Reading accounts of professional work and research with SM in the 1960s and 1970s, it is striking for a reader today to see the casual and unsystematic ways in which children’s use of speech in different contexts was described and evaluated. A major change over the last 50 years has been the development of simple strategies for recording patterns of speaking and measuring change. Table 2.1 shows a ‘Summary Grid’ that Sylvia Baldwin and I developed some years ago (Cline and Baldwin 2004). An approach to this task that is visually more interesting but does not record quite so much information, the ‘Talking Map’, was developed by Johnson and Wintgens (2001, pp.71–73). An advantage of that approach is that children themselves can be given a copy of the ‘map’ and record their own habits of speech. An instrument that facilitates a similarly broad and systematic profile of a child’s communication behaviour may be found in Kearney (2010).
In Table 2.1, community settings will be local places outside the home such as a park or a corner shop. It may be important to include more than one school setting so that a record can be made of a child’s use of speech in their main classroom, a more intimate support room and the relatively adult-free playground. It is intended that the grid be used flexibly. Additional columns and rows can be inserted to allow for the recording of communication with a person or in a setting that is of interest in a particular case. For example, a row might have been allocated to a child’s pet dog if that is the only individual or one of few who hears the child’s voice regularly. A simple notation can be used to summarize whether a child speaks normally to someone or replies to questions and conversational initiatives from them but does not speak spontaneously on their own initiative, or communicates with this person in this setting only non-verbally – for example, through pointing, nodding or shaking head or other gestures. Frequency of speech and volume can also be recorded. That may be of particular interest where a child communicates with some people only in whispers.
The development of SM
It has become increasingly clear that a full understanding of SM requires a sophisticated understanding of anxiety. Most selectively mute children show signs of a high level of anxiety about communication, if not about other things too. Because some of the children can be wilful, defiant and controlling as well, it was suggested in the past that the determination and oppositional behaviour were of central importance (e.g. Wright 1968), but in recent years it has been increasingly recognized that – while many factors may play a part in the development of SM – anxiety seems to be the crucial factor. It is now commonly argued that, when the children are manipulative or controlling in their behaviour, ‘it is more helpful and accurate to view the mutism as an involuntary defence against the child’s severe anxiety’ (Anstendig 1999, p.429). The overall picture was possibly concealed in the past because most studies of children with SM were based on individual clinic cases, in which the descriptions of defiant and wilful children were very striking. When survey methods began to be used to study larger numbers of selectively mute children, it became clear that the majority were shy and anxious rather than oppositional or negative. This has been confirmed in a series of area surveys and follow-up studies starting in the 1990s (e.g. Black and Uhde 1995; Steinhausen and Juzi 1996).
The view that anxiety is a central factor in SM has been further strengthened by the observation that some selectively mute children are rather inactive and passive, which is seen as suggestive of an underlying heightened level of anxiety. If genetic propensity plays a role in SM, it may be relevant that other family members are often reported to appear shy and anxious too. It is significant that those children who have associated problems, in addition to their mutism, tend to present with anxiety-related problems such as social phobia rather than motivational or conduct problems. But why do a small proportion of the children who have difficulties with anxiety focus their concerns on communication and remain silent in the presence of some of those they meet? It is not enough to understand that SM may have its roots in anxiety; we need to go further to identify how anxiety which is expressed in many different behaviours by other children finds a very unusual form of expression in this group. Table 2.2 (page 46) reproduces an account of the process that Sylvia Baldwin and I developed some time ago (Cline and Baldwin 2004, Table 3.3).
One aim of this account is to make clear that, as the example from the Appalachian Mountains above illustrated, factors in the community as well as factors in the child and the family may play a part in the process. Adopting a traditional behavioural framework, this figure differentiates between disposing factors that create a situation that is favourable to the development of SM, precipitating factors that trigger the behaviour on the first few occasions, and maintaining factors that keep it going. It is not necessary to have factors operating at each of the levels (the community, the family and the child) for full-blown SM to develop, but when there are active influences at more than one level we can anticipate that that will be more likely – a hypothesis that has not been tested through systematic research.
There has been a shift in research attention over the past 50 years. Up to and during the 1960s a great deal of emphasis was placed on the risk factors within the family. From the 1970s and into the early 1980s ecological factors outside the family are mentioned much more often. At the same time, during the 1970s an interest in learning theory and behaviour therapy led to a greater emphasis on the factors that keep SM going – reinforcement from other people’s reaction to the child’s communication profile (family members and others). Steadily, in recent years, advances in genetics have led to increasing interest in the possibility that children who are selectively mute have a temperamental predisposition to SM. Finally, during the last 20 years increasing attention has been paid to the argument that many factors may play a part in the development of SM. Although the pattern of behaviour appears distinctive and unique, it can be seen as a heterogeneous phenomenon that may develop in different ways in different circumstances and with different individuals.
|
The community |
The family |
The child |
|
|
Disposing factors (Risk Factors) |
The family is isolated or marginalized in the community |
The parents have personal experience and/or a family tradition of silence/reticence Factors within the family encourage mutism as a reaction to challenge |
The child has the temperamental characteristics of behavioural inhibition Factors within the child favour mutism as a reaction to challenge |
|
Precipitating factors (The trigger) |
The child faces a challenging transition to the outside world (or other stressful challenge) and reacts by not speaking in some situations |
||
|
Maintaining factors (Keeping it going) |
Reaction from adults and peers reinforce mutism |
Reactions from family members reinforce mutism |
The child experiences reduced anxiety and secondary gains |
The changing technology of therapy and treatment
In the first report of the successful treatment of SM nearly 80 years ago, Moritz Tramer, a child psychiatrist who worked in the German-speaking area of Switzerland, reported in 1934 on the cure of an eight-year-old selectively mute boy whom he called A. ‘During the Easter holidays in 1931 the mother had…received blessed wax from a Capuzin monk to whom she had complained about her son’s case. She was supposed to feed the boy from it or sew it into his waistcoat.’ On the first day at school after a break the boy said nothing, although he had been told that his parents had accepted the suggestion from the teachers that he should not be allowed to progress to the next grade with his classmates if he did not start talking at school. So they confirmed that he would stay, as agreed, in the second grade. It should also be mentioned that this coincided with a change of teacher.
The mother reported that on that first day she forgot to give A. the blessed wax as intended. ‘The next day she made up for it. She said he took the wax ‘with delight’ On that day he did speak in school, even though only softly. From then on there was progress. After three weeks, during which only one weak relapse occurred, he could be moved up to the third grade where he is now, according to the teacher, the best pupil.’ A check-up two years later by a welfare officer indicated that A. was attending fifth grade at grammar school and ‘according to his teacher he is a good and hard-working pupil, lively in the lessons, definitely does not exhibit shyness, does not in any way give reason for complaint.’ During a home visit the mother reported that ‘A. had never had further relapses, was uninhibited with strangers and does all the shopping without any inhibition. She believes that, apart from the wax, the change of teacher at that time and the unpleasant prospect of being moved down had an influence’ (Tramer 1934).
Many later observations have supported the view that a change of class or teacher is often associated with a positive shift in patterns of selectively mute behaviour, but that this may not be enough in itself (Cline and Baldwin 2004, pp.99–100). If the blessed wax played a part in A.’s transformation, it will not have been properties of the wax in itself but his understanding of what it represented. In the final section of this chapter I will illustrate changing approaches to the treatment of SM through an examination of the technology associated with them.
The issues and goals that have seemed important to therapists have changed over time. Different theoretical orientations are associated with goals as varied as:
•The child must shape the sounds of speech.
•The boundaries in the child’s world must become fuzzier.
•The child must develop the social skills they need for effective communication.
•Others in the family and schools must be helped to allow these developments.
•The child must come to think and feel about speech and silence in different ways.
•The child must develop a new identity – an image of him/herself as a universal speaker.
It might be expected that the use of medication would be targeted simply on reducing general levels of anxiety, but even drug treatments can be conceptualized in different ways according to the practitioner’s theoretical explanation of the behaviour. In 1971 it was reported from Ontario, Canada, that a ten-year-old girl called Wilma, who was being treated as an in-patient, was given intravenous injections to help her to ‘overcome her presumably strong inhibitions regarding speech’. Although her mute behaviour did not alter, it was noticed that she experienced the injections as a kind of punishment for not speaking – a punishment that she would try to avoid by producing minimal speech. The injection programme was continued with the rule that Wilma could avoid a morning dosage if she met certain speech requirements by bedtime the previous day. The requirements were slowly and systematically increased. ‘It appeared that the daily renewed threat situation became a conditioned aversive stimulus, which her speech automatically terminated, resulting in both operant conditioning of her speech and counteraction of the anxiety by aversion relief’ (Shaw 1971, p.580).
Thus the medical team in Ontario adapted the drug treatment at their disposal in the service of the behavioural approach to therapy that was current at the time. Later trials of the use of medication in the treatment of SM have tended to focus on the need to reduce overall levels of anxiety, while sometimes exploiting side-effects of some medications that directly facilitate talking (Golwyn and Weinstock 1990). The multi-dimensional causation of SM suggests that medication might be best used as an adjunct to other forms of intervention, but there has been little systematic research comparing the efficacy of either combined approaches to therapy or the outcomes of different forms of medication (Manassis and Tannock 2008; Wong 2010).
Some approaches to treatment evolve not because the process is being conceptualized differently but because improvements in the technology make the original therapeutic goals easier to achieve. This can be seen in the ways that video and audio recording devices can be used to help children who are selectively mute. These were first employed for that purpose over 30 years ago (Dowrick and Hood 1978). The aim was to foster children’s perception of their own competence – to help them change their self-image and to develop a new identity as a confident speaker to a wider range of people. The technique is sometimes called self-modelling.
In one example a video recording was made of a child’s teacher asking questions in their classroom. The target child made no contribution to the discussion. Then a recording was made using members of the child’s family to whom he spoke freely. In that recording family members put to the child the same questions that were put by the teacher in the classroom. This time the child did give oral answers. The two recordings were then edited together to produce a fake video in which the child appears to answer questions competently in the classroom. This was shown several times to the child, who responded by slowly beginning to speak to a wider range of people in school. Following this initial work, others reported the successful use of this type of intervention. Its rationale comes from social learning theory, which would predict that self-modelling will help children to speak because it changes their perception of their own effectiveness.
This approach has a convincing theoretical basis, and the reported success rate is high. It might have been expected that it would be widely adopted and developed further, but in the past the process was a lengthy one, and the technical equipment and expertise were not often easily available to those involved in planning treatment for selectively mute children. Technical changes in consumer electronic equipment mean that that may be changing fast. Whether using audio or video equipment, both the recording and the editing phases are much simpler and quicker than they used to be. Of course, better and cheaper technology is not enough. If video-manipulated self-modelling works, it is not because cameras are smaller and editing is easier; it is because the process draws upon powerful psychological processes. In the end, it is our understanding of SM that has to improve if we are to respond more effectively to the children’s needs.
Acknowledgements
This chapter is based on a presentation given to the annual meeting of the Selective Mutism Information & Research Association. I am grateful to Alice Sluckin and the SMIRA Committee for providing the stimulus that led me to reflect back over the last 50 years of work in this field.