EDUCATION
Selective mutism in children What are the causes of selective mutism and can it be prevented or treated? What signs should a dentist pay attention to? Which are the appropriate approaches to a SM patient in the dental office?
Laura Elena Narita, Romania
S
elective mutism is a childhood disorder affecting mostly children entering school age. It is a rare condition that makes children unable to speak in certain social situations, while in more comfortable settings (e.g. at home) they speak normally. Selective mutism results in significant social and academic impairment in those affected by it. This disorder was first identified in the 19th century when Kussmaul named it “aphasia voluntaria” in 1877 to describe the condition where individuals would voluntarily not speak in certain situations. In the early ‘30s, the disorder was renamed “elective mutism” (Wong, 2010). Selective mutism is classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text revision (DSM-IV-TR), under the category of disorders first diagnosed in infancy, childhood or adolescence. In order for one to get diagnosed with this condition, the symptoms must be present for a minimum of one month, excluding the first month of school. The prevalence of social mutism ranges from 0.47 to 0.76% of the population based on pooled
case studies from the United States, Western Europe and Israel (Wong, 2010). The onset of the condition typically occurs between ages 3 to 6, but it is mostly discovered after the child enters school. It is slightly more common in girls than in boys, although the difference may be accounted for by research limitations. The disorder can occur over a few months or persist for several years (Nieves and Beidel, 2012).
Theories regarding etiology
Therapists and psychologists have yet to agree as to the actual cause of selective mutism. In reviewing the literature, there appears to exist a large etiological spectrum of theories concerning this disorder. Around 1990, regarding the onset and persistence of this disorder, there were three major theoretical schools of thought: (1) hostility and control, (2) anxiety and social phobia, and (3) family communication. In recent times, the developmental psychopathology framework aims to integrate perspectives as: biological, genetic, behavioural, developmental, psychodynamic, family systems, and ecological factors at the root of
this condition (Wong, 2010). a) Psychodynamic theory: this refers to the concept of unresolved conflict, often between parent and child. The articles describing some of the plausible hypotheses for selective mutism present this condition as a coping mechanism of the child for any anger or anxiety they are experiencing. According to this theory, the child is focusing negative emotions towards the parents, with the intention of punishing them. However, there is insufficient data to reinforce this hypothesis. b) Social phobia and social anxiety: this theory proposes the idea that selective mutism might be a symptom of social phobia characterised by excessive social anxiety. It has been found that the severity of social anxiety is positively correlated with the severity of mutism. They based this theory on data showing high incidences of selective mutism in families with social phobia. Powell and Dalley (1995) reported that the nonverbal behaviours involved in selective mutism have been linked to anxiety and fear, and can be viewed as
Spring 2021
| 39
