Selective mutism associated with language disorder in the bilingual child:

 Issues concerning differential diagnosis

Maria Vlassopoulos*, Dimitris Anagnostopoulos**[1]

 

Selective mutism is the condition where children do not speak in at least one social situation, despite the ability to speak in other situations. Although this disorder is displayed with considerable variation, it is characterized by certain common psychological and personality features.  DSM-IV (APA, 1994) criteria are that it is a “consistent failure to speak in specific social situations, despite speaking in other situations” and that the duration of this disturbance is for at least one month. Although DSM-IV criteria are also that failure to speak is not due to “lack of knowledge of the spoken language required not can be better accounted for by a communication disorder”, many studies have found that these criteria are difficult to ascertain since there is a much higher incidence of selective mutism in children from immigrant or bilingual backgrounds and in children with communication disorders (Krysanski, 2003; Kristensen, 2000; Toppelberg et al., 2005).

 

Selective mutism is a rare condition (approximately 0.5% of all referrals of children and adolescents ), although it may be more common than is generally thought. Onset of this disorder is usually before the age of 5, although commonly it is first noticed and reported upon school entry, because parents are more lenient with this behaviour and do not see it as problematic.  In immigrant children, it is interpreted as a result of bilingualism, since some bilinguals do exhibit a temporary “silent period” when learning two languages.

 

Psychological and personality features are fairly typical in these children: they appear anxious, shy or socially inhibited. According to some researchers, failure to speak may be a result of fear or anxiety (Steinhausen & Juzi, 1996; Anstendig, 1999; Kristensen, 2000; Rosenbaum et al., 1993). According to DSM-IV, children with selective mutism are almost always given an additional diagnosis of Anxiety Disorder, in particular Social Phobia. With respect to differential diagnosis, an important factor is that children with SM show affectionate social relationships at home and even when mute, usually do communicate non-verbally and show interest in what is going on in the environment. However they do often show social anxiety and fear of the unfamiliar.

 

Although organic factors leading to the child’s failure to speak must be ruled out, many investigators (Kolvin & Fundudis, 1981; Wilkins, 1985; Elizur & Perednik, 2003; Krysanski, 2003) have reported that children with SM have neurodevelopmental delays and disorders, in particular speech disorders. Kristensen (1997) argues that there may be an underdiagnosis of developmental disorders in children with SM, something which he confirms in a later study (Kristensen, 2000). The question which these investigators address is whether this is due to a concurrent condition or whether the selective mutism is a result of the speech disorder. Comorbidity is also high with other disorders, such as motor immaturity, minor physical anomalies and encopresis/ enuresis (Elizur & Perednik, 2003).

 

There is a higher incidence of SM in communities where there are a lot of ethnic minorities or immigrants (Lesser-Katz, 1986; Bradley & Sloman, 1975). Two recent studies (Elizur and Perednik, 2003; Toppelberg, 2005) confirmed that SM prevalence was 3 times higher in children of immigrant backgrounds. It must be noted that for the diagnosis of selective mutism to be given to a bilingual child, failure to speak must be present in both languages, in several unfamiliar settings and for significant periods of time. It has been suggested that children with SM reflect the tensions within the family concerning the use of language (Sluzki, 1983; Albert-Stewart, 1986), which may be compounded by the home language’s relatively low status in society generally.

 

The process of migration itself may be an important factor for immigrant families: that is, it is often accompanied by anxiety, depression and social isolation on the part of the parents. The capacity of the family to offer mutual support is decreased.  It may also be a symptom developed by families where withholding speech is an acceptable way of expressing anger.

 

Although the families of SM children also have certain characteristics in common, such as shyness and social inhibition, high levels of social anxiety and stress, they are not described as being significantly more dysfunctional or prone to child abuse. However, some studies (Elizur & Perednik, 2003) suggest that marital conflict is higher in families with SM.

 

In this study we present two cases to illustrate some of the characteristics of these children and to illustrate a multifactorial approach to intervention. Although these cases are rare and therapists do not often have experience in treating them, a better understanding of the interaction of all of the features involved in this impairment, may lead to more successful intervention techniques. The role of the speech therapist in the multidisciplinary team is important, both in the diagnosis and therapy of children with SM. Differential diagnosis is a crucial issue in this disorder, particularly with respect to bilingual children and children with communication disorders: the specific “load” which each parameter carries must be assessed so that treatment may cater to the specific needs of the child and his family The cases which are described reflect such an approach to these disorders.

 

Case study 1: Flamour

Flamour is the first child of an Albanian immigrant family. He was born in Greece, just after his parents immigrated to that country. He was referred to the Community Mental Health Centre by the local medical services, upon request from his mother, Mrs B.

 

Flamour was 5;3 years old at intake. His mother reports that Flamour went to pre-school last year, where the teacher said that, although he participated in all activities, he did not speak at all. His teacher justified this situation by saying he was excessively shy. Flamour is presently in kindergarten class and although he loves going to school and participates in all activities, he continues not to speak. His teacher and consequently his mother are extremely concerned about Flamour’s lack of speech at school. At home, his mother describes a completely different picture: he is particularly lively and enjoys rough play and drawing. He talks to his parents, his younger sister and his cousins who live nearby, but not to anyone outside the home.

 

The parents: Mrs B’s Greek is poor, whereas his father’s is at a more functional level. Mrs B has a more consistent contact with our Centre. She appears very distraught that Flamour does not choose to speak. She cannot understand what’s wrong and fears for his future. She is a very anxious person and worries that Flamour will not be able to assimilate in Greek society, something which has very high stakes for her. The family immigrated to Greece with high expectations but is finding it very difficult both economically and socially. Flamour’s father works as a painter and is away from home for many hours. Mrs B on the other hand does not work. The family’s social life is restricted although they live close to some cousins, who they see very often. With respect to Flamour, his mother has a particularly close relationship. She weeps in front of him and implores him to speak outside the home and at school. Even in front of the therapist, and in Flamour’s presence, she is tearful and negative towards Flamour. She reports that he is often manipulative and once said to her: “I know what you want most: for me to speak!” Although the father is not able to attend meetings at our Centre owing to his work, he was able to come to one meeting where he appeared a mild-mannered man, who cares for his children and when he has time, plays with his son. He reports that they are a quiet family, who do not use corporal punishment with their children: neither he nor his wife ever hit the children. His only ‘punishment’ is to threaten Flamour that he will send him to Albania to relatives, since he does not speak Greek. He believes that Flamour’s lack of speech is oppositional and that he will grow out of it.

 

Language: The language spoken at home is Albanian. At home Flamour talks a mixture of Greek and Albanian with his cousins and his younger sister. Mrs B describes Flamour’s language development as normal. However, she says that his language level in Albanian is poor: he makes syntactic errors and has poor articulation, in comparison to his sister who is two years younger.

 

School: His teacher reports that although he participates in class, he never speaks to her nor to the other children. Furthermore, he does not make any attempts to communicate with another Albanian boy in his class. He has no friends and does not play with the other children in the playground. However, he does observe their games keenly and is not isolated. The teacher does not pressure him to speak and accepts his lack of speech without comment.

 

Developmental history: There were no complications related to Flamour’s birth; he was breast fed for a year and a half and still drinks over a kilo of milk a day. His motor development is normal and his language acquisition appears to have a premature development according to his mother, who reports that he said first words at 6 months and 2 word sentences at a year old. Particularly striking is the report that he toilet-trained himself at 12 months. He has a history of ear infections and his tonsils are often infected.

 

Initial diagnosis: Flamour was examined by child psychiatrist, psychologist and speech therapist. Flamour proceeded with ease from one professional to the other, he made good eye contact and was smiling. According to the psychiatric examination, no pathology was found: PDD and emotional disturbance were ruled out. He did not appear to have behavioural inhibition nor social phobia. He communicated non-verbally with the examiner, by smiling, shaking his head for “yes” and saying “tch” for “no”. He shrugged when he did not know something. The psychological examination ruled out cognitive problems and confirmed the above. His drawings were age-appropriate and his symbolic play was good. A question was raised with regard to his language comprehension and the impact of bilingualism in Flamour’s disorder. The speech therapist evaluation focused on Flamour’s language comprehension in Greek. He was very cooperative and communicative in a non-verbal sense, however his Greek language comprehension according to PLS was at least 1 year behind chronological age. He was not able to follow instructions, had difficulties with spatial terms and was not able to put a sequence of picture in the right order. When the therapist spoke to him in Albanian, she saw no difference either in his comprehension or in his willingness to communicate verbally. It was concluded that Flamour had a developmental language delay, which was acerbated by his lack of consistent exposure to the Greek language. A diagnosis was made, upon consensus of the multidisciplinary team, of selective mutism with possible complications from bilingualism and a substratum of language delay or disorder. He was offered clinical intervention at our Centre by the speech therapist.

 

Clinical Intervention (Phase 1): Intervention was begun 3 months after initial diagnosis, in the spring. Upon return to the Centre, Flamour’s mother reported that now he does not even want to go to school and she allows him to remain at home. He watches television all day, which seems to be the only thing that satisfies him. In the first session, Flamour happily followed the therapist into the therapy room. He smiled and cooperated very willingly. He made good eye-contact, nodded and made gestures, but only whispered once or twice. When the session ended, his mother and sister came into the therapy room. The therapist asked his sister what her name was and Flamour answered for her, saying her name. His mother reacted in an exasperated manner, and even though it was perfectly audible, told him to repeat the name since the therapist had not “heard him”. The following sessions were very different: although Flamour always came to therapy willingly, he was much more passive, did not smile and easily resorted to shrugging. He avoided eye-contact with the therapist. After approximately five sessions his anxiety lessened, but the therapist did not hear him speak again till the summer.

 

Therapy goals: The focus of intervention consisted of standard speech therapy goals, for improvement of comprehension skills, auditory memory and sequencing. Flamour’s non-verbal communication was reinforced and there was no pressure to speak. A supportive environment ensured that Flamour’s anxiety gradually diminished. The therapist often gave parallel verbal input in Albanian. No augmentative communication strategies were used.

 

Cooperation with the family: Cooperation with the family was not consistent. The father was not able to attend sessions and the mother always repeated the same worries, in an over-emotional manner. She did not appear to be able to follow instructions, not to change her attitude towards Flamour’s lack of speech. Her main worry and demand was “when will Flamour speak?” The one positive step he did make was to start speaking to a neighbour who lived in the same apartment block in the building.

 

School readiness: In the summer, Flamour was assessed for school readiness, since he was due to go to 1st Grade in the autumn. His results showed difficulties in language comprehension and in phonological awareness tasks, apart from the language expression tasks which could not be assessed. His pre-arithmetic skills are very poor in both languages, and he has poor visual memory. This assessment reconfirmed the initial diagnosis of specific developmental disorder. It was recommended to his parents that Flamour should repeat kindergarten, so that he should be better prepared for school. However his parents did not comply with this recommendation and did not return to our service after the summer. They came again in November, after he had begun first grade. Flamour was still not speaking at school, was already having difficulties with literacy skills, and was showing signs again of not wanting to go to school.

 

Re-assessment and intervention(Phase 2):

Flamour was re-assessed and intervention was re-commenced. Flamour’s language comprehension skills were still significantly behind age-level. During the psychiatric examination, he spoke to the therapist mainly in one word sentences but was able to maintain a conversation, by answering questions. He presented an articulation problem and word-finding difficulties. It was concluded that Flamour’s selective mutism was maintained by his language disorder.

 

Speech therapy has since been relatively successful: initially Flamour whispered to the therapist and now speaks to his mother and sister in her presence but not directly at her. It is hoped that this progress will be generalized in other situations. He cooperates well in all tasks presented to him and usually whispers his replies. Positive reinforcement is used with success.

 

Case Study 2: Lule

 

Lule is the 2nd child of Albanian immigrants, who emigrated to Greece approximately 10 years ago. Lule was 3;3 years at intake. She has an elder brother with speech and learning difficulties who was assessed at our Centre 6 months before. Mrs N., Lule’s mother, is very worried about her little daughter because she does not speak and is excessively shy and dependent on her. Lule was born with Holt-Oram syndrome. This syndrome presents aplasia or dysplasia in the phalanges and often is accompanied by congenital heart problems. Lule has bilateral aplasia of both thumbs and was born with a hole in the heart which was successfully operated on as an infant. Holt-Oram syndrome is a genetic condition and in milder form is present in both her brother and father: they both have dysplasias in fingers. Mrs N hopes that Lule may be operated on, but this is not possible at the present time.

 

The parents: Mrs N. accompanies her children to our Centre, because her husband works for long hours and has never been able to attend. Lule’s mother describes her relationship with her husband as “good”: her husband is the decision-maker in the family. They are quiet people, quite isolated socially. The chief problem which concerns the parents is the children’s problems with their fingers. This may be an additional source of tension and stress within the family. Mrs N. is a shy person, who was initially very worried about our Centre’s aims with regard to her children. She mistrusted the professionals but on the contrary always kept her appointments, almost submissively. Later she expressed these fears, saying that she thought initially that we would take her children away from her, and showed trust and willingness to cooperate, attending most parent meetings although the level of her Greek was very low. She also expresses great concern about Lule’s lack of speech.

 

Language: The family’s home language is Albanian, although the few words that Lule speaks at home are Greek. Her mother believes this is because she is learning Greek through her brother, who refuses to speak Albanian at home.

 

Developmental history: Lule’s developmental history, apart from her language development, does not present any difficulties.

 

Initial diagnosis: Lule was examined by speech therapist, psychologist, child psychiatrist and occupational therapist. Throughout the diagnostic procedure, she submissively entered each different therapist’s office, was cooperative, but was very limited in non-verbal communication: She made eye-contact but did not smile, nor signal or make any gestures. Her lips were “tightly sealed”. The conclusion of the diagnostic procedure was that she presented language delay, which was not due to the bilingualism per se, without ruling out the fact that bilingualism probably compounded her impairment. Furthermore, it was speculated that Lule was probably also socially inhibited and that this led to selective mutism.

 

Intervention: The clinical team decided to place Lule in the Early Intervention Programme at our Centre. This programme is designed for children with specific developmental disorders in language and motor coordination on a multidisciplinary model. It consists of 4 hours per week of speech and occupational therapy, as well as a structured programme for parents. The children are placed in small groups of 3-4 children with similar disorders.

 

Lule has now been attending the EIP for almost two years. During the first year although she participated in all non-language activities willingly and successfully, during language activities she was very passive, closed and resilient. However, she always followed the other children’s efforts very keenly, without once opening her mouth to speak. Her non-verbal communication was also limited. During the second year her attitude changed completely: She now smiles and greets the therapists by waving, and responds well to encouragement. During the sessions she often responds in small sentences although she still has difficulty initiating a conversation. Her relationship with the other children in her group is friendly and interested.  Her speech impairment is still obvious: her utterances are telegraphic and she still has difficulty following verbal instructions. On the contrary her fine motor skills despite her disability are very well developed. She is a much happier child and does not appear as anxious. She still does not speak to strangers.

 

School readiness: After testing, it was concluded that Lule should remain in kindergarten, which her mother willingly accepted. Therapy will continue during the following year, to improve her communication and verbal skills. Good progress has been made with regard to her selective mutism and it is believed that this latter will recede as she gains confidence.

 

Discussion

These cases illustrate the interplay between personality, environmental and developmental factors which characterize the initiation and maintenance of selective mutism in children. The different therapeutic approaches conducted on these cases also highlight the importance of assessing these factors according to each individual’s specific needs for the best possible outcome.

 

Initially, differential diagnosis is essential to ascertain that the child’s failure to speak in all social situations is not due to lack of knowledge or proficiency in the required language, since SM is not a consequence of normal bilingual development, nor of communication disorder as such.  It appears however that the child with SM is susceptible to certain vulnerabilities, which make him predisposed to develop this disorder. These vulnerabilities may be categorized as those pertaining to the child, and those pertaining to his family, and their position in the dominant society; for instance a social anxiety disposition in the child and his parents, in conjunction with family immigrant status increase the vulnerability of the child; a neurodevelopmental disorder further increases the vulnerability factor. This is an interdependent system, which interferes with coping mechanisms and resilience.

 

A multifactorial approach which assesses comprehensively all of these parameters, has significant therapeutic implications. Intervention is thus focused on various features of the disorder, the child’s communication disorder, through speech therapy; his educational needs, through psychoeducational intervention; his psychological vulnerability through play therapy; other neurodevelopmental impairments through occupational therapy. Therapeutic interventions should also focus on alleviating anxiety symptoms in both the child and his parents. Coping skills may be developed in the family through support therapy.

 

Conclusion

In conclusion, the most positive outcome in these cases may be attained through a multifactorial therapeutic approach, which is based on the assessment of each of the following parameters separately and an understanding of their interactions:

  1. Child: Child’s temperament is usually anxious and shy, which leads to social inhibition. This phenotype is often compounded by developmental issues, such as language delay or disorder and/or often accompanied by other disorders (motor, physical anomalies, etc.).
  2. Family: Often other members of the family are also shy and socially inhibited. This leads to social isolation and a difficulty generally with communication skills, outside the close family. More often associated with immigration, where families are more likely to have increased stress and are socially ill-at-ease. Language is a semantically loaded issue within these families.
  3. Environment: These children are pressured to assimilate and to function in another culture, with different norms. The school does not help these children to overcome their fears and expects them to learn and use the language of the environment successfully, thus increasing the stress factor.

 

 

 

 

References

 

Albert-Stewart, PL (1986) Positive reinforcement in short-term treatment of an electively mute child: a case study. Psychological Reports 58: 571-576.

 

Anstendig, KD (1999) Is selective mutism an anxiety disorder? Rethinking its DSM-IV classification. Journal of Anxiety Disorders 13(4):417-434.

 

APA (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-IV). Washington, DC: American Psychiatric Association.

 

Bradley S, Sloman, L (1975) Elective mutism in immigrant families. Journal of the American Academy of Child Psychiatry, 14:510-514.

 

Elizur Y, Perednik R (2003) Prevalence and Description of Selective Mutism in Immigrant and Native Families: A Controlled Study. Journal of the American Academy of Child and Adolescent Psychiatry, 42 (12): 1451-9.

 

Kolvin I, Fundudis T (1981) Elective mute children : psychological development and background factors. Journal of Child Psychology and Psychiatry 22(3):219-232.

 

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Kristensen, H (2000) Selective mutism and comorbidity with developmental disorder/delay, anxiety disorder and elimination disorder. Journal of the American Academy of Child and Adolescent Psychiatry 39(2): 349-256.

 

Krysanski, VL (2003) A brief review of Selective Mutism literature. The Journal of Psychology 137(1):29-40.

 

Lesser-Katz, M (1986) Stranger reaction and elective mutism in young children. American Journal of Orthopsychiatry 56(3):458-469.

 

Rosenbaum JF, Biederman J, Bolduc-Murphy EA et al., (1993) Behavioural inhibition in childhood: a risk factor for anxiety disorders. Harvard Review of Psychiatry 1:2-16.

 

Sluzki, CE  (1983) The sounds of silence: two cases of elective mutism in bilingual families. Family Therapy Collections 6:68-77.

 

Steinhausen H & Juzi C, (1996) Elective mutism: an analysis of 100 cases. Journal of the American Academy of Child and Adolescent Psychiatry 35(5):606-614.

 

Toppelberg CO, Tabors P, Coggins A, Lum K, Burger, C (2005) Differential diagnosis of Selective Mutism in Bilingual Children. Journal of the American Academy of Child and Adolescent Psychiatry 44(6):592-595.

 

Wilkins, R (1985) A comparison of elective mutism and emotional disorders in children. British Journal of Psychiatry 146:198-203.

 


[1] *Lecturer in Language and Communication Pathology,

University of Athens Medical School, Department of Psychiatry

 

**Lecturer in Child Psychiatry,,

University of Athens Medical School, Department of Psychiatry