MUTISM
Neurogenic mutism is a lack of speech due to underlying damage to the brain. The mutism can be short or long term, static or progressive—it all depends on the region of the brain affected and the level of damage sustained.
Selective mutism is when a child can’t speak in certain settings, but can speak fine in others. For example, a child may not be able to speak at school, but can speak with no problem at home. It is called selective mutism because the child is only mute in select situations. It’s a rare childhood condition. It can cause problems with school and social situations.
A child with selective mutism may find certain social situations very stressful. This may cause anxiety so severe that the child feels unable to speak. Selective mutism is not caused by a child’s willful refusal to speak.
In some cases, a child may have other speech problems as well. But in many cases, a child may not have any trouble at all when he or she feels comfortable.
Selective mutism often starts in very young children, around ages 2 to 4. But it may not be recognized until a child starts school.
Types of Psychogenic Mutism
Over the years, the way psychogenic mutism has been classified, and the terms used to describe these classifications and different aspects of the disorder, have shifted and evolved. Even today there isn’t total agreement across fields regarding how to classify psychogenic mutism. The most common “types” of classifications you will hear of include:
1. Elective Mutism: A person chooses not to speak as a result of psychological issues.
2. Selective Mutism: A person wants to speak, but in certain circumstances finds that they can’t
3. Total Mutism: A person doesn’t speak under any circumstance.
In older literature, you’ll find that selective mutism was essentially considered elective mutism, but we now understand they are two distinct issues.
Common characteristics of
children with Selective Mutism
Most, if not all, of the characteristics of children with Selective Mutism can
be attributed to anxiety.
· Temperamental Inhibition: Timid, cautious in new and unfamiliar situations, restrained, usually evident from infancy on. Separation anxiety as a young child.
· Social Anxiety Symptoms: Over 90% of children with Selective Mutism have social anxiety. Uncomfortable being introduced to people, teased or criticized, being the center of attention, bringing attention to himself/herself, perfectionist (afraid to make a mistake), shy bladder syndrome (Paruresis), eating issues (embarrassed to eat in front of others).
· Social Being: The majority of children/teens with SM have age appropriate social skills and are on target developmentally, although some do not. Most children on the autism spectrum struggle with speech/language skills, social skills and have developmental challenges.
· Physical Symptoms: MUTISM, tummy ache, nausea, vomiting, joint pains, headaches, chest pain, shortness of breath, diarrhea, nervous feelings, scared feelings.
· Appearance: Many children with Selective Mutism have a frozen-looking, blank, expressionless face and stiff, awkward body language with lack of eye contact when feeling anxious. This is especially true for younger children in the beginning of the school year or then suddenly approached by an unfamiliar person. They often appear like an animal in the wild when they stand motionless with fear! The older the child, the less likely he/she is to exhibit stiff, frozen body language. Also, the more comfortable a child is in a setting, the less likely a child will look anxious. For example, the young child who is comfortable and adjusted in school, yet is mute, may seem relaxed, but mutism is still present. One hypothesis is that heightened sympathetic response causes muscle tension and vocal cord paralysis.
· Emotional: When the child is young, he/she may not seem upset about mutism since peers are more accepting. As children age, inner turmoil often develops and they may develop the negative ramifications of untreated anxiety (see below).
· Developmental Delays: A proportion of children with Selective Mutism have developmental delays. Some have multiple delays and have the diagnosis of an autistic spectrum disorder, such as Pervasive Developmental Disorder, Aspergers, or Autism. Delays include motor, communication and/or social development.
· Sensory Integration Dysfunction (DSI) symptoms, Processing Difficulties/Delays: For many children with SM, sensory processing difficulties are the underlying reason for being ‘shut down’ and their mutism. In larger, more crowded environments where multiple stimuli are present (such as the classroom setting), where the child feels an expectation, sensory modulation specifically, sensory defensiveness exists. Anxiety is created causing a ‘freeze’ mode to take place. The ultimate ‘freeze mode’ is MUTISM.
· Common symptoms: Picky eater, bowel and bladder issues, sensitive to crowds, lights (hands over eyes, avoids bright lights), sounds (dislikes loud sounds, hands over ears, comments that it seems loud), touch (being bumped by others, hair brushing, tags, socks, etc), and heightened senses, i.e., perceptive, sensitive, Self-regulation difficulties (act outing, defiant, disobedient, easily frustrated, stubborn, inflexible, etc).
· Common symptoms within a classroom environment: Withdrawal, playing alone or not playing at all, hesitation in responding (even nonverbally), distractibility, difficulty following a series of directions or staying on task, difficulty completing tasks. Experience at the Smart Center dictates that sensory processing difficulties may or may not cause learning or academic difficulties. Many children, especially, highly intelligent children can compensate academically and actually do quite well. MANY focus on their academic skills, often leaving behind ‘the social interaction’ within school. This tends to be more obvious as the child ages. What is crucial to understand is that many of these symptoms may NOT exist in a comfortable and predictable setting, such as at home. In some children, there are processing problems, such as auditory processing disorder, that cause learning issues as well as heightened stress.
· Behavioral: Children with Selective Mutism are often inflexible and stubborn, moody, bossy, assertive and domineering at home. They may also exhibit dramatic mood swings, crying spells, withdrawal, avoidance, denial, and procrastination. These children have a need for inner control, order and structure, and may resist change or have difficulty with transitions. Some children may act silly or act out negatively in school, parties, in front of family and friends. WHY? These children have developed maladaptive coping mechanisms to combat their anxiety.
· Co-Morbid Anxieties: Separation anxiety, Obsessive Compulsive Disorder (OCD), hoarding, Trichotillomania (hair pulling, skin picking), Generalized Anxiety Disorder, Specific phobias, Panic Disorder.
· Communication Difficulties: Some children may have difficulty responding nonverbally to others, i.e., cannot point/nod in response to a teachers question, or indicate thank you by mouthing words. For many, waving hello/goodbye is extremely difficult. However, this is situational. This same child can not only respond nonverbally when comfortable, but can chatter nonstop! Some children may have difficulty initiating nonverbally when anxious, i.e., have difficulty or are unable to initiate play with peers or go up to a teacher to indicate need or want.
· Social Engagement Difficulties: When one truly examines the characteristics of a child with Selective Mutism, it is obvious that many are unable to socially engage properly. When confronted by a stranger or less familiar individual, a child may withdraw, avoid eye contact, and ‘shut down,’ not only leaving a child speechless but preventing him/her from engaging with another individual. Greeting others, initiating needs and wants, etc., are often impossible for many children. Many shadow their parents in social environments often avoiding any social interaction at all. The common example given is; ‘A child in grocery story can sing, laugh and talk loudly, but as soon as someone confronts him/her, the child freezes, avoids and withdraws from social interaction.’ As the child ages, freezing and shutting down rarely exist, but the child remains either noncommunicative or will respond nonverbally after an indeterminate amount of warm up time
There is no single known cause of selective mutism. Researchers are still learning about factors that can lead to selective mutism, such as:
· An anxiety disorder
· Poor family relationships
· Untreated psychological issues
· Self-esteem problems
· Problems with sound processing
· A speech or language problem, such as stuttering
· Family history of anxiety disorders
· A traumatic experience
Selective mutism can also run in families.
Broca's Aphasia.
Broca's aphasia is characterized by nonfluent speech, varying from mutism to hesitant, struggling efforts to speak (Table 140-2). The patient utters the principal, content-carrying words, mainly nouns and verbs, of a sentence, omitting pronouns, prepositions, and articles, a phenomenon called telegraphic speech or agrammatism. Patients hesitate on names but often can indicate some knowledge of the word (tip-of-the-tongue phenomenon). Repetition is effortful and slow. Auditory comprehension is adequate for simple conversations and commands but breaks down on complex grammatical constructions, which are also difficult for the patient in expressive speech. Reading often is more affected than auditory comprehension. Writing is impaired, even with the nonparalyzed left hand. Patients with Broca's aphasia are aware of their deficits, often becoming frustrated and depressed. The lesions of Broca's aphasia involve the left frontal lobe, classically the posterior portion of the inferior frontal gyrus, anterior to the motor face area. Small lesions of Broca's area permit nearly complete recovery, whereas larger left frontoparietal lesions produce an early global aphasia that evolves gradually into Broca's aphasia. Associated damage in the subcortical and periventricular white matter (especially the periventricular white matter and subcallosal fasciculus) may be necessary to produce lasting loss of expressive speech.
Aphemia is a transitory syndrome of muteness or nonfluent speech, with preserved writing and comprehension. Some authorities equate aphemia with isolated apraxia of speech. Lesions involve the face area of the motor strip, sometimes with extension into the inferior frontal gyrus and underlying white matt