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PubMed2005

When silence is not golden: an integrated approach to selective mutism.

Selective mutism (SM) is a rare disorder that is associated with both anxiety and communication impairments. Preliminary evidence suggests that educational attainment and development of social skills and self-esteem may be affected by SM in a significant proportion of cases. There is a critical need for cross-disciplinary research from the fields of speech-language pathology, psychiatry, and clinical psychology to develop protocols for assessing language and cognitive functioning in children with SM and developing interventions that address psychiatric, communicative, and social aspects of this disorder.

Anxiety↗
PubMed1994

[Mutism and aphasia--a review of the literature].

Mutism in the sense of a complete inability to produce oral language is a rare symptom in aphasic disorders and most often occurs as a transient initial sign. Among the pathomechanisms causing muteness in aphasia, disturbances of speech initiation and of limbic aspects of speech production on the one hand and speech motor programming impairments on the other are considered. This article reviews clinical reports of extremely reduced speech or complete muteness in the context of aphasia, discussing the observed symptom patterns as well as their neuroanatomic correlates and aspects of their recovery.

Aphasia↗
PubMed1996

Cerebellar mutism following posterior fossa tumour surgery.

Two cases of transient mutism following operative removal of cerebellar medulloblastoma are reported. These add to the few cases reported in the literature of this rare complication of posterior fossa tumour surgery in children.

Articulation Disorders↗
PubMed1997

Cerebellar mutism with subsequent dysarthria in an adult: case report.

An adult case of mutism and subsequent dysarthria after posterior fossa surgery is presented. An EEG performed during the mute phase showed widespread left hemisphere abnormality although the CT findings were normal. The possible mechanisms underlying this syndrome are discussed.

Cerebellum↗
PubMed2006

A case of serotonin syndrome and mutism associated with methadone.

A patient was seen on the palliative care service at our institution who developed serotonin syndrome and mutism associated with methadone use. Serotonin syndrome is often described as a clinical triad of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities, but not all of these findings are consistently present in all patients with the disorder. The incidence of the serotonin syndrome is thought to mirror the increasing number of proserotonergic agents being used in clinical practice. In 2002, the Toxic Exposure Surveillance System, which receives case descriptions from office-based practices, inpatient settings, and emergency departments, reported 26,733 incidences of exposure to selective serotonin-reuptake inhibitors (SSRIs) that caused significant toxic effects in 7349 persons and resulted in 93 deaths. Serotonin syndrome is not an idiopathic drug reaction; it is a predictable consequence of excess serotonergic agonism of central nervous system (CNS) receptors and peripheral serotonergic receptors. The myriad of symptoms with which serotonin syndrome may present is compounded by the fact that more than 85% of physicians are unaware of serotonin syndrome as a clinical diagnosis. Other SSRIs such as fluoxetine and fluvoxamine have been shown to increase methadone plasma concentrations in dependent patients. Although the exact mechanism is unknown, there are several pathways via which a significant interaction could occur. This would include the effects methadone has on N-methyl-D-aspartate (NMDA) in addition to the impact of methadone on the cytochrome P450 enzyme system. The mainstay of treatment of serotonin syndrome is withdrawal of the offending agent and supportive care. These actions resulted in resolution of our patient's symptoms. Serotonin syndrome is becoming more common, and with the utilization of polypharmacy on many palliative care services should be considered as unifying differential diagnosis in the appropriate setting.

Aged↗
PubMed1992

A study of the effectiveness of a specific treatment for elective mutism.

Elective mutism represents a relatively rare clinical syndrome in which children with normal verbal capabilities totally refuse to speak in select settings for prolonged periods of time. It is often described as particularly treatment resistant. This study describes 20 strictly diagnosed elective mutes treated, using the Hawthorn Center approach. As found in other studies, most of the elective mutes in this sample (90%) were described as controlling, negative, or oppositional, and a high rate (50%) of maternal-child overenmeshment was found. Treatment outcome using the Hawthorn Center approach was found to be at least fair for all cases and excellent for 85%.

Child↗
PubMed1996

Elective mutism: an analysis of 100 cases.

OBJECTIVE: An extended series of 100 children with elective mutism (EM) was clinically analyzed. METHOD: The total sample included two subgroups of clinically referred children at different locations and a subgroup of nonreferred children with EM. The study was based on comprehensive item sheets and, in the nonreferred sample only, the Child Behavior Checklist. RESULTS: EM is a rare disorder in the referred child psychiatric samples. It typically starts at preschool age, is more common in girls, and is seen in all social strata. A background of migration and early developmental risk factors is also quite common. Premorbid speech and language disorders play a role in one third of the clientele, and three quarters of children with EM had behavioral abnormalities during infancy and preschool age. School and unfamiliar people create the social context in which children with EM most frequently do not speak. Shyness and internalizing behavior problems are the most common personality features in EM, and comorbid diagnoses are quite frequent. CONCLUSION: This large series of affected children has identified the most typical features of EM and thereby extends the limited knowledge of this rare disorder of childhood.

Adolescent↗
PubMed2002

Prevalence and description of selective mutism in a school-based sample.

OBJECTIVE: To examine the prevalence of selective mutism (SM) in a public school sample and compare the functioning and symptoms of children with SM to age- and gender-matched unaffected children. METHOD: Kindergarten, first, and second grade teachers in a large district were asked to identify pupils who met DSM-IV criteria for SM and to complete ratings of speaking behavior, social anxiety, other internalizing and externalizing symptoms, and overall functioning for these and comparison youngsters. Teachers completed the same ratings on the SM children 6 months later. RESULTS: A participation rate of 94% (125 of 133 teachers) was obtained, and the prevalence of SM was .71% (16/2,256). Measures were completed for 12 (75%) of 16 identified children. Compared with peers, children with SM were more symptomatic on measures of frequency of speech, social anxiety, and other internalizing symptoms. As a group, children with SM had improved 6 months later but remained impaired and symptomatic when compared with the comparison group. CONCLUSIONS: SM may not be as rare as previously thought. The functioning of children with SM is impaired, and although there is some improvement over time, notable impairment remains, suggesting that intervention is preferable to waiting for SM to remit spontaneously.

Child↗
PubMed2003

Prevalence and description of selective mutism in immigrant and native families: a controlled study.

OBJECTIVE: To assess the incidence of selective mutism (SM) in West Jerusalem's state preschools and evaluate social anxiety/phobia disposition (SAP), social competence (SC), markers of neurodevelopmental delay/disorder (NDD), mothers' psychological adjustment, and marital conflict in immigrant and native children with SM and their matched controls. METHOD: Mothers of 9 immigrant and 10 native children with SM and their matched controls completed questionnaires evaluating themselves, their marriages, and their children. RESULTS: A response rate of 30% (19/64) was obtained. The general prevalence of SM was 0.76%, while the rate among immigrants was 2.2%. Except for mothers' adjustment, all immigrant/native group effects were significant. There were significant interactions between the SM/control and immigrant/native groups for SAP, NDD, and SC. Immigrant children with SM had higher SAP and SC scores and lower NDD scores than native children with SM. CONCLUSIONS: This study distinguished between homogenous (socially anxious) and comorbid children with SM. In this sample, the disorder appeared to be associated with a combination of a specific diathesis (SAP) with intrinsic (NDD) and/or environmental (family immigration) vulnerabilities. Marital discord appeared to be a general risk factor for SM.

Anxiety Disorders↗
PubMed2000

Tacrolimus-associated mutism after orthotopic liver transplantation.

BACKGROUND: Mutism/speech apraxia has been well documented as a toxic effect of cyclosporine after liver transplantation but has been reported only rarely with tacrolimus. Brain imaging with magnetic resonance or computed tomography has failed to demonstrate abnormalities in affected patients. METHODS: We present the first example of an acute onset of loss of speech associated with a sudden elevation of serum tacrolimus level after successful orthotopic liver transplantation. We also describe the positron emission tomography (PET) scan of this patient's brain. RESULTS: PET scan imaging of the brain was abnormal, demonstrating decreased metabolism in the posterior temporo-parieto-occipital regions. Statistical probability mapping revealed additional areas of hypometabolism in the cingulate gyrus. CONCLUSIONS: PET scan revealed abnormalities of the brain in a patient with tacrolimus-induced mutism. The cingulate gyrus may play a role in the mutism/speech apraxia syndrome seen with cyclosporine/tacrolimus neurotoxicity.

Brain↗
PubMed2003

OKT3 neurotoxicity presenting as akinetic mutism.

BACKGROUND: Muromonab-CD3 (OKT3), a mouse monoclonal antibody directed against human T lymphocytes, is a potent immunosuppressive agent used to reverse and more recently to prevent allograft rejection, mostly in cardiac transplant recipients. Neurotoxicity from OKT3 usually manifests itself as a transient aseptic meningitis and remains uncommon. METHODS: The authors describe a dramatic neurologic syndrome after orthotopic heart transplant characterized by akinetic mutism, blepharospasm, anomic aphasia, and delirium. RESULTS: Magnetic resonance imaging (MRI) showed meningeal enhancement and single-photon emission computed tomography (SPECT) showed markedly reduced tracer uptake. Discontinuation of OKT3 resulted in resolution of this neuropsychiatric syndrome and reversal of abnormalities on neuroimaging that coincided with normalization of CD3+ lymphocyte count. CONCLUSIONS: In the initial posttransplant period, it remains difficult to attribute encephalopathic signs to toxicity of immunosuppressive drugs. However, MRI and cerebral perfusion studies may help support the diagnosis. More precise characterization of the prevalence of OKT3-associated encephalopathy could come from prospective SPECT studies.

Adult↗
PubMed2004

Behavioral and emotional adjustment, family functioning, academic performance, and social relationships in children with selective mutism.

This study addressed four questions which parents of children with selective mutism (SM) frequently ask: (1) Is SM associated with anxiety or oppositional behavior? (2) Is SM associated with parenting and family dysfunction? (3) Will my child fail at school? and (4) Will my child make friends or be teased and bullied? In comparison to a sample of 52 community controls, 52 children with SM were more anxious, obsessive, and prone to somatic complaints. In contrast, children with SM were less oppositional and evidenced fewer attentional difficulties at school. We found no group differences in family structure, economic resources, family functioning, maternal mood difficulties, recreational activities, or social networks. While parents reported no differences in parenting strategies, children with SM were described as less cooperative in disciplinary situations. The academic (e.g., reading and math) and classroom cooperative skills of children with SM did not differ from controls. Parents and teachers reported that children with SM had significant deficits in social skills. Though teachers and parents rated children with SM as less socially assertive, neither teachers nor parents reported that children with SM were victimized more frequently by peers.

Achievement↗
PubMed2006

A long-term outcome study of selective mutism in childhood.

OBJECTIVE: Controlled study of the long-term outcome of selective mutism (SM) in childhood. METHOD: A sample of 33 young adults with SM in childhood and two age- and gender-matched comparison groups were studied. The latter comprised 26 young adults with anxiety disorders in childhood (ANX) and 30 young adults with no psychiatric disorders during childhood. The three groups were compared with regard to psychiatric disorder in young adulthood by use of the Composite International Diagnostic Interview (CIDI). In addition, the effect of various predictors on outcome of SM was studied. RESULTS: The symptoms of SM improved considerably in the entire SM sample. However, both SM and ANX had significantly higher rates for phobic disorder and any psychiatric disorder than controls at outcome. Taciturnity in the family and, by trend, immigrant status and a severity indicator of SM had an impact on psychopathology and symptomatic outcome in young adulthood. CONCLUSION: This first controlled long-term outcome study of SM provides evidence of symptomatic improvement of SM in young adulthood. However, a high rate of phobic disorder at outcome points to the fact that SM may be regarded as an anxiety disorder variant.

Adult↗
PubMed2006

Practitioner review: Psychosocial interventions for children with selective mutism: a critical evaluation of the literature from 1990-2005.

BACKGROUND: There have been several reports of successful psychosocial interventions for children with selective mutism (SM), a disorder in which a child consistently fails to speak in one or more social settings (e.g., school) despite speaking normally in other settings (e.g., home). The present literature review was undertaken in order to provide an up-to-date summary and critique of the SM treatment literature published in the past fifteen years. METHODS: PubMed, PsycINFO, and Web of Science databases were searched to identify SM treatment studies published in peer-reviewed journals between 1990 and 2005. RESULTS: A total of 23 studies were included in the present review. Of these, ten used a behavioral/cognitive behavioral approach, one used a behavioral language training approach, one used a family systems approach, five used a psychodynamic approach, and six used multimodal approaches to SM treatment. CONCLUSIONS: Although much of this literature is limited by methodological weaknesses, the existing research provides support for the use of behavioral and cognitive-behavioral interventions. Multimodal treatments also appear promising, but the essential components of these interventions have yet to be established. An outline of a cognitive-behavioral treatment package for a typical SM child is provided and the review concludes with suggestions for future research.

Adolescent↗
PubMed1998

Akinetic mutism: a report of three cases.

OBJECTIVES: To report 3 new cases of akinetic mutism, a clinical syndrome defined by silent immobility with preserved visual alertness not accountable by lesion of the areas and/or effector pathways of speech and voluntary movements. MATERIAL AND METHODS: Anatomopathological studies were performed in Cases 1 and 2; clinical follow-up, EEG, angiography and CT scans in Case 3. RESULTS: Case 1: Bipallidal necrosis; Case 2: Left pallidal necrosis with right frontoparietal cortico-subcortical infarction; Case 3: Striato-capsular infarction on the left side, involving the caudate nucleus and the anterior arm of the internal capsule, together with obstructive hydrocephalus. CONCLUSION: The roles of both globus pallidus and prefrontostriatal circuits in the onset of voluntary movements are discussed.

Adult↗
PubMed1979

Elective mutism.

Eleven children who had received a diagnosis of elective mutism upon admission to the children's psychiatric clinic, were followed up 8--18 years later. The average age upon admission was 9 1/2 years, and at the time of follow-up, 23 years. Nine of the children came from homes with a strong familial shyness and reservation, and eight lived in social isolation. Six were particularly overprotected. Six came from discordant family constellations. All were diagnosed neurotic, eight specified as compulsion-neurosis. All were of normal intelligence. Six children received extensive individual psychotherapy (four upon admission to the clinic, two by way of out-patient treatment). We were unable to offer similar treatment to the remaining five. During the course of treatment three of the admitted patients improved, the fourth and the two ambulatory patients remained unchanged after up to 4 years of therapy. The follow-up study showed the three unchanged patients and the five who had received treatment, now were cured of the symptom; improvement took place in connection with a change of environment. The five who had not received treatment were better adjusted than those who had been separated from home for several years, at a vulnerable age. The importance of early prophylactic intervention is emphasized.

Adult↗