There have been some conflicting figures regarding the prevalence of selective mutism (SM) (or elective mutism according to the ICD-10) among elementary school populations; early epidemiological studies concluded SM was rare, while more recent studies showed figures as high as 2% of 2nd graders. Whatever the prevalence of SM, a recent Canadian study addressed the need for further research to contribute to the small number of existing studies including controls. The results of the Canadian study, published in the November issue of the Journal of Child Psychology and Psychiatry, confirmed previous associations between internalizing disorders (anxiety, depression and obsessive behavior) and SM.
The study's core consisted of four questions of frequent concern to parents of children with SM: 1) Is SM associated with anxiety or oppositional behavior? 2) Is SM associated with parenting and family dysfunction? 3) Will my child fail in school? And 4) Will my child make friends or be teased and bullied?
Because a child's behavioral and emotional responses can vary between home and school, parents and teachers completed independent ratings. During a home visit parents underwent a structured interview and responded to a battery of questionnaires addressing a range of symptoms and characteristics. Children also completed brief reading and arithmetic tests. A set of questionnaires was mailed to teachers, with a return rate of 96%.
Regarding internalizing and externalizing problems, parents and teachers completed a Revised Ontario Child Health Study (OCHS-R), rated on a 3-point Likert scale (0 = never true, 1 = sometimes true, 2 = often or very true). To examine family structure, resources and functioning, the study considered parental responses regarding marital status, income, economic assistance and immigration, as well as completing three assessment scales: A 17-item 4-point Likert scale; a 12- item Family Assessment Device (FAD) General Functioning Scale; and a Social Provision Scale.
Parental depression was measured with a 20-item Center for Epidemiological Studies Depression Scale (CES-D), rated on a 4-point Likert scale. And Dependent measures were evaluated with the OCHS-R scales for both parent and teacher responses, relating to three categories: academic performance (math, reading and general performance), social competence (social assertion, control, cooperation and responsibility, in addition to levels of extracurricular activity) and submissiveness and victimization.
The study group included 104 children with an average age of seven and an average age of onset ranging from two to five years. Exactly half (N=52) had been diagnosed with SM, defined by DSM-IV criteria as failing to speak in selected situations, speaking in other situations and mutism persisting for at least one month. The children with SM were recruited over a period of nine years from a regional service providing child assessments. According to parents, 100% of the children with SM spoke in a "normal" (non-whisper) tone of voice to their mothers and siblings. In contrast, only 11.5% had ever spoken in a "normal" voice to their teachers in the classroom.
A community control group (N=52) was randomly selected from a stratified sample of 2,439 children (89.4% of those approached) selected by the Ministry of Education. The SM and control groups did not differ on child gender (mean SM group = 59.6% female and mean control group = 57.7% female) or age (mean SM age = 85.9 months and mean control age = 83.4 months). Family status, principle caregiver employment, family income, the receipt of economic assistance and child immigration status were also consistent between groups.
Researchers found that children with SM were more anxious, obsessive and prone to somatic complaints; however, they were less oppositional and showed fewer attention difficulties in the school setting. Regarding parenting strategies, the SM and control groups reported no difference in approach. And although children with SM were described as less cooperative at home than the control group, there were no significant differences in degree of family functioning. These results regarding family functioning are consistent with earlier studies and researchers feel they question the generality of case reports linking SM to family dysfunction.
Researchers were surprised to find no differences in academic performance between groups, and children with SM seemed to participate in the same range of extracurricular activities as their peers in the control group. Their deficits in social skills, however, were notable, especially in social assertiveness, with significantly lower scores on the SSRS Social Assertiveness scale. But contrary to predictions, the children with SM were no more likely to be bullied or victimized.
Researchers claim that this is the first such "study of child characteristics and social factors that may compensate for the failure to speak at school and prevent children with SM from being victimized by peers."
*Funded by Ontario Mental Health Foundation Senior Research Fellowship
Cunningham CE: Behavioral and emotional adjustment, family functioning, academic performance, and social relationships in children with selective mutism. Journal of Child Psychology and Psychiatry 2004; 45(8): 1363- 1372. |
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