DIAGNOSIS AND TREATMENT OF ELECTIVE MUTISM IN CHILDREN

Evelyn Browne) M.S. W.) Viola Wilson) M.S. W.) and Paul C. Laybourne, M.D.

Periodically, children are seen in psychiatric facilities who refuse to speak in school and to strangers, but who can and do speak to certain specific people, usually one or both parents, and sometimes peers. Nearly always, these children speak to their siblings. Elective mutism is the diagnosic term that we have applied to this behavior. This definition excludes all other forms of mutism, including hearing loss, schizophrenia, hysterical aphonia, and aphasia. The children with elective mutism are characteristically immature; most of them have average or above average intelligence and do not seem to suffer from any organic disorder. REVIEW OF LITERATURE

Although it is our impression that elective mutism is not an uncommon disorder, it is one that has been largely neglected in the American. literature. Our review of the literature includes German articles and articles published in English. In a historical survey of the

German literature, von Misch (1952) reports that in 1877 Kussmaul used the term "aphasia voluntaria" to describe mentally sound persons, who forced themselves into mutism for purposes they refused to disclose. From 1877 to 1936, the description of mutism cases was sketchy. In 1936, Waterink, Vadder and Weber all offered classificaDr. Laybourne is Director of the Division of Child Psychiatry, University of Kansas Medical Center, Kansas City, Kansas. Evelyn Browne and Viola Wilson are social workers on the staff of the Division.

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tions of mutism. However, these classifications seemed to be based more on precipitating factors than symptomatic manifestations. In 1944 Spieler reviewed fifty cases of mutism and stated that the neurotic personality was the outstanding feature in the mute children. In 1945, Tramer interpreted the infantile shyness of mute children in the presence of strangers as "an archaic defense reflex retained abnormally long." Von Misch described four cases of elective mutism and compared them with four of Weber's which had been published in 1950. Some of von Misch's observations were: (1) environmental factors may precipitate mutism; (2) mutism often occurred upon the child's separation from the family, especially at the time of his entry into school; (3) while possibly heredity and intelligence might play some part, the disorder was basically psychogenic; (4) all cases demonstrated excessive ties to the mother; (5) the selection of mutism as a symptom was possibly related to a traumatic experience at the time that the child was developing speech. Therapeutically, von Misch recommended changing the child's environment by placement, giving instructions of a therapeutic nature to the persons who would care for the child when he returned home, adequate treatment of the neurosis itself, and speech exercises. Glanzman described the "anal sulker" syndrome, the three main symptoms being, (1) mutism, total or elective, (2) urinary retention, (3) voluntary retention of stools. Leaving the German literature and turning to articles published in English, D. ]. Salfield (1950) made the following observations: The onset of elective mutism occurs between three and five years of age; there is no mental defect; there frequently seems to be a familial factor; there is relatively great resistance to treatment; and there may be an early somatic, psychological, or compound trauma. Adams and Glassner (1954), in the United States, seem to have included some cases which we would have excluded by definition. They particularly emphasized that the children in their cases came from severely disturbed home situations, were unable to develop trust in their parents, were slow in toilet training, and despite their ability to hear and understand the spoken word, used pantomime and a peculiar sign language to communicate. GENETIC AND DYNAMIC FORMULATION

It would appear that most of the published material concerning

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elective mutism focuses on the psychopathology of the child. Although many of the reports make reference to the family, they are sketchy and incomplete. The therapeutic focus remains on the child and treatment consists of doing things with him and to him. If therapy of the parents is mentioned, it seems to be of an instructional or pedagogic nature. Our experience with ten cases of elective mutism, observed during a twelve-year period, has led us to formulate the problem in different terms. If one makes an intensive study of the entire family, it becomes apparent that the symptom in these children represents not only individual psychopathology, but family psychopathology. We have been impressed repeatedly with the tendency of these families to be split into two factions with the identified patient firmly allied with one parent, usually the mother, in a tight symbiotic relationship. This symbiosis between mother and child is related to the hostile and disappointing relationship that the mother has with the father. This has been described in different ways in a number of our cases. For example, in our earliest case, one of the observations recorded in the chart is: "For all practical purposes, this household is divided into two sets, the mother and Tommy (the patient) and the father and John." The same concept is expressed in another of our cases by: "The father's work takes him out of the home most of each summer and the mother deeply resents this, although she has felt unable to tell him of her feelings. The mother fears to express her anger to her husband, because he then punishes her by refusing to talk to her several days at a time. In her relationship with the patient, the mother has infantilized him and while she resents his constant demands on her, she is not able to refuse him. She caters to him, allows him to hit her, and is dominated by him." Here again, we have the dissatisfaction of the wife with the husband, and the symbiotic infant-like relationship between the mother and child. We have some evidence to indicate that these children may experience a traumatic event at the time speech is forming which is, theoretically, a critical phase of speech development. One of our children was hospitalized with acute giant urticaria at the age of twenty-two months, and it was after this event that his tendency to speak to fewer and fewer people developed. Another child at two and one half years of age was grabbing at her mother, who was pregnant at the time; her father scolded her quite severely for the action. She immediately ceased

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talking to her father and did not speak to him until the time of her psychiatric evaluation nine years later. With the fixation or regression to the level of beginning speech development, the child behaves like a two-year-old in other ways. A \ typical description of one of the children indicates that he was a shy boy, who would not talk to strangers. He would appear to be very timid, would hang his head, and would not be able to look people in the eyes. However, he would always talk to children in the neighborhood and would actually seek them out to play with. It is well known that two-year-old children often behave in this shy, reticent way around strange adults and are afraid to speak at these times. The electively mute child seems to be afraid of the sound of his own voice. One of our patients had to give a talk at school. She taped the material, took the recorder to school, and fled from the room after turning on the recorder.Jf'he hostile retentive aspects of this mutism are difficult to overlook. The refusal to speak to someone that we are angry with is well known in our culture. Adults frequently use this method of expressing hostility to each other. These children seem to punish their parents by refusing to talk to them-Many of these children stop talking to a parent, particularly the father, after he has punished them in some way. The mothers get a vicarious pleasure from this behavior in their children and we have evidence that they do little to discourage and probably much to encourage it. Thus, in the study of the family, the genesis of the behavior can be understood. The neurotic interaction of the family members is such that it preserves the symptom indefinitely. IMPLICATIONS FOR THERAPY

It would appear that elective mutism, like many other psychiatric symptoms, responds to a number of different types of therapy in some cases, while in other cases the results are disappointing. In reviewing the literature, it was our impression that the long-term results of treatment by the methods described were not very satisfactory. Our own treatment program has undergone an evolution, as has much of child therapy in general. The first case that we worked with therapeutically was treated with the traditional child guidance methods of that day. We worked directly with the child, utilizing the services of two trainees in psychiatry, while the mother was seen by a social worker.

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After a year and a half of disappointing results, the boy was hospitalized and given an injection of Desoxyephedrine and Amy tal in an attempt to break through his mutism. The result of this injection was some silent crying; otherwise the effort was futile. Fortunately, during his hospitalization, we were able to ascertain that he had a severe articulatory problem and referred him to our speech clinic, while we continued with his psychotherapeutic work. He formed a strong relationship with his speech therapist, who taught him speech sounds at a sotto voce level. Finally he began to talk with her, then with the people in the speech clinic, later, with everyone who was unaware that he didn't talk. However, he continued not to talk in school for nearly a year. It was decided by the psychiatric personnel, the speech personnel, and the child that it would be helpful for his speech teacher to go to school with him and show the children how he could talk. This was done, and the boy talked. He became the class hero with his triumph over silence of twelve years' duration. As far as we were able to ascertain, he continued to talk adequately after this experience. It was difficult to assess what, if any, effect we had on altering the difficulty between the parents. As our experience increased, we discovered that the treatment of elective mutism was difficult, long, and involved. We gradually learned that it is frequently necessary to involve the mother, father, and child in an intense therapeutic relationship in order to resolve the kinds of problems which exist in these families. Therapy must be directed toward helping the mother and father to clarify their relationship with each other, as well as with the child. The child needs to be helped to resolve his anxious, hostile relationship toward his parents and adults in general, and to give up his neurotic mechanisms in order to mature psychologically. The following case will illustrate a number of these points. CASE REPORT

Billy seemed to develop normally in the early months of his life. He said words at eight months and simple sentences at eighteen months, but never used personal pronouns. Temper tantrums appeared at sixteen months. The parents reacted differently to these, the father becoming angry and the mother trying to reason with the child. A maid who came in twice a week seemed best able to deal with Billy

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and his angry outbursts. At the age of sixteen months, Billy developed urticaria that was present during the day, but disappeared during the night. At twenty-two months, he was hospitalized for four days with acute urticaria, which was generalized and severe. Billy cried for eighteen hours without resting after being taken to the hospital. He wanted to turn the lights off and on constantly and to drink from the water fountain. No one was able to quiet him until, finally, the maid was called to the hospital and Billy stopped crying. The following day, when mother appeared, Billy immediately began screaming and became upset. At the age of three, Billy stopped talking to the nurse upon visits to the doctor's office. At the age of three-and-a-half, when the mother was in the hospital for the birth of the younger sister, Billy refused to talk to the aunt who cared for him. From that time, he became more selective of people to whom he would talk, eventually narrowing it to his immediate family, his two grandfathers, and neighborhood children, but only with the latter if they played without adult supervision. He would talk on the telephone to some adults to whom he would not talk in person. At the age of three-and-a-half, Billy became identified with Roy Rogers, and his sentences changed from "Billy wants" to "Roy wants." He would only answer to this name and had a cowboy hat from which he was inseparable. The parents felt he carried the pretense too far, seeming to live in a world of his own. At the age of four, his previous good toilet training broke down and he became enuretic at night. At the age of five, he was evaluated by the speech department. They found he was intellectually within normal limits and that he suffered from no speech pathology other than his mutism. Prior to coming to child psychiatry at the age of six, he was seen by a psychiatrist in private practice who tried working with Billy by also being mute. This was discontinued as Billy began screaming from the time they stopped at the doctor's office and had to be forced into the interview. Billy did not speak in class or on the playground during his kindergarten year, but asked his mother for a magic toy to make him talk at school. It is interesting that she seriously considered giving him a toy.

Treatment of the Child The decision of our diagnostic team was to attempt treatment of Billy on an outpatient basis, while he remained in his own home and

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in public school classes. He has been seen for twenty-seven months with a total of 125 treatment hours. For the first thirteen months of treatment, there was difficulty in separating the boy from his mother. It appeared that the mother clung to him as much as he clung to her. Initially the therapist assured Billy he would not be pressured to talk. The first eight hours were characterized by passive, immature and disorganized play. Always he came with his pockets full of bits of paper and string, which he began to show to the therapist after about ten hours. By then he felt secure enough to begin hammering with his fists on the steel cabinets and on the screen and the window. The therapist permitted this behavior, but interpreted the angry feelings revealed. With this Billy became more aggressive and began throwing the ball at the therapist. Then he used the ball in many ways, to masturbate, to get bodily contact with the therapist, to show her where to go for the hour, etc. At this point, it was necessary for her to prevent Billy from 'Smearing paint or glue on her. The earliest communications with the therapist were animal sounds and "yes" and "no" sounds, which Billy made with his head in the waste basket. Later, written notes were passed back and forth in the playhouses under the table. Next, he moved out to the blackboard. As his play became more integrated, he showed distinct regressive behavior with his therapist. He wanted more bodily contact. He would cling to her back or legs, would find opportunities to explore the therapist sexually, the latter behavior being limited repeatedly. He began to lie flat on the floor and close his eyes; next, he moved to lie across the legs of the therapist. After seven months of treatment, he urinated in the playroom. Three weeks later, while allowing himself to be held in the therapist's arms for the first time, he soiled. Following this, he wanted to be pushed around the playroom on a roller chair, while he held his head back against the therapist. It was much like pushing a baby in a buggy. After nine months of no verbal communication other than that described above, the therapist began to feel angry and frustrated with Billy and told him so. He then began a limited speech in a falsetto voice. At the end of the year, he was building with bricks and beginning to make crude models with the train tracks and cars. He no longer fought limitations. He had stopped wetting the bed. After thirteen months (80 hours), a decision to attempt to re-enact the traumatic hospital experience was decided upon. The playroom was set up for a hospital scene. A doll was

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placed in the crib, and an intravenous set was obtained with a hypodermic needle attached. He reacted to this by treating the doll with injections and sugar pills. Fascinated, he continued this play for the next three hours. Following the second hour, he broke out in giant urticaria, which lasted for the rest of the day. This was the first time he had experienced urticaria since he was in the hospital at the age of twenty-two months. The change following this spectacular physiological regression was marked. In the third hour, Billy began talking freely in a normal voice. Once he had begun talking, he manifested resistance to coming to therapy. He told the therapist that his house had burned down and that he was moving away. The resistance lasted for the next five weeks; then he began playing out some of the problems related to his home. His father had no car license, he had to go to jail, he had no money, etc. The ball had been neglected for the previous several months. He began playing with it again, but it was no longer used for bodily contact. He no longer behaved like a baby during his therapeutic hour. For the last seven months, Billy has worked through such things as cheating in play. He has begun talking to the children in school and reading in a very low voice . He had one reoccurrence of bed-wetting after three canceled appointments which had not been explained to him by his parents. During his therapy hours, he has begun to verbalize his feelings. For the last six months, he has been going outside of the playroom for part of each hour. When he first began going outside of the playroom, he would not talk; then he began talking if there were no others around. Later, he would speak while in the coffee shop when there were no strangers around. Now he will talk with the therapist in the waiting room. Most recently, there was a three-way conversation, including his mother. His behavior has improved markedly in all spheres. He has become a leader with the children and does average or above average work in school. He is including all relatives in his conl versation. The teacher reports Billy has begun talking in the halls and in line, both places where speech is forbidden.

Treatment of the Mother The mother was seen twice weekly for the first six months and has been seen once weekly for the past year and a half. In the early sessions, separation of the mother and child for the therapeutic hours was

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marked by extreme difficulty. She was tense and anxious and complained that she could not remember details about anything. It was difficult for her to express and clarify her feelings, The only emotion she could clearly identify was the intense anger that she experienced at certain times when she would lose control. This was dealt with and worked through during many therapeutic sessions with support, clarification, and interpretation. The mother became free enough to discuss her real feelings about her relationship with her husband, and her own personal conflicts. She had a deep resentment toward her husband which she was unable to express verbally in any constructive way and which came out in periodic explosive outbursts. Because of her frustration with her husband, the mother had developed a symbiotic-like relationship to Billy. In the past she had sobbed and clung to him in an attempt to deal with her feeling of disappointment in her husband. Billy and his mother seemed to team up against the father in their anger. At times Billy was mute and closed up when in the presence of his father. There was a seductive quality in the mother's behavior with Billy, which she probably could not resolve until a more satisfactory relationship with the father was developed. Mother was helped to allow Billy to establish independence in areas where he seemed competent and to recognize these instances where his need was for her to be more giving and supporting. Separation became less of a problem as she was able to recognize her own feelings of wanting and needing the child to cling to her. Firmness and consistency were hard for the mother to develop, but as she worked at it, she began , to experience results, and Billy began to show a gradual increasing maturity. Mother then began to experience great relief of tension around her new-found ability to express her anger toward the clinic personnel for allowing her husband to "goof off," get out of therapy hours, and act out his feelings against therapy. She complained that he felt, "there's nothing wrong with me, it's you and Billy." She stated that the father used his therapy hours to "be a buddy with the therapist." The case was reviewed and the staff felt that the father probably was improperly assigned to an inexperienced therapist; in view of the nature and depth of his psychopathology, it would be reasonable to assign him to a permanent staff member. At this point, the mother's therapist also began to work with the father. Immediately, the mother began to make considerable improvement in her own therapeutic hours.

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For the past year the mother and father have been seen by the same therapist. This has proven to be a most successful way to work with these parents. The neurotic interaction between them was often so subtle and both parents used denial so effectively, that it was almost impossible for the therapist working with only one parent to understand and deal with the distortions that they brought to their therapeutic hours.

Therapy with the Father In the early hours of the father's therapy, he was assigned to pediatric residents rotating through child psychiatry. The relationships were superficial. He limited his discussions to the problems with his son and his basic difficulty was never dealt with. He was next assigned to a psychologist trainee at the time the family was undergoing a serious financial crisis. The father had gone into business for himself and it had failed; neither the father nor his therapist could bring themselves to discuss this material and its meaning. The fee the family was charged was unrealistic and the amount they owed the clinic was increasing rapidly. Attempts were made to get the father's therapist to deal with this. However, before this was resolved, the therapist, because of a personal matter, was unexpectedly forced to terminate his relationship at the clinic. The father was then assigned to his present therapist, who was also the mother's therapist. We knew from the mother that the father was acting out his conflicts. He was writing bad checks and was seriously in debt, thus threatening the financial integrity of the family. Since we felt it was undesirable to cross-communicate this material, we decided to deal with the realities of the debt to the clinic. The fee for therapy was reduced to a token payment, but it was clearly defined with the father that this obligation must be met. The father continued to forget to pay his therapy bill and when it was discussed with him, there was always an excuse. It became necessary for the therapist to remind the father in each session that he must pay the bill, and later it became necessary for her to accompany him while he paid his bill. Even then there were repeated attempts to escape by not having the correct change, trying to cash a bad check, etc. The therapist felt considerable embarrassment about finding it necessary to make the father pay his bill and the effect of his behavior on her was discussed with him. The father tested the limits in the same way a

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small child would, and only by setting definite limits and rigidly insisting that they be carried out was the therapist able to establish a relationship that ultimately proved to be therapeutic. The father began to work in his therapeutic hours. It became clear that he equated love and money, and that most of his acting out had been centered around this conflict. He was then able to talk about his discovery at the age of fourteen that his father was not really his father, but his stepfather. Until this time, he had always been industrious and hard-working, but he suddenly changed and began to spend the stepfather's money recklessly and became a "playboy." It would appear that he was attempting to punish his stepfather for having concealed this fact from him. When he was able to discuss this, he began to handle his money better, but this was not to be the end of his acting out regarding his clinic bill. He wrote a bogus check to the clinic on a bank where his wife had an account, but he did not. It was decided that we would deal with this by means of a family conference, attended by both parents and their therapist, the child's therapist, and the clinic director. The mother was unaware of the fact that he had written a bad check to the clinic, but on many previous occasions had either picked up his bad checks herself, or had persuaded her husband's father to do so. In the conference, the self-destructive quality of the father's behavior and the mother's contribution to it was discussed with them. It was clearly stated that the therapists were "about at the end of their rope" and that if the father was trying to convince them that it was useless to work with him, they were about convinced. We stated clearly that this kind of activity must stop, because it was destructive to him and that we could not permit it. We again stated that the bill would have to be paid each week, and a regular fixed amount toward his outstanding balance would have to be paid. Since the conference, the father has met these requirements, except on two occasions when he was not able to make a payment on the balance. He did not, however, try to "get by," but discussed his financial situation with us in a realistic way. In his therapeutic hours, he began to verbalize his feelings and developed considerable insight into his lifelong behavior disorder. He has been working regularly as an insurance salesman and paying on the numerous bills that he had incurred. It is our opinion that he is definitely attempting to work out his problems now. Recently he asked for a joint interview with his wife to dis-

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cuss their mutual problems. There would appear to be a direct correlation between the improvement in the father and the improvement in the child. It was apparent from the work with the child that he was aware of his father's financial difficulties and dishonesty. He verbalized it very clearly in the play sessions, and when his father began to meet his responsibilities in a more mature way, the boy became more relaxed and therapy with him progressed much more rapidly. IMPLICATIONS FOR THE SCHOOL

In our work with children exhibiting effective mutism, we have noted that the reactions of the school seem to follow a definite evolution. It would appear that, generally, the school identified with the child in his anxious and withdrawn behavior. Many times the teacher made no attempt to indicate to the child that she expected him to talk. She stopped giving him opportunity to talk by falling into the same pattern that so many other people in the child's life utilized. She accepted him as a nonspeaking child, responded to his pantomime requests, and generally treated him differently from the other children. In our experience, after this has gone on for a period of months or years, eventually someone in the school reacts with frustration and anger; then overt attempts are made to insist that the child talk. These attempts are usually met with panic and increased resistance by the child, so that often an impasse is reached between the family on one hand and the school on the other. The school insists that the child talk, or not be promoted to the next grade. Probably these patterns of reaction contribute something to the continuing pathology. We have noticed that when the teacher patiently but clearly indicates to the child that she expects him to talk, he has an increased tendency to do so. This is also true in the therapeutic sessions. It is our opinion at this time that close work with the school, and early referral of these cases by the school, is beneficial to all parties involved. DISCUSSION

As we have become more experienced in dealing with the problem of elective mutism, it appears to us that this disorder has certain unique features and certain features in common with other neurotic disorders of children. These children appear to be either fixated or ~·i

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regressed to the anal stage of development. They frequently have urinary and bowel difficulties at this time; wetting and soiling persists longer than would be normally expected.cThese children are negativistic, shy, and withdrawn. Their manifest behavior in many ways reminds one of a child of about two, who cannot speak to people other than those with whom he is familiar. He regards people, other than his immediate family, as strange and frightening. In addition to this, these children seem to develop an intense negativistic and sadistic relationship toward most adults. They utilize muteness as a weapon to punish people who have offended them. 'Parents of these children are unhappy in their marriage, and the mothers utilize the children to attack the fathers. Although many therapists probably would not use the specific methods that our clinic has found useful, it would appear that the resolution of the difficulty in the child rests on the successful treatment of the parents, as well as the child. In our opinion, one must be prepared to deal with serious psychopathology in the parents of these children. Flexibility in treatment design needs to be maintained. Family conferences, joint interviews, treatment of both parents by the same therapist all need to be considered and utilized where therapeutically indicated. SUMMARY

We have presented and discussed the dynamics of elective mutism. We regard it as a family neurosis and feel that the symptom can be understood only by studying the entire family constellation. Therapeutic work with all three members of the family is indicated. Close liaison with the schools is extremely helpful, and the schools can play an important role in early case findings and referral to psychiatric facilities. REFERENCES ADAMS, H. M. & GLASSNER, P. J. (1954), Emotional involvement in some forms of mutism.. l- Speech & Hearing Disorders, 19:59-69. SALFffiLD, D. J. (1950), Observations on elective mutism in children. l- Ment, Sci., 96:10241032. VON MISCH. A. (1952). Elektiver Mutismus im Kindersalter. Z. Kinderpsychiat., 19:49-87..