Mutism: elective or selective, and acquired


      When a child does not speak, this may be because there is no wish to do so (elective or selective mutism), or the result of lesions in the brain, particularly in the posterior fossa. The characteristics of the former children are described, especially their shyness; and it is emphasized that mild forms are quite common and a definitive diagnosis should only be made if the condition is significantly affecting the child and family. In the case of mutism due to organic causes, the commonest of these is trauma to the cerebellum. Operations on the cerebellum to remove tumours can be followed by mutism, often after an interval of a few days, and it may last for several months or longer, to be followed by dysarthria. Other rarer causes are discussed, and also the differential diagnosis. The so-called posterior fossa syndrome consists of mutism combined with ataxia, cranial nerve palsies, bulbar palsies, hemiparesis, cognitive impairment and emotional lability, but the post-operative symptoms are often dominated by the lack of speech. The most accepted cause for the condition is vascular spasm with involvement of the dentate nucleus and the dentatorubrothalamic tracts to the brain-stem, and subsequently to the cortex. Diaschisis may be involved in causing the loss of higher cerebral functions, and possibly, complicating hydrocephalus. The treatment of elective mutism is reviewed, either using a psychotherapeutic approach or a variety of drugs, or both. These may well be ineffective, and it must be remembered that the condition often resolves on its own. The former treatment must concentrate on the training of social skills and activities of daily life and must be targeted to both the child, the family, and the school. Also, all kinds of punishment and insistence on speech must be discouraged. The drug, which seems to be most effective, is fluoxetine. Discovering more about the causes of mutism due to organic causes may well depend on studies using such techniques as magnetic resonance imaging and single photon emission tomography.


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        • Steinhausen H.C.
        • Juzi C.
        Elective mutism: an analysis of 100 cases.
        J Am Acad Child Adolesc Psychiatry. 1996; 35: 606-614
        • Kopp S.
        • Gillberg C.
        Selective mutism: a population-based study: a research note.
        J Child Psychol Psychiatry. 1997; 38: 257-262
        • Segal N.L.
        Silent partners: twins with selective mutism.
        Twin Res. 1999; 22: 238-241
        • Hagerman R.J.
        • Hills J.
        • Scharfenaker S.
        • Lewis H.
        Fragile X syndrome and selective mutism.
        Am J Med Genet. 1999; 83: 313-317
        • Gordon N.
        Speech, language, and the cerebellum.
        Eur J Disord Commun. 1996; 31: 359-367
        • Burruss J.W.
        • Chacko R.C.
        Episodically remitting akinetic mutism following subarachnoid haemorrhage.
        J Neuropsychiatry Clin Neurosci. 1996; 11: 100-102
        • Nishikawa M.
        • Komiyama M.
        • Sakamoto H.
        • Yasui T.
        • Nakajima H.
        Cerebellar mutism after basilar artery occlusion. Case report.
        Neurol Med Chir (Tokyo). 1998; 38: 569-573
        • Janssen G.
        • Messing-Junger A.M.
        • Engelbrecht V.
        • Gobel U.
        • Bock W.J.
        • Lenard H.G.
        Cerebellar mutism syndrome.
        Klin Padiatr. 1998; 210: 243-247
        • Sinha A.K.
        • Rajender Y.
        • Kinakar I.
        Transient cerebellar mutism after evacuation of a spontaneous vermian haematoma.
        Childs Nerv Syst. 1998; 14: 460-462
        • Vandeinse D.
        • Hornyak J.E.
        Linguistic and cognitive deficits associated with cerebellar mutism.
        Pediatr Rehabil. 1997; 1: 41-44
        • Schmahmann J.D.
        • Sherman J.C.
        The cerebellar cognitive affective syndrome.
        Brain. 1998; 121: 561-579
        • Schmahmann J.D.
        An emerging concept. The cerebellar contribution to higher function.
        Arch Neurol. 1991; 48: 1178-1187
        • van Mourik M.
        • Catsman-Berrevoets C.E.
        • Neville B.G.R.
        Complex orofacial movements and the disappearance of cerebellar mutism: report of five cases.
        Dev Med Child Neurol. 1997; 30: 686-690
        • Doxey D.
        • Bruce D.
        • Sklar F.
        • Swift D.
        • Shapiro K.
        Posterior fossa syndrome: identifiable risk factors and irreversible complications.
        Pediatr Neurosurg. 1999; 31: 131-136
        • Erşahin Y.
        • Mutluer S.
        • Çağli S.
        • Duman Y.
        Cerebellar mutism: report of seven cases and review of the literature.
        Neurosurgery. 1996; 38: 60-66
        • Koh S.
        • Turkel S.B.
        • Baram T.Z.
        Cerebellar mutism in children: report of six cases and potential mechanisms.
        Pediatr Neurol. 1997; 16: 218-219
        • Erşahin Y.
        • Mutluer S.
        • Saydam S.
        • Barçin E.
        Cerebellar mutism: report of two unusual cases and review of the literature.
        Clin Neurol Neurosurg. 1997; 99: 130-134
        • Quattrini A.
        • Del Pesce M.
        • Provinciali L.
        • Cesarano R.
        • Ortenzi A.
        • Paggi A.
        • et al.
        Mutism in 36 patients who underwent callosotomy for drug-resistant epilepsy.
        J Neurosurg Sci. 1997; 41: 93-96
        • Liu G.T.
        • Phillips P.C.
        • Molloy P.T.
        • Needle M.N.
        • Galetta S.L.
        • Balcer L.J.
        • et al.
        Visual impairment associated with mutism after posterior fossa surgery in children.
        Neurosurgery. 1998; 42: 253-257
        • Erşahin Y.
        Visual impairment associated with mutism after posterior fossa surgery in children.
        Neurosurgery. 1998; 43: 983-984
        • Joseph P.R.
        Selective mutism – the child who doesn't speak at school.
        Pediatrics. 1999; 104: 308-309
        • Szabo C.P.
        Selective mutism and social anxiety.
        J Am Acad Child Adolesc Psychiatry. 1996; 35: 555
        • Blum N.J.
        • Kell R.S.
        • Starr H.L.
        • Lender W.L.
        • Bradley-Klug K.L.
        • Osborne M.L.
        • et al.
        Case study: audio feedforward treatment of selective mutism.
        J Am Acad Child Adolesc Psychiatry. 1998; 37: 40-43
        • Rye M.S.
        • Ullman D.
        The successful treatment of long-term selective mutism: a case study.
        J Behav Ther Exp Psychiatry. 1999; 30: 313-323
        • Amari A.
        • Slifer K.J.
        • Gerson A.C.
        • Schenck E.
        • Kane A.
        Treating selective mutism in a paediatric rehabilitation patient by altering environmental reinforcement contingencies.
        Pediatr Rehabil. 1999; 3: 59-64
        • Aicardi J.
        Diseases of the nervous system in childhood.
        in: 2nd. Mackeith press, 1998: 839
        • Russell P.S.
        • Raj S.E.
        • John J.K.
        Multimodal intervention for selective mutism in mentally retarded children.
        J Am Acad Child Adolesc Psychiatry. 1998; 37: 903-904
        • Stein M.T.
        • Rapin I.
        • Yapko D.
        Selective mutism.
        J Dev Behav Pediatr. 1999; 20: 38-41
        • Dummit E.S.
        • Klein R.G.
        • Tancer N.K.
        • Asche B.
        • Martin J.
        Fluoxetine treatment of children with selective mutism: an open trial.
        J Am Acad Child Adolesc Psychiatry. 1996; 35: 615-621
        • Lafferty J.E.
        • Constantino J.N.
        Fluvoxamine in selective mutism.
        J Am Acad Child Adolesc Psychiatry. 1998; 37: 12-13
        • Golwyn D.H.
        • Sevlie C.P.
        Phenelzine treatment of selective mutism in four prepubertal children.
        J Child Adolesc Psychopharmacol. 1999; 9: 109-113
        • Rupp S.N.
        Haloperidol for Tourette's disorder plus selective mutism.
        J Am Acad Child Adolesc Psychiatry. 1999; 38: 7
        • Caradoc-Davies T.H.
        Traumatic mutism in severe head injury relieved by oral diazepam.
        Disabil Rehabil. 1996; 18: 482-484
        • Schmider J.
        • Standhart H.
        • Deuschle M.
        • Drancoli J.
        • Heuser I.
        A double-blind comparison of lorazepam and oxazepam in psychomotor retardation and mutism.
        Biol Psychiatry. 1999; 46: 437-441
        • Caner H.
        • Altinörs N.
        • Benli S.
        • Çalişaneller T.
        • Albayrak A.
        Akinetic mutism after fourth ventricle choroid plexus papilloma: treatment with a dopamine agonist.
        Surg Neurol. 1999; 51: 181-184
        • Turgut M.
        Transient ‘cerebellar’ mutism.
        Childs Nerv Syst. 1998; 14: 161-166
        • Kolvin I.
        • Fundudis T.
        Elective mute children: psychological development and background factors.
        J Child Psychol Psychiatry. 1981; 22: 219-232
        • Miyakita Y.
        • Taguchi Y.
        • Sakakibara Y.
        • Matsuzawa M.
        • Kitagawa H.
        Transient mutism resolving into cerebellar speech after brain stem infarction following a traumatic injury of the vertebral artery in a child.
        Acta Neurochir. 1999; 141: 209-213
        • Erşahin Y.
        Is splitting of the vermis responsible for cerebellar mutism.
        Pediatr Neurosurg. 1998; 28: 328
        • Riva D.
        • Giorgi C.
        The cerebellum contributes to higher functions during development. Evidence from a series of children surgically treated for posterior fossa tumours.
        Brain. 2000; 123: 1051-1061
        • Germanò A.
        • Baldari S.
        • Caruso G.
        • Caffo M.
        • Montemagno G.
        • Cardia E.
        Reversible cerebral perfusion alterations in children with transient mutism after posterior fossa surgery.
        Childs Nerv Syst. 1998; 14: 114-119
        • Erşahin Y.
        SPECT in cerebellar mutism.
        Childs Nerve Syst. 1998; 14: 611