Patient Presentation
A 6-year-old male came to clinic for his health supervision visit and to establish care as he had recently moved to the area. He had autism spectrum disorder and needed to have multiple specialist consultations initiated for continuing care and therapy. He was already enrolled in school and his individualized education plan was being carried out to his parent’s satisfaction. His father described him as pretty compliant with activities but he still was fairly rigid about routines, clothing and choices of foods. “He’s non-verbal most of the time, but in certain circumstances he will talk but that is rare,” he described his son. He continued, “the speech therapist is working with him to try to get him to talk more, but he prefers to communicate by signing, drawing or just not interacting. Sometimes he just has a tantrum too.” The mother described several events where the child seemed to be very anxious too. The past medical history was positive for autism in a maternal cousin.
The pertinent physical exam showed a healthy boy with growth parameters 50-75%. Blood pressure and vision screenings could not be accomplished because of uncooperation. The boy did not speak or try to communicate with the physician but did maintain good eye contact throughout most of the visit. He did not appear anxious during the visit but more curious. The rest of his physical examination was normal.
The diagnosis of a healthy boy with autism spectrum disorder and possible selective mutism or other language disorder was made. The pediatrician offered, “I’m certainly not a specialist in autism or language disorders, but we have a regional children’s hospital nearby that has specialists. I’d like to refer you there for more evaluation, particularly about the language issue. I know that many of the behaviors and problems you are seeing can be caused by more than 1 thing and maybe it is not just the autism. Now that he is a little older, it might be easier to figure some of this out and he was evaluated when he was 4 years old. He’s already 2 years older and can help us more to understand him better. Sometimes there are other treatments too available for some of the other problems. I’ll put in the referrals for the children’s hospital, the local speech therapist and the ophthalmologist so we can check his vision properly. I also have a couple of dentists in the area who are excellent with children and used to children with some special needs too.”
Discussion
Children can be non-verbal for many reasons with most just not wanting to talk in a given situation for a short period of time (e.g. angry with a person, scared to give a speech at school, etc.). Children may have the ability to communicate verbally but for some reason it is physically impaired for a period of time.
Selective mutism (SM) “… is characterized by an individual’s consistent failure to speak in social situations in which there is an expectation to speak (e.g., at school), despite speaking in other situations.” The lack of speech cannot be due to discomfort speaking in a given language (i.e. a person learning a new language) or be due to another developmental condition or communication disorder. It must occur for at least 1 month. The prevalence rate ranges depending on the group studied. In a general population setting about 0.7% has been cited. Symptoms generally appear between 2-4 years. Children usually will not speak in a public or semi-public setting and are more likely to speak at home. The cause is felt to be multifactorial with an interplay between genetics (there is increased rate of relatives with SM, anxiety and social phobia), temperament (more common in persons who avoid unfamiliar situations), environment (more common in immigrant children, where the problem is out of proportion to the language acquisition or may occur in both languages) and development (more common in children with motor delays, speech or language delays, and cognitive delays). Treatment currently is using treatments for anxiety including cognitive behavioral therapy and pharmacotherapy with selective serotinin reuptake inhibitors. SM usually resolves but there may be persistent communication disorders, psychiatric and academic problems even into adulthood. SM is highly comorbid with Social phobia. Social phobia is “marked fear or anxiety about one or more social situations, in which [the person is] exposed to possible scrutiny by others. The anxiety must be expressed in peer settings and be expressed by behaviors such as “crying, tantrums, freezing, clinging, and failure to speak.”
A child who is consistently non-verbal may have an intellectual disability that impairs their ability to communicate verbally. This does not mean they cannot communicate in other non-verbal means or through assistive devices. Cerebellar mutism syndrome is another type of mutism that “is characterized by delayed onset mutism/reduced speech and emotional lability after cerebellar or 4th ventricle tumor surgery in children….The mutism is always transient, but recovery …may be prolonged. Speech and language may not return to normal, and other deficits of cognitive, affective and motor function often persist.”
Learning Point
Autism Spectrum Disorder (ASD) is a social communication disorder estimated to affect about 2% of children in the United States. There are problems with social-emotional reciprocity, non-verbal communication and developing and maintaining social relationships. People with ASD usually have some type of restricted or repetitive behaviors, interests and/or activities.
The cross-over between ASD and other problems can make it difficult to discern if the problem is primary, comorbid or two or more different issues. For example, specific language impairment or social pragmatic communication disorder have many of the same difficulties with language and symptoms begin at the same age as many patients with ASD. Children with intellectual disabilities may have social or language impairments similar to ASD. Similarly, anxiety disorders can occur in children with ASD or be a separate entity such as generalized anxiety disorder and reactive attachment disorder
Two studies (1998 and 2000) cite ~7% of patients with SM also having ASD. A 2018 retrospective study found 63% of children with SM had ASD. These 2018 authors felt that the large difference was partially because they are an autism referral center. Their research showed an overlap between SM and ASD and also intellectual disabilities. In the 2018 study, SM symptoms occurred outside the home in 100% of families but only 5% inside the home. For those with symptoms in both locations, 4 of the 5 patients also had ASD.
Questions for Further Discussion
1. What resources are available in your community for children with speech or language disorders?
2. Explain how the theory of how cognitive behavior therapy helps for anxiety disorders?
Related Cases
- Disease: Being Non-Verbal | Mutism | Speech and Communication Disorders
- Symptom/Presentation: Behavior Problems | Developmental Delay
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Speech and Communication Disorders.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Andersson CB, Thomsen PH. Electively mute children: An analysis of 37 Danish cases. Nord J Psychiatry. 1998;52(3):231-238. doi:10.1080/08039489850139157
Kristensen H. Selective mutism and comorbidity with developmental disorder/delay, anxiety disorder, and elimination disorder. J Am Acad Child Adolesc Psychiatry. 2000;39(2):249-256. doi:10.1097/00004583-200002000-00026
Hua A, Major N. Selective mutism. Curr Opin Pediatr. 2016;28(1):114-120. doi:10.1097/MOP.0000000000000300
Steffenburg H, Steffenburg S, Gillberg C, Billstedt E. Children with autism spectrum disorders and selective mutism. Neuropsychiatr Dis Treat. 2018;14:1163-1169. doi:10.2147/NDT.S154966
Simms MD. When Autistic Behavior Suggests a Disease Other than Classic Autism. Pediatr Clin North Am. 2017;64(1):127-138. doi:10.1016/j.pcl.2016.08.009
Catsman-Berrevoets CE. Cerebellar mutism syndrome: Cause and rehabilitation. Curr Opin Neurol. 2017;30(2):133-139. doi:10.1097/WCO.0000000000000426
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 