Day: February 19, 2024

What are Some Causes of Acute Onset of Loss of Speech Abilities?

Patient Presentation
The senior resident in clinic came to the attending asking if she had seen the patient just scheduled for clinic with a chief complaint of new onset of not speaking in a 3 year old. They both agreed that this needed to be triaged by the nursing staff right away and probably referred to the emergency room. The nurse reported that her parent was very upset saying that the child couldn’t talk but was awake and looking around. This had been going on for about 30 minutes. There was no reported respiratory distress or problems handling secretions and no obvious seizure activity. The nurse had instructed the parent to call emergency services to have the child taken to the emergency room right away. Later the senior resident had heard from another pediatric resident in the emergency room that they were treating the child for a diagnosis of probable seizures as the radiologic evaluation of head imaging was normal and it didn’t appear that the child had other problems such as respiratory causes. They also thought this was an acute onset and not due to selective mutism.

Discussion
Acute mental status changes are worrisome in the least and scary at their worst. Seizures, cerebrovascular problems and central nervous system tumor swirl in professionals’ heads as they take in the history, physical examination and start to evaluate and manage the problem. Usually respiratory distress is recognized by family members and treatment is also sought.

Another cause of loss of speech is selective (or elective) mutism (SM). The child does not speak at all or minimally. When speaking it is usually within a close group of individuals or in certain circumstances such as only speaking to a parent or close family member or only at home and not in a public situation. This can be normal where a child may be quiet or shy especially when entering a new situation or meeting new people. The child though with time will “warm up” and can/will have normal speech. SM is defined as a “…consistent failure to speak in social situations in which there is an expectation to speak… despite speaking in other situations.” It must be occurring for at least one month and be interfering with their activities of daily living. A child with SM continues to behave this way outside the normal range of time and situation, and SM has a strong relationship with anxiety including social phobia. Children who are immigrants/bilingual or learning a new language may also choose not to speak and again this can be a normal behavior for the situation. If this continues outside the normal range of time and situation this could be SM. There is some data which supports a higher rate for children in immigrant families. Prevalence ranges from 0.11 – 2.2% depending on the population with 2.2% cited in some immigrant children’s populations. The cause is not known but felt to be multifactorial with temperament, genetic, developmental and environmental factors playing a part. Treatment is supportive with cognitive behavioral therapy as a common treatment. Some children are also treated with selective serotonin reuptake inhibitors especially fluoxetine. Prognosis is good. Studies cite 58% complete remission, and additional ~30% improvement of symptoms. Others may have another psychiatric disorder with social phobia being very common in this remaining group. Speech therapy also may be helpful with helping the child’s self-efficacy. Alternative or augmented communication and specific therapies for the child and/or caregivers can be appropriate.

Another problem causing acute loss of speech is cerebellar mutism syndrome which is also called posterior fossa syndrome. This occurs after resection of a posterior fossa tumor (can occur with other CNS surgeries too) and occurs in 8-39% of children in studies. There are problems with dysphasia, but also processing speed, memory, cognitive planning and emotional lability. Ability to chew and do emotional phonation remain intact. Swallowing can be affected. Both speech production and swallowing usually improves quickly in patients. Latency to the problem is cited at 0-6 days with resolution from 4 days to 4 months.

Learning Point
The differential diagnosis of the loss of speech abilities includes:

  • Seizure – new onset seizure, tumor
  • Stroke / transient ischemic attack
  • Dysphonia – laryngospasm and vocal cord dysfunction
  • Anxiety/panic attack
  • Selective/elective mutism
    • Traumatic event / Post-traumatic stress disorder
    • Cerebellar mutism syndrome

Questions for Further Discussion
1. How are brain tumors classified? A review can be found here
2. How are seizures classified? A review can be found here
3. How is selective mutism different than being non-verbal? A review can be found here

Related Cases

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.

Gordon N. Mutism: elective or selective, and acquired. Brain Dev. 2001;23(2):83-87. doi:10.1016/S0387-7604(01)00186-3

Hua A, Major N. Selective mutism. Curr Opin Pediatr. 2016;28(1):114-120. doi:10.1097/MOP.0000000000000300

Pettersson SD, Kitlinski M, Miekisiak G, Ali S, Krakowiak M, Szmuda T. Risk factors for postoperative cerebellar mutism syndrome in pediatric patients: a systematic review and meta-analysis. J Neurosurg Pediatr. 2021;29(4):467-475. doi:10.3171/2021.11.PEDS21445

Selective Mutism. American Speech-Language-Hearing Association. Accessed December 1, 2023. https://www.asha.org/practice-portal/clinical-topics/selective-mutism/.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa