What is selective syndrome?

Selective mutism (sm) is a kind of mental disorder, which is a clinical syndrome characterized by children's persistent "refusal" to speak in some places where verbal communication is needed (such as school, environment with strangers or crowds, etc.). ), and on other occasions their speeches are normal. Children can often talk normally and actively at home, but they "refuse" to talk to teachers or classmates at school. China people are introverted. Children don't talk from kindergarten or primary school, and they are often ignored because of introversion and shyness, which leads to children not being found and treated in time. Most of them begin to get sick at the age of 3 ~ 5, and girls are more common. Because of anxiety or extreme shyness on some occasions, patients dare not speak even if they can. With the increase of social pressure, social conflict, social mobility, family problems and family conflicts, the factors leading to SM increase, and SM children in China not only exist, but also increase.

[Edit this paragraph] English translation

Abstract: Selective mutism is a kind of syndrome, which shows that although you speak in other occasions, you can't speak in social occasions where you expect to speak. This problem is most common among children who speak positively and appropriately at home, but refuse to speak at school. The debate revolves around the origin and cause of the disease. In this paper, the literature on etiology, prevalence, evaluation and treatment is briefly reviewed from several theoretical directions, including behavior, family system and psychopharmacology 1.

Keywords: selective mutism, mutism, anxiety, speech and language disorders

[Edit this paragraph] The concept of SM was put forward.

In 1877, Kussmaul first described a clinical dysfunction, which was characterized by children being able to speak, but in some cases they could not. It is named Voluntaria, which emphasizes that patients will not speak spontaneously. 1934, Tramer called similar cases selective mutism, emphasizing that children choose not to talk in some cases. The change of DSM-IV in the United States to selective mutism is intended to show that children refuse to speak in "carefully chosen" occasions or situations, and emphasize that psychological factors may be the main reason for SM. The World Health Organization Classification of Diseases-10 (ICD- 10) defines SM as a child with normal or nearly normal speech or language ability, which is obviously caused by emotional factors in some specific occasions, and emphasizes that emotional disorder is an important etiological basis of SM.

[edit this paragraph] epidemiology

SM is a rare disease. 1994, the American Psychological Association estimated that the number of clinical SM patients was less than 1% of the total number of children. Kopp, Kamulainen and Bergman made an epidemiological survey of SM, and found that its incidence rate was between 0.2% and 2.0%, and most patients lasted for more than one year. Studies have shown that there are slightly more girls with SM than boys, with a ratio of 2: 65433. Domestic literature reports or reviews only mention sporadic cases, and there is no epidemiological study. Due to the large population base in China, SM is rare, and the absolute number of children is also large.

[Edit this paragraph] Causes and manifestations of selective mutism

Selective silence refers to children who have no organic pathological changes in speech organs, normal intelligence and acquired language function, and show stubborn silence under the influence of some mental factors. This disease is considered as a special form of neurosis in children, and usually begins at the age of 3~5. Neuropsychiatric diseases such as hysteria, schizophrenia, autism and mental retardation in children may also be accompanied by asymptomatic symptoms, but they do not belong to this disease.

[Edit this paragraph] The etiology of SM is unclear, and the etiology theory is as follows.

SM is a psychological disorder;

Early SM case studies attributed the problems to family factors or intractable inner conflicts, such as transitional protection of parents. Recent studies believe that SM is closely related to anxiety. Some experts even think that SM is a type of anxiety disorder. SM should be called children's social phobia. SM children and adults have many common characteristics. Another strong evidence that SM is related to anxiety disorder is that anti-anxiety drugs are effective in treating SM.

SM is a behavioral disorder:

Behaviorists believe that SM is a behavioral problem caused by a series of reinforced negative learning patterns, and it is a "habitual response to the external environment". In other words, silence is a behavioral expression of the relationship between children's processing process and their environment. Behavioral experts believe that children's silent behavior is functional, and advocate that bad external environment is the maintenance factor of this state. Therefore, children's silence is an adaptive behavior, not a pathological behavior.

Sm is related to mental retardation;

Kristensen and others believe that SM is related to mental retardation, pregnancy or childbirth diseases, and is often complicated with chewing and swallowing disorders, motor coordination disorders and sleep disorders. Anxiety symptoms may be caused by cognitive difficulties. For example, working memory disorder can easily lead to anxiety symptoms. When completing cognitive tasks beyond cognitive ability, children's individual working memory lacks available resources and their anxiety is aggravated, so they adopt a compromise way (negative and silent) to complete the task. However, children with SM usually do not have low cognitive ability. Katharina et al.' s research shows that there is no significant difference in cognitive function between children with SM and children in the control group.

Sm is related to speech or language barriers:

Studies have found that children with SM have speech or language disorders, Kolvin and Fundudis [Studies have confirmed that children with SM start to speak later than normal children, and 50% of SM children are immature, while only 9% of the children in the control group. Wilkins studied 24 children with SM. Although only 8% children have speech problems during the assessment, 25% children have speech delay and 265,438+0% children have unclear speech. In Europe, in a large-scale study of 100 SM children, at least 38% of them have speech or language expression disorders. The high incidence of SM among immigrant children also proves that language barriers are related to SM. Often moving or changing schools will induce SM, so SM should not be just a language problem.

Clinical diagnosis of selective mutism

At present, it is generally believed that SM is an independent disease, but some scholars believe that SM is a familial social anxiety disorder, which is closely related to anxiety disorder. SM may be a symptom of anxiety, a variant of social phobia, or one of the symptoms of other mental diseases, but it is not an independent disease. The accurate diagnosis of SM is quite difficult, which requires comprehensive examination and evaluation, including nervous system examination, psychological examination, listening examination, social ability examination, learning ability examination, language and speech examination, and various related objective examinations (such as EEG, skull image, event response potential). , and related exams are all necessary [3].

In DSM-IV of the United States, SM is classified as "other diseases of children and adolescents". SM has five clinical features, which can be used as a diagnostic basis:

1) "can't" speak when you need verbal communication, but speak normally in other environments;

2) The duration is more than one month;

3) There are no speech barriers and speech problems caused by speaking a foreign language (or different dialects);

4) It is due to the influence on children's lives, such as entering or changing schools, moving or socializing.

5) Not suffering from developmental or psychological diseases such as autism, schizophrenia, mental retardation or other developmental disorders.

[Edit this paragraph] Treatment plan

Selective mutism has a good prognosis. After treatment, most of them can recover within several months to several years. A few children develop chronic diseases. Some children still have excessive shyness and social anxiety in adolescence and adulthood, and they still have the performance of not speaking fluently and expressing their ideas in some social occasions.

[Edit this paragraph ]6 kinds of treatment methods

Psychotherapy: it is the earliest treatment method applied to SM, and it is still widely used in the treatment of SM. Psychologists believe that SM is a mental illness and a manifestation of social phobia. Physical or mental trauma is the root of SM, and they advocate psychoanalysis and psychotherapy. Psychotherapy aims at alleviating children's inner conflicts and emphasizes individualized treatment. Specific methods include psychological suggestion, psychological consultation, psychoanalysis and cognitive therapy. Psychologists believe that psychotherapy is effective from case study and experience, but it is a long-term process. Case study can't rule out the interference of SM natural rehabilitation factors, and can't confirm whether psychotherapy is really effective.

Behavioral therapy: Behavioral therapy is a special form of psychotherapy. SM is a kind of behavior disorder, which often occurs in children who are very shy and have social anxiety, and needs to be corrected. Studies have confirmed that behavioral therapy is effective, and new research shows that behavioral therapy can help children adjust their emotions, overcome impatience and anxiety, and correct their behavior patterns in dealing with problems. Commonly used methods include positive enhancement, negative enhancement, desensitization, video self-modeling, etc.

Family therapy: including family education and family games. The purpose of family education is to improve unhealthy family environment and family relations, strengthen parents' understanding of SM, create a suitable family environment for children, improve family relations, reduce rude scolding, and increase goodwill encouragement, such as giving appropriate encouragement (eyes, gestures, posture, words, etc.) when children actively communicate with guests. ), and don't force children to talk; Family games, invite children's friends, classmates and teachers to be guests at home, play games with children, and let children communicate with them in a familiar environment. Children are not encouraged to communicate in other ways, but they can't object to it, so as to increase their anxiety and induce them to talk. Tourists from familiar to unfamiliar, from few to many. In the end, children come into contact with people they are familiar with at school, ignoring that school is a strange environment.

Participation and support of school and social environment: create a good environment for children, encourage children to talk more, do not make fun of children's speech barriers, and do not intimidate and tease. In the school, teachers and some students form a support group, telling them the importance of cooperating with doctors, understanding the child's situation and treatment characteristics, communicating with children more, not forcing children to respond verbally, and encouraging children to respond in various forms. Class: at first, children are encouraged to participate in collective answering, and the number of answers is gradually reduced; Encourage children to communicate with teachers alone, prepare questions to be answered in advance, and then answer them alone in a small range. Teachers or classmates use words to induce, prompt and cooperate with children to answer questions, and gradually expand the scope.

Drug therapy: In recent ten years, antidepressants have been studied to treat SM, and it is considered that drug therapy is effective. Golwyn and others think that the inhibitor of monooxygenase is effective in the treatment of social phobia, and its inhibition of dopamine degradation in synaptic cleft can promote the excitability of central nervous system and improve social function, so it is suitable for the treatment of SM. Therefore, 4 patients with SM were treated with phenylhydrazine, of which 1 patient switched to fluoxetine after treatment failure, and the curative effect was remarkable. SSRI drug cases and SMall case groups are effective in treating sm. Black and others designed a small case group, that is, a double-blind controlled study, in which 6 cases were treated with fluoxetine. The evaluation results of parents of children showed that the efficacy of fluoxetine treatment group was better than that of control group, but the evaluation results of professional doctors and teachers showed that there was no significant difference between the two groups. Dummit et al reported the study of SSRI drug fluoxetine in the treatment of 265,438+0 SM children. There is no comparability. After 9 weeks of treatment, 16 children's anxiety was relieved and their symptoms were improved. Children talk more and more in public, and the improvement is inversely proportional to their age. The curative effect is better than psychological or behavioral therapy. Generally speaking, drug therapy is not the first treatment method, but if other methods fail, drug therapy can be added to the treatment plan.

Comprehensive treatment: Because the etiology of SM is not clear, it may be caused by many factors. Various methods have different curative effects, so at present, SM treatment mostly adopts comprehensive treatment schemes, including psychotherapy, behavioral therapy, family therapy, school social support and possible psychotropic drugs.

[Edit this paragraph] Children's selective mutism

Selective mutism refers to the phenomenon that children who have acquired language ability remain silent on some occasions due to the influence of mental factors. Its essence is social dysfunction rather than language disorder.

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This disease usually begins at the age of 3-5, and it is more common in girls. Children's intellectual development is normal, mainly manifested in silence or even long silence. This phenomenon of silence is selective, that is, you can speak in certain occasions, such as talking to familiar people (father, mother, grandmother and some friends). The occasion of refusing to speak generally refers to school or in front of strangers. On the contrary, a few children talk at school and don't talk at home. When you are silent, you can use gestures, nod and shake your head to express your views, or you can only use words such as "yes", "no" and "want" and occasionally use words to express your views. ?

Three manifestations of selective mutism in children

1. This disease mostly begins at the age of 3-5, and is more common in girls, mainly manifested as silence or even long-term silence. But this kind of silence is selective, that is, speaking in some occasions, such as at home or to familiar people, and not speaking in other occasions, such as in kindergarten or to strangers.

2. A few children, on the other hand, don't talk at home, but talk in kindergarten. When you are silent, you can express your opinions by gestures, nodding and shaking your head, or answer questions with the simplest words such as "yes", "no", "want" and "don't", thus communicating with others. After learning to write, you can occasionally express your views through writing.

3. This kind of child is not easy to be found by parents before going to school, and is unwilling to talk to unfamiliar people, and is often considered timid and shy by parents. It was not until after primary school that he was unwilling to answer any questions, talk to other students and participate in group activities that he was discovered. Children can participate in the study as usual, and their academic performance is different. Some children refuse to go to school

Three causes of selective mutism in children

This disease generally has no brain organic cause. At present, it is believed that mental factors act on children with certain personality characteristics, which may be related to the following reasons-

1. had personality characteristics before illness.

Children often have sensitive, timid, shy, withdrawn, fragile, dependent and other personality characteristics before illness, and their parents often have personality abnormalities and mental disorders.

2. Delayed development and maturation

Although children have acquired language function, the time to start speaking is obviously delayed compared with normal children, and it is often accompanied by other language problems. It is often accompanied by developmental disorders such as functional enuresis and functional enuresis, and some children have abnormal changes such as immature EEG.

3. Psychosocial factors

Children often experience emotional trauma in their early years, such as family conflicts, parents' discord, parents' separation and divorce, parents' abuse of children, and sudden changes in family environment. Some children get sick after family environment changes or obvious mental stimulation.

Diagnosis of selective mutism in children

The accurate diagnosis of children's selective mutism is quite difficult, which requires comprehensive examination and evaluation, including nervous system examination, psychological examination, listening examination, social communication ability examination, learning ability examination, language and speech examination and various related objective examinations. At present, experts in the United States believe that there are five clinical features that can be used as the basis for diagnosis-

1. You can't speak when you need verbal communication, but you can speak normally in other environments.

2. The duration exceeds 1 month.

3. No language barriers, no language problems caused by speaking a foreign language (or different dialects).

4. It is due to the impact on children's lives, such as entering or changing schools, moving or socializing.

5. Not suffering from developmental or psychological diseases such as autism, schizophrenia, mental retardation or other developmental disorders.

Differential diagnosis of selective mutism in children

Because of children's selective mutism, children's hysteria, children's catatonia, children's paranoia, children's depression and so on. There are silent performances, and it is particularly important to identify them.

1. Selective mutism in children

The high selectivity of "silence" is the characteristic of this disease. Children's intellectual development is normal. Wechsler children's intelligence test IQ is above 70, and most of them are sensitive and shy. There is no abnormality in nervous system examination and no other mental or physical disorder.

2. Hysterical mutism in children

Hysterical silence often lasts for weeks to months, and there are often obvious emotional contradictions before illness, but silence is non-selective. And silence, like other clinical symptoms, has the characteristics of sudden onset, good recovery and easy acceptance of hints.

3. Children's catatonic mutism

Children are taciturn, or their language is incomplete, accompanied by rejection, disobedience, numbness, waxy buckling, impulsiveness and other symptoms. Although children are conscious and not mentally retarded, they lack self-awareness.

4. Paranoid mutism in children

In addition to the symptoms of silence, there are other obvious mental symptoms, such as poor contact with the outside world, dislike for anyone, stiff expression, strange behavior and so on.

5. Children's depressive mutism

It is characterized by numbness or mumbling, sad face, sometimes accompanied by paroxysmal anxiety, absolute silence when the condition is serious, and it can return to normal after electroconvulsive treatment.

Children's mutism belongs to psychological disorder and should be mainly treated with psychotherapy. ?

(1) Avoid mental stimulation. Children in language development should try to avoid all kinds of mental stimulation. Cultivate children's broad interests and open-minded personality. ?

(2) Eliminate psychological stress factors, properly arrange and improve the living and learning environment, and encourage them to actively participate in various collective activities. ?

(3) Transfer method should not pay too much attention to the child's silence, so as not to cause further emotional tension or even resistance due to forced speech. Transfer method can be used, such as parents playing games with their children and going out to play, to distract their nervousness. ?

(4) Positive reinforcement is the best way to correct behavior. On the basis of emotional relaxation, children are rewarded and encouraged as soon as they open their mouths; You can also use what your child needs and likes most as a reward condition to let your child speak. ?

(5) Medication For some children with severe symptoms, if they have excessive anxiety, nervousness and fear, they can take a small amount of anti-anxiety drugs under the guidance of a doctor. ?

After treatment, most children can recover. Untreated children may remain silent for a long time until early adolescence. Some will affect language expression and interpersonal skills.