Selective mutism - Springer Link

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Sep 10, 2007 - epidemiological studies. Two society-based studies were published before 1997 and both were conducted in UK: Brown and Lloyd [1] studied ...
Eur Child Adolesc Psychiatry (2008) 17:114–117 DOI 10.1007/s00787-007-0644-x

I. Karakaya S¸ . G. S¸ is¸ manlar ¨ . Y. O ¨ c¸ O N. C ¸ . Memik A. Cos¸ kun B. Ag˘aog˘lu C. I. Yavuz

Accepted: 18 June 2007 Published online: 10 September 2007

I. Karakaya, MD ¨ .Y. O ¨ c¸, MD S¸ .G. S¸ is¸ manlar, MD Æ O N.C ¸ . Memik, MD Æ A. Cos¸ kun, MD B. Ag˘aog˘lu, MD Department of Child and Adolescent Psychiatry Kocaeli University Medical School Derince-Izmit, Kocaeli, Turkey I. Karakaya, MD (&) Cumhuriyet mah. Misir Sok. EK-AS sitesi A Blok Daire:7, Plaj Yolu Kocaeli 41100, Turkey Tel.: +90-262/303-8699 E-Mail: [email protected] C.I. Yavuz, MD Department of Public Health Kocaeli University Medical School Derince-Izmit, Kocaeli, Turkey

ORIGINAL CONTRIBUTION

Selective mutism A school-based cross-sectional study from Turkey

j Abstract Objective The aim of

this study is to examine the prevalence of selective mutism (SM) in Kocaeli, Turkey. Method Kindergarten, first, second and third grade students of all public/private schools within the city were included in the study. ‘‘SM screening forms’’ prepared on basis of DSMIV were submitted to classroom teachers in all these schools asking whether they had any students meeting such symptoms. Results About 84.51% of the schools returned forms covering 64,103 children. Five hundred and twenty six of these children were thought to have symptoms of SM by their teachers. After their DSM-IV based clinical evaluation by a child

ECAP 644

Introduction Selective Mutism (SM) is a rare childhood disorder. The frequency of SM vary according to the results of epidemiological studies. Two society-based studies were published before 1997 and both were conducted in UK: Brown and Lloyd [1] studied 4 and 5-year-old children with the help of primary school teachers and found that the ratio of children presenting with total mutism 8 weeks after beginning of the school was 0.69% (42 out of 6,072). In a second evaluation after 8 months, they found that only five children (0.08%) sustained the same clinical condition. Fundudis et al. [2] diagnosed only two (0.08%) SM cases in a group of 3,300 7-year-old children in the ‘‘New-Castle Epide-

and adolescent psychiatrist, only 21 children were diagnosed as SM. Among the SM group, three were in the kindergarten, 15 were in the first grade and three were in the second grade. Twelve of the children were male and nine were female (male: female ratio is 1.3:1). In this cross-sectional study, 0.83% of children were reported to have SM symptoms by their teachers. After the clinical evaluation of these children, the prevalence rate of SM was found to be 0.033%. j Key words selective mutism – childhood – school-based study – prevalence – Turkey

miology Study’’. By the end of 1990s, two studies were reported from the Scandinavian countries in which the focus was on the school environment and both of these studies evaluated a relatively high age group. In the study conducted by Kopp and Gilberg [3] in Sweden, children ranging between 7 and 15 years were evaluated according to the DSM-IV diagnostic criteria with the assistance of their teachers and the SM frequency was found to be 0.18% (five among 2,793). Kumpulainen et al. [4] investigated the frequency of SM in second year primary school students by sending forms to their teachers questioning the DSM-III-R diagnostic criteria. In this study, which was conducted in Finland, the results showed a higher incidence (1.9%, 38 among 2,010) of SM [4]. Two recent

I. Karakaya et al. Selective mutism: a school-based cross-sectional study from Turkey

studies were conducted in the USA and the West Jerusalem. Bergman et al. [5] investigated the frequency of SM in kindergarten children, first and second grade students in public schools using the DSM-IV diagnostic criteria. In this study, 16 out of 2,256 children were diagnosed with SM and the frequency was 0.71%. Elizur and Perednik [6] included children from both the immigrant and native-born families in their study in an attempt to determine the frequency and definition of SM. In this study which was carried out with children aged 4–6 years, the frequency of SM was 2.2% in the immigrant group and 0.76% in the overall group. The present study was planned in two stages: In the first stage, the goal was to determine the frequency of SM among the kindergarten (5-year-old children), first (6-years-old children), second (7-year-old children) and third (8-year-old children) grade students attending both public and private schools in Kocaeli province. The second stage is focused on the clinical evaluation and the treatment processes for the children diagnosed with SM, and is still in progress.

Method j Sample This study was conducted in the province of Kocaeli, one of the outstanding industrial cities of Turkey. The province has a population of 1,206,085. The total number of students in the province is 277,817 and 98% of them receive education in public schools. Four percent of the total student population is of preschool age, while 72% (199,428 students) of the student population are in elementary school [7]. The study is a school-based cross-sectional study. No sample was selected: instead, the goal was to try to reach first, second, third grade students attending all private and public elementary schools and kindergartens. The number of schools throughout the province at the time of study was 324 (299 public and 25 private schools). Approximately 81% of these schools were in the urban/semi urban regions (municipality regions—regions that have a population of 2,000 or more). A list of all schools was obtained from the Province Educational Directorship submitting a letter to all these schools informing them of the aims and the duration of the study.

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the DSM-IV (SM screening form item 1) was sent to the teachers and they were asked if there were any children with these symptoms in their class. Step 2: The authors discussed the SM symptoms with the referring teacher by phone. Step 3: After the telephone interview with the teacher, six of the authors met with parents to evaluate each child who met criterion A. The study was conducted between February and June 2005. Forms were sent to schools in February, the feedback was collected before the beginning of April and the evaluation of the reported children was performed in May and June. The study period was designed to exclude the first month of the school year in order to ensure that teachers had a chance to examine their students better and be able to distinguish the clinical signs of ‘‘selective mutism.’’ The study design was approved by the university ethic committee and the city governorship.

j Measures Sociodemographic information form A 10-item form prepared by the authors was designed to obtain information on demographic characteristics (i.e. age, gender, school, class, parents’ age, education level and job)

SM screening form This form was prepared by the authors and given to 12 teachers by a clinician in a randomly chosen school to test for comprehensibility. Necessary corrections were made in the form after this preliminary trial. One requirement was the first item of the description of SM according to the DSM-IV [8]; ‘‘Although they easily talk to family members at home, they refuse to talk to their teachers or friends at school or in various other social environments’’ (DSM-IV criterion A) to be positive. Then, the other characteristics of the disorder were mentioned: (2) they express themselves with gestures, mimics, head nodding, whispering, monosyllabled words and monotonous speech, (3) Thus, they cannot establish friendships and may experience learning difficulties, (4) SM symptoms did not appear to be caused by hearing loss, speech disorders (stuttering, misarticulations, not knowing the language), severe nervous system disorders or mental disorders.

Results j Procedure The procedure for diagnosing SM was performed in several steps. Step 1: A description of SM according to

In this study, forms were sent to a total of 324 schools, and feedback was received from 265 out of 299 public schools (88.63%) and all private schools (n = 25,

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European Child & Adolescent Psychiatry (2008) Vol. 17, No. 2 Ó Steinkopff Verlag 2007

100%). Therefore, a total of 290 schools participated in the study (89.51%). There was a total of 64,103 pupils compromising kindergarten (n = 4,372), first grade (n = 20,092), second grade (n = 19,882) and third grade (n = 19,757) in these 290 schools. However, the total number of children, which actually forms the universe of the study, remains unknown as no information could be obtained from the provincial educational directorship. Within the sampling group, 526 (0.82%) students were reported to have symptoms of SM by teachers. Among these, 78 were in kindergarten, 178 were in the first grade, 140 were in the second grade and 142 were in the third grade. After the assessment, only 21 children were diagnosed to have SM. Among those, three were in kindergarten (0.01%), 15 were in the first grade (0.076%) and three were in the second grade (0.015%). Of the SM cases, 47.6% (n = 10) were living in the province center. When the sociodemographic data of the children was considered, it was found that most of the mothers were elementary or high school graduates and 61.9% of them were housewives. Most of the fathers were high school graduates and all had professional jobs. Twelve of the children were male and nine of them were female, the male: female ratio was 1.3:1. The frequency of SM was 0.033% (21 children in 64,103). Of the 21 children with a diagnosis of SM, 17 (all were kindergarten and first grade students) were reported to completely refuse to talk to their teachers or friends at school, while four (two in the first grade and two in the second grade) were reported to speak rarely, and whisper when they did so.

Discussion This study is the first school-based SM study in Turkey, with one of largest sampling groups ever used (if not the largest). The study group consisted of 64,103 children living in the province of Kocaeli. Among all schools in the province, 89.51% returned the forms. No data were obtained from schools that did not return the forms and these were all rural schools. All of these rural schools were public schools and considering their probable lower student capacity, it can be assumed that the impact of these schools on the results of the study would have been negligible. Only 21 children out of the reported 526 students were diagnosed as SM. The ‘‘SM Screening Form’’ was pretested before the study for understandability and it was found to be comprehendible. In view of this pretest, over-reporting noted in the present study was perhaps associated with the need for help for those children who experience problems in other fields. This raises questions concerning the deficiency of psychosocial programs and guidance services in schools.

Two large-scale community-based epidemiological studies have reported prevalence rates for SM. The New Castle Epidemiological Study reported a prevalence of 0.8 per 1,000 in a cohort of 7-year-old children [2]. Brown and Lloyd [1] reported the prevalence of SM in young children: 8 weeks after the beginning of school the rate was 7 per 1,000, and 64 weeks after the beginning of school the rate was 0.17 per 1,000 (1 of 6,000). More recently, two studies from Scandinavia reported higher prevalence rates among slightly older populations of children 20 per 1,000 among second graders in Finland [4], and 1.8 per 1,000 among school-age children (ages 7–15) in Sweden [3]. A school-based survey of kindergarten, first grade, and second grade students in a Los Angeles school district revealed a prevalence of 7.1 per 1,000 [5]. Our prevalence of 0.033% of SM is not accordance with the previous studies. The prevalence estimates range from 0.03% to 2%, and thus there is not a commonly accepted prevalence rate in the literature. Variations in the prevalence rates may be related to the selected age groups, diagnostic criteria, the methods and timing employed. Previous studies focused on children in the 4–5 and 7–15 years age groups, while we preferred to investigate kindergarten, and first, second and third grade students considering the fact that the disorder presents at primary school years. For instance, Brown and Lloyd [1] took the symptom of ‘‘total mutism’’ as the only criterion in their study, while Kumpulainen et al. [4] used DSM-III-R and excluded the educational and social functioning disruption. Fundudis et al. [2] conducted a society-based study while the other studies were school-based [1, 3, 5, 6, 9]. Our study was also schoolbased; data was obtained from the teachers by using the DSM-IV diagnostic criteria. Teachers provide significant data about children’s social and academic function. In general, teachers are preferred over parents for such a study because teachers spend more time with the children, enabling them to compare children and have more opportunity to evaluate their attitudes. In certain studies, it was found that teachers; compared to the parents, could recognize the emotional difficulties like depression and anxiety disorders and evaluate the social and academic functioning better in children [10]. Our study was initiated approximately 6 months after the beginning of the school year in order to avoid misdiagnosis due to timing; where children with a prediagnosis of SM were assessed by a specialist 8 months later. For the 21 children with a DSM-IV based diagnosis of SM, 12 were male and nine were female. The female: male ratio was 1:1.3. In the literature, it is reported that SM is slightly more frequent in females and has a ratio that range between 2.6:1 and 1.5:1 [3, 4, 11, 12]. Our results are different from those of other

I. Karakaya et al. Selective mutism: a school-based cross-sectional study from Turkey

studies in the literature. This difference might be specific to Turkey, which may be associated with sociocultural and genetic factors. However, it is not possible to make detailed comments because of the insignificance of the difference in the ratio and the fewer number of children with a diagnosis of SM in this study, as well as the lack of similar studies in Turkey. Typically, children with SM tend to talk easily and loudly at home and in familiar social environments, while they do not talk in public, particularly at school. Partial or total mutism towards teachers, friends or strangers is the most prominent clinical sign. They express themselves with gestures, nodding or whispering [13]. Sixteen out of 21 SM cases in our study were children who completely refused to talk, while the other five partially talked to their teachers or friends by whispering. SM is known as a rare childhood disorder. However, recent epidemiological studies showed SM to be more frequent than previously thought. Our results show some similarity to the frequency of the ‘‘pervasive developmental disorder’’, another rare childhood disorder. The lower frequency results of our study may be explained by the regression of symptoms over time. Furthermore, the limited sample sizes, the exclusion of the functional disruption component and the study of smaller age groups in other studies might be the reason for higher prevalence.

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Our study devoted to SM is to our knowledge the largest sampling size in English speaking literature to date. Confirmations of the diagnosis with the data obtained from both the teachers and the parents, as well as specialist-conducted interviews based on DSM-IV were the advantages of the study. However the diagnosis made by a single specialist, the use of a semi-structured interview method are the main disadvantages of the study.

Conclusions Our study is significant in terms of having a large sampling size, of comprising all public and private schools in the research area and of being the first study concerned with the frequency of SM in Turkey. The frequency of SM was found to be 0.033% in this study and the female: male ratio was 1:1.3. Teacher reports affirming that there are great number of students who have difficulties other than SM suggest that further school mental health studies and multidisciplinary approaches are needed. Follow-ups in different periods of time, detailed evaluations of the SM’s clinical characteristics and comparison with the control group, which together comprise the second part of the study, will help obtain more insight concerning the nature and course of the disorder.

References 1. Brown J, Lloyd H (1975) A controlled study of not speaking in school. J Assoc Workers Maladjusted Children 3:49–63 2. Fundudis T, Kolvin I, Garside RF (1979) Speech retarded and deaf children: their psychological development. Academic Press, London 3. Kopp S, Gillberg C (1997) Selective mutism: a population based study: a research note. J Child Psychol Psychiatry 38:257–262 4. Kumpulainen K, Rasanen E, Raaska H, Somppi V (1998) Selective mutism among second-graders in elementary school. Europ Child Adolesc Psychiatry 7:24–29 5. Bergman RL, Piacentini J, McCracken JT (2002) Prevalence and description of selective mutism in a school-based sample. J Am Acad Child Adolesc Psychiatry 41(8):938–946

6. Elizur Y, Perednic R (2003) Prevalence and description of selective mutism in immigrant and native families: a controlled study. J Am Acad Child Adolesc Psychiatry 42(12):1451–1459 7. Kocaeli Governership (2006) http:// www.kocaeli.gov.tr, August 2006 8. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th edn. text revised (DSM-IV-TR). American Psychiatric Association, Washington, DC 9. Steinhausen HC, Juzi C (1996) Elective mutism: an analysis of 100 cases. J Am Acad Child Adolesc Psychiatry 35:606– 614

10. Mesman J, Koot HM (2000) Child- reported depression and anxiety in preadolescence; I: association with parent and teacher-reported problems. J Am Acad Child Adolesc Psychiatry 39:1371–1378 11. Dummit IIIES, Klein RG, Tancer NK, Asche B, Martin J, Fairbanks JA (1997) Systematic assessment of 50 children with selective mutism. J Am Acad Child Adolesc Psychiatry 36:653–660 12. Kristensen H (2002) Non-spesific markers of neurodevelopmental disorder/delay in selective mutism: a casecontrol study. Eur Child Adol Psychiatry 11:71–78 13. Krysanski VL (2003) A brief review of selective mutism literature. J Psychol 137:29–40