Right or Wrong: Elective Mute.

 

a paper plane

I

 have never really come to terms with Elective Mutes or, if preferred, Selective Mutes.

         Where do they really fit in the schema of various diagnostic categories, or more precisely, in what way can we understand them?  In terms of Freudian, Jungian or Kleinian theories, or Erikson’s or Mahler’s more child friendly models, or modern neuro-transmitter bio-physiology?

         Yet we have all seen them in our career as psychiatrists.  Because we are essentially rendered ineffectual in our therapeutic approach, they are often treated as a novelty and one’s hope is that either the family come to terms with what might best be described as a quirk of nature, for which little can be done, or the patient grows older and never really commits anything that requires hospitalisation.

         I can also see how in time, guideline controlled health practice will allow little room for anyone practising child psychiatry to be spending any time at all with these cases.

         We do not get to see them that often and I can remember three cases in my three decades of work with children, or at least, three that stuck in my mind.

         To put it simply, Elective Mutes (a term I prefer as it gives a hint of election by the patient) are not true mutes as they speak at home, often to only one person such as the mother, but not to anyone else, especially at school. At some point in the history of child psychiatry someone changed the diagnosis to Selective Mute and so it was included here in case anyone thought I was talking about a non-existent condition.

                                                                       

A Chinese Patient

         An exceptional consultation was requested by a psychiatrist friend of mine in a nearby town. He had a patient, a Chinese mother who spoke little English and she was very concerned about her son. Exceptional consultations are allowed within the NHS when the need arises to call on the expertise of another consultant not working for the authority, for a specified fee. In this case the expertise was not clinical but language; although by asking a child psychiatrist instead of just an interpreter he was killing two birds with one stone.

         The family ran a Chinese Fish and Chips shop and lived in the flat above the shop in the older part of the town. There was an older daughter and a young baby. The referred patient had turned five and just started school. Five is generally the age when these patients get referred. I was offered a seat by a small table in a corner near the rear window of the flat.  Some steps led from the shop to this sitting area at the back of the flat. Whiffs of frying oil crept through the tightly shut windows. On the wall was the traditional Buddhist shrine with remnants of the previous day’s incense sticks. I was not entirely sure if I preferred the smell of incense stick or frying oil.  On the bench across from me, the older girl was diligently doing her homework. My patient was playing with his new looking power ranger, possibly a bribe so that he would stay and see the doctor. The baby was in mother’s arms sound asleep. She apologised that her husband was busy getting ready for the shop to open in about an hour’s time.

         This was fairly typical of Chinese families in similar take away businesses. They probably made a reasonable living but some of the money might have to be sent to their folks back in their home village. Décor at home would be basic although most would have the latest model of television set and video recorder.

         Mother was relieved that I could speak fluent Cantonese, but her daughter would barge in now and again in perfect English about her brother.

         The boy conversed at home with both parents and sister, although I could sense that with his sister’s talkativeness he would hardly stand a chance.  

         Both my patient and his sister spoke fluent Cantonese with the parents and mother did not notice anything unusual about the boy until the school complained.

         To prove that he could really speak, mother said that they had a video recording made during the last Chinese New Year when they took the family to Hong Kong. He was even speaking to other relatives in Hong Kong. Dutifully the daughter put the tape into the video machine and played the video. There were also bits of English spoken between him and his sister.

         What worried mother was that after father received the complaint letter from school, he stood the boy in front of him with a cane and said that he would cane him if he did not talk to his teacher the next day. The boy did not wait and put out his hands.

         His father did not hit him. He only wanted to threaten him.

         A week went by and another letter came. The boy was again summoned before father. His sister urged him in English not to be afraid of his teachers and to speak in school or he would be punished. This time father held a clever and threatened to chop his hands off if he were to receive another letter from school.

         The boy put out his hands again.

         Suddenly I was extremely worried for the parents. The town they lived in was hot on Child Abuse at the time.  Although I had no fear at all that these parents would chop their son’s hands off, some over vigilant social workers might take it upon themselves to act.  I took it upon myself to advise the parents that any such threat might bring the wrath of Social Service upon them.

         Chinese families and perhaps oriental ones in general want little to do with authorities. The parents had in fact resisted the involvement of Educational Psychologists and I was only let in because I was Chinese. 

         Now, mother was worried.

         “Would they take him away?”

         She asked if they should send him to a private school or do something else. They just did not want to lose him. She assured me that her husband loved him as he was his first son but he just did not want to upset school in any way.

         I suggested that it was probably too early to act, as the boy might soon decide to speak.  It would be important to check if he was making any progress, but on the video recording, he was reading with his sister. If it became necessary for them to see a Psychologist I would help to facilitate. I suggested that three months might be a good time for me to see him again.

         Two month later, I received a call from my psychiatrist friend. No follow up appointment would be necessary.

         “Did the boy speak?”

         I was anxious to know.

         “No, they sent him back to Hong Kong to live with the grandparents.  They said he was doing well at school there.”

         How stupid of me!  I should have guessed from the tape and from what I know of the Eastern way: avoid authorities more than you need to avoid tigers.

         And who is to say that the boy would have done better if he had continued here.

         Who knows? 

        

 

Norman

         Paper darts or planes were one of my favourite pastimes as a child and from a plain piece of paper I am able to build one that will be able to do nice aerobatics in a small room by minute tweaking of the under-wing rudder.  Now and again with the appropriate child I might resort to building one to start a therapeutic relationship and most times it worked like a treat.

         So it was after weeks of struggling with an elective mute that I decided to try my luck.

         Little Norman was a handsome looking boy of six and never spoke to anyone outside of the house. He would speak to his parents indoors but not out. Of all other relatives he would only speak to his maternal grandparents who lived nearby but only in his own home, never theirs.

         He had made reasonable progress at school as mother was an infant teacher before she had him and regularly checked his progress.

         He just would not speak to anyone else.

         He looked like an autistic child and certainly had the tendency to avoid eye contacts. However he acquired his language at the usual times and mother had a normal uneventful birth. Father was an accountant working in London, of the quiet type as mother put it. I only met him once on their first appointment.

         Norman was their pride and joy, being the first grandchild on both sides of the family.  The paternal grandparents lived in the West Country and did not see Norman too often.

         So, there we were, one of my first mutes since I became a consultant.  Despite all recorded difficulties with Elective Mutes, I decided to try my luck with some therapy sessions.

         The boy got quite used to me after a while.  He would draw, write and often look at all the story books I had around. He would play with Lego, assemble and dissemble the train set but he just would not speak.

         I was young then and had the mistaken belief that getting him to speak with me would be counted as some sort of cure. This has not been written up anywhere and we had little knowledge of the long term outcome of these cases.

         I was determined, determined to get him to speak, at least with me.

         Paper plane. 

         I hit on the idea of my faithful friend.

         I built one, then two. He had one and I had the other. They flew, made beautiful loops, did aerobatics and he was thoroughly enjoying it.

         I sensed that he wanted to take them home to show his dad.

         “You will have to ask me for them.”

         How nasty could I be?

         He turned solemn, then pale, then red.

         I was beginning to hate myself. How could I? He was my little friend. We could have gone on for months playing.

         “Please may I have the planes?”

         I was shocked, so was mum when she heard what happened. I was not pleased with myself. I had tricked the little boy to give up his principles, whatever they were.

         Mum on the other hand thought I was brilliant.

 

Simone

         Little Simone, aged five, had a beautiful crop of blonde hair with the cute little face and blue eyes to go with it. I was wondering if it was a genetic thing. Good looks and mutism. She had a brother four years older. He was smart, too smart sometimes as he always seemed to know what she wanted and would speak up for her.

         Simone did not even talk to her father or brother. Only to her mother and only when no one else was around.

         Her brother was doing extremely well at school and they were thinking of sending him to a private school.

         Father was a pilot and was hardly home which might explain in part why Simone did not speak to him. At least that was how mother tried to help me understand. Also, her brother might be too old for her, especially as he had his own friends and she was a girl. “Boys of that age don’t talk to girls” was the other lesson I received.

         I hardly needed to do any talking from the first time I met mother as she would ask the questions and answer them.  Most were sensible answers and I was sure many child psychiatrists would not have such a deep understanding of children.

         No, mother was not worried, as she could check on Simone’s progress.

         At the time, we had just moved to our new clinic and we had a video link and recording facility in our playroom.

         What an opportunity to test out our equipment.

         So we had Simone set in a routine of spending some time first with mother and then one of my female junior doctors would join us in the second half of the session to talk to mother.

         At first Simone would stay quiet throughout.

         After about three months, the breakthrough came. Simone started talking to mother when she was alone playing with her. When the door handle turned, she switched off. This continued for some sessions. Simone by now would be reading story books with mother and she was an avid and good reader for her age.

         One day, watching the proceedings, I hit on an idea, a very naughty idea.

         What if my junior doctor played back the video recording to her? It might disclose the secret. We knew she could speak.

         As if by magic, it worked. The rest you might have guessed.

         Was it the right thing to do? Did making an elective mute speak represent a cure? I do not know.

        On one cold April morning in 2007 in Virginia a former mute went on a shooting rampage and many innocent lives were lost[1].

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[1][1] https://en.wikipedia.org/wiki/Virginia_Tech_shooting: In middle school, he was diagnosed with a severe anxiety disorder with selective mutism, as well as major depressive disorder.

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