Case Report: Evaluation strategies and cognitive intervention: the case of a monovular twin child affected by selective mutism

Introduction

Selective mutism (SM) is a developmental disorder of biological and environmental etiopathogenesis. It is characterized by the child’s significant inability to speak in specific social situations (for instance at school) or in non-familiar circumstances. The clinical and research data confirm that SM is a complex etiological multifactorial disorder whose maintenance is connected with the interaction of biological (familiarity with shyness, preterm birth) (Capobianco & Cerniglia, 2017) and environmental early factors (anxiety and overprotectiveness of the mother) (Capobianco et al., 2010; Capobianco et al., 2017; Capozzi et al., 2017; Pizzuto & Capobianco, 2008) Analysis of the underlying thoughts and emotions in mutacic behavior reveals fear of judgment, fear of failure and being mocked, shame, depression, feelings of worthlessness or inadequacy,catastrophizing, and confirms the comorbidity between selective mutism and internalizing symptoms. The typical age of onset for selective mutism is between 3–6 years, even though the disorder gets usually diagnosed belatedly during the school age (around 7–8 years). It seems that the twins condition in presence of frequent associated additional biological and environmental conditions (prematurity, maternal stress, isolation) plays a crucial role in aggravating mutacic difficulties (Capobianco & Cerniglia, 2017; Capobianco & Cerniglia, 2018). The possibility to improve and change the symptomatology of SM-diagnosed children is strongly related to the severity of the disorder and the biological environmental factors implicated in each single case. Cognitive-behavioral intervention on the child has as its purpose to change the resulting cognitive biases and emotional states, but parallel efforts on the environmental dynamics that determine the disorder maintenance are needed (family and school).

Case report

F is a child with a belated diagnosis of selective mutism (diagnosed after the third grade of elementary school). The mutacic symptomatology appears particularly in the school environment, in interaction with teachers and peers during teaching activities. She has a monovular twin sister (L) with the same diagnosis. She is born at 36 weeks without any particular pre- or perinatal problems. The mother describes F’s development as regular through the “normal” stages and does not recall any developmental problems in the motor and/or linguistic realms during F’s first years of life (Capobianco et al., 2017; Pizzuto & Capobianco, 2008).

In short, F has always been a very shy girl, showing difficulties and fear in relating to non- familiar people . F has always perceived similar situations with an intense discomfort, anxiety and concern and has learned to react through inhibition, behavioral and verbal withdrawal. As a result of functional evaluation (cognitive and projective tests), spontaneous observation and exploration of the ABC (through various simulation techniques with characters, drawings, written questions and cartoons) emerges fear of judgment, fear of failure and being mocked, being made fun of, (“everyone will laugh at me”), shame, and the fact that others might notice this feeling. Depressiveness and catastrophizing prevail over the possible consequences on others of her speaking, her perception of inadequacy and her feelings of worthlessness (“I am afraid to make a mistake”, “I didn’t study”, “I am not capable”). F shows her discomfort via “critical-provocative” behavior especially when her sister L is present, although the twins seem to have a strong complicity: “a mute complicity” in keeping the mutism part.

Maternal relationship. The mother’s behavior represents an important maintenance factor of F’s mutism. The girl shows indeed an anxious-dependent attachment style (Pattern C) towards the mother. The mother actually appears to be anxious and worried showing a pressure attitude to make the girl speak (sometimes even punitive), and she often replaces F in her responsibilities. Another important aspect is the confrontation with F’s twin sister. The mother often tends to compare the two sisters. This creates conflict situations and a quest for attention by F, who uses various maternal affection manipulation strategies.

Maternal thoughts and emotional states. During the interviews, the mother shows extreme attention to maintaining a positive image in front others and a propensity to avoid feelings of shame to which she gives a meaning of failure, devaluation and humiliation. These aspects are strongly connected to her life story and particularly to experiences of abandonment and maltreatment. Her necessity not to feel ashamed and her focus on avoiding situations, in which she could be exposed to that risk, have an extreme importance to the mother of F and L.

The belated diagnosis has led F to reinforce her behavioral style such that, by now, has became habitual and an integral part of her way of being, and the basis of an equilibrium reached in the dependent relationship with her mother and her twin sister. Behaviors of passivity, lack of interest, creativity and pro-activeness, are products of the extended time in missing use of verbal language as a necessary means to develop the formation of concepts, thoughts, complex thoughts, and metacognition. Despite F’s functional evaluation, she has a normal intelligence level but her neuropsychological profile indicates poor cognitive functioning.

Therapy

Consent

Written informed consent for publication of their clinical details was obtained from the parent of the patient.