Selective Mutism

Selective mutism is a rare disorder, affecting fewer than1% of individuals seen in a mental heath setting, but it can obviously make conducting an examination very difficult because of the lack of communication.  This photo of hot air balloons firing up reminded me of an encounter that we had in our office recently involving Rachel, a young child with a history of selective mutism.  Knowing that we would be relying on nonverbal information, when her mother scheduled an appointement for an evaluation we arranged to conduct a sweep VEP test with Rachel first.

All well and good, but Rachel had selective visual looking as well, and was clearly under anxiety and would not fixate the screen long enough to obtain a VEP response. The only activity I did which let me know that Rachel had some reasonable level of acuity was when I tossed a ball to her mother from across the room.  Rachel was sitting in mom’s lap in the examination chair, and with mom’s permission I threw my best pitch located just to the left of Rachel’s right ear.  She flinched slightly as the ball approached.  That was the only functional looking response I could obtain.  Needless to say I was unable to obtain a retinoscopic reflex, but was able to obtain a quick enough flash to see that the reflex was nowhere near neutral.  Something told me there was a wad of refracive power there I would scope if Rachel could cope with looking long enough. I took mom over to the closed view autorefractor, and asked mom to look down the peephole while Rachel sat in her lap.  I told Rachel that she wasn’t allowed to look even if she wanted to – that this was mom’s turn.  I escorted them to the recpeption area, gave mom some crayons and while sheets of paper, and asked her to draw a picture of what she saw when she looked into the peephole.

What mom drew, and Rachel added her scribbles to, bore little resemblance to the actual hot air balloon at the end of the highway that is the internal target of the autorefractor.  The scene looks more like the hot air balloon at the end of the highway above.  That doesn’t matter.  The key is that Rachel was now intrigued enough to look into the peephole to see if their picture looked anything like what she and mom created.  As she looked down the highway, the autorefractor went zzzzt … zzzzt … zzzt, and up popped the numbers +6.75 -2.75 x15.  No wonder Rachel found it stressful to sustain looking!  As she left the office, Rachel’s mom couldn’t stop thanking our staff enough for the wonderful way in which she was treated.  At our morning staff meeting today our patient care coordinators shared with everyone that as she and mom left the office, Rachel began speaking!  I suspect when Rachel obtains her first spectacle lens prescrption, it may lessen her anxiety to the point where it aids her speech-language professionals in guiding her out of the tunnel.  An incredibly feel-good experience for Rachel, her mom, and our staff …