Selective Mutism: Natural Approaches for Vocal Restoration
What do you do when your patient or client appears to respond to every instruction you give them yet when you directly ask him or her a question there is no response? Do you repeat the question, assuming the individual has not heard what you said? Do you move forward with the intake and make note of the individual’s demeanor? These questions without a doubt leave numerous clinicians pondering what the next course of action might be.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), selective mutism (SM) is a disorder in which individuals fail to speak in some social settings, despite speaking normally in other settings. SM can significantly interfere with the individual’s ability to complete normal daily activities. There has been much debate regarding SM and its formal classification. Most recently it has been reclassified from “disorders of childhood and adolescence” to “anxiety disorder.” It is no longer viewed as behavior (oppositional defiance or avoidant behavior) and may coexist with social and developmental disorders, neurocognitive deficits and even auditory processing disorders.
Girls are twice as likely to exhibit SM compared to boys. Current conventional treatment for SM includes 2 main therapies: cognitive behavioral therapy and pharmacotherapy, primarily selective serotonin reuptake inhibitors (SSRIs).
Possible Causes of Selective Mutism
Traumatic Events: One of the first things that should be determined is whether a traumatic event has occurred. The trauma need not be physical or sexual. Emotional and verbal abuse can trigger anxiety and therefore influence the development of SM.
Lead Toxicity: Lead is a heavy metal known to cause cognitive and neurological issues in children. It crosses the blood-brain barrier, interferes with production and release of brain chemistry molecules (aka neurotransmitters) and neurotransmission, and decreases neuronal growth. Paints, soil, toys, and water pipes are common exposures. Chlorella, cilantro, milk thistle, bentonite clay and activate charcoal gently assist lead detox.
Genetics: MTHFR is responsible for converting a B vitamin called folate into an active, or bioavailable, form that the body can utilize. Methylfolate has two important functions in the body. The first is to help make neurotransmitters in the brain. Neurotransmitters are brain chemistry molecules that enable us to sleep, express emotion, learn, and respond to stress. The second function of methylfolate is to create another molecule in the body called SAMe, which is responsible for regulating over 200 different enzymes in the body, some of which are linked directly to our ability to detox. COMT assists the body with breaking down catecholamines (dopamine, norepinephrine, and epinephrine).
Variations in another gene, contactin-associated protein-like 2 (CNTNAP2), have been implicated in neurodevelopmental and language impairment disorders and is associated with an increased risk for SM. CNTNAP2 functions in the nervous system as cell adhesion molecules and receptors. Studies have demonstrated high levels of expression in the prefrontal and anterior temporal cortex, caudate, putamen, and amygdala.
Thyroid: The thyroid gland regulates the metabolism of every single cell in the body. Hypothyroidism (underactive thyroid) is relatively common. The gold standard for diagnosis of hypothyroidism by conventional methods is dependent on measuring thyroid markers, primarily thyroid stimulating hormone (TSH), secreted from the anterior pituitary. In addition to TSH, T4 and T3 should be measured as part of the thyroid work up. The thyroid gland produces T4 and T3, which exert influence on tissues and is absorbed into the cells to initiate intracellular activity. Hypothyroidism may cause hypoglossal motor nerve dysfunction, resulting in language disfluency.
Iron Status: Iron is a cofactor for serotonin production. It is absorbed much more efficiently from meat products than from plant-based products. Vitamin C can enhance iron absorption. Best food sources: protein (meat, poultry, fish), blackstrap molasses lentils, beans, green leafy veggies. quinoa, almonds, and sunflower seeds.
Foundational Support for SM
Diet: The body requires adequate levels of nutrients to function. When it comes to diet, macronutrient (carbohydrates, protein, and fat) balance is essential. Protein is of importance as it has a wide variety of physiological roles. Protein is the building block of DNA, our genetic profile; and helps to transport molecules around the body through the bloodstream and into the cells for metabolism; immune and enzymatic functions; homeostasis, and yes, the formation of neurotransmitters. Inadequate levels of protein can wreak havoc on the body in many ways, including brain function. Many food components are essential, meaning the body cannot make them on its own accord, so we must ensure the foods consumed are supplying those essential nutrients. Phenylalanine and tryptophan are essential amino acids required for catecholamine (dopamine, norepinephrine, and epinephrine) and serotonin formation, respectively.
Certain foods can contribute to or exacerbate anxiety. Gluten and caffeine are two primary examples of things that appear to make anxiety worse. An elimination trial of these substances may prove beneficial for helping to reduce anxiety. It should be noted it may take many months to see significant changes or improvements. One could also test for food sensitivities to ascertain whether there are other foods that potentially negatively affect health or symptoms.
Vitamins B & C: Vitamins B and C are water-soluble, meaning they are found in the watery part of cells in the body and foods. Because they are excreted through the kidneys, there is less potential for buildup and toxicity. They must be continually supplied through the diet and/or supplementation, especially during stressful times.
There are multiple B vitamins (B1, B2, B3, B5, B7, B9, B12). It’s important to know they work in synergy even though they each have distinct functions. B5 (pantothenic acid) is critical for the synthesis of adrenal gland hormones like cortisol. B1, B3, B6, B9, and B12 are required for normal neurological function, including neurotransmitter production and metabolism.
Vitamin C is a fantastic antioxidant that prevents free radical damage. It is involved in connective tissue formation, wound healing, assists with immune enhancement, drug metabolism, and detox. Interestingly, vitamin C is also essential for normal adrenal gland function. The adrenal glands contain the richest source of vitamin C in the body which minimizes cortisol secretion. Studies have shown people who have higher levels of vitamin C are better able to cope with stress. Too much vitamin C can cause GI upset (i.e. abdominal pain and diarrhea) which can be reversed by decreasing the dose or using buffered forms.
Additionally, animal-assisted therapy and cannabidiol (CBD) appear to be promising treatments for SM.
When using natural therapies to treat SM, it should be noted that progress may be slower than using other therapies. My advice – be patient and trust the process. Never attempt to force the individual outside of his or her comfort zone; always meet the individual where they are at and ensure a judgment-free safe space. Find a practitioner who is willing to listen, learn, and establish a true connection with the individual.
Dr. Shyron Alston is a licensed naturopathic physician and clinical nutritionist specializing in autism and autism spectrum disorders, thyroid disorders, and weight loss and management. She is an associate at the Pediatric & Family Center for Natural Medicine and maintains a private practice in Norwalk, CT. She is available for complimentary consults. Please call: (203) 265-0444 or visit: www.naturopathicanswer.com for more information.