Selective mutism

What Is Selective Mutism?

Selective mutism (SM) is a childhood anxiety disorder characterized by an inability to speak or communicate in certain settings. The condition is usually first diagnosed in childhood. Children who are selectively mute fail to speak in specific social situations, such as at school or in the community.

It is estimated that less than 1% of children have selective mutism. The first described cases date back to 1877 when German physician Adolph Kussmaul labeled children who did not speak as having “aphasia voluntaria.”

Selective mutism can have a number of consequences, particularly if it goes untreated. It may lead to academic problems, low self-esteem, social isolation, and social anxiety.

Signs of selective mutism

Selective mutism usually starts in early childhood, between age 2 and 4. It’s often first noticed when the child starts to interact with people outside their family, such as when they begin nursery or school.

The main warning sign is the marked contrast in the child’s ability to engage with different people, characterised by a sudden stillness and frozen facial expression when they’re expected to talk to someone who’s outside their comfort zone.

They may avoid eye contact and appear:

• nervous, uneasy or socially awkward
• rude, disinterested or sulky
• clingy
• shy and withdrawn
• stiff, tense or poorly co-ordinated
• stubborn or aggressive, having temper tantrums when they get home from school, or getting angry when questioned by parents

More confident children with selective mutism can use gestures to communicate – for example, they may nod for “yes” or shake their head for “no”.

But more severely affected children tend to avoid any form of communication – spoken, written or gestured.

Some children may manage to respond with a few words, or they may speak in an altered voice, such as a whisper.

What causes selective mutism 

Experts regard selective mutism as a fear (phobia) of talking to certain people. The cause is not always clear, but it’s known to be associated with anxiety.

The child will usually have a tendency to anxiety and have difficulty taking everyday events in their stride.

Many children become too distressed to speak when separated from their parents and transfer this anxiety to the adults who try to settle them.

If they have a speech and language disorder or hearing problem, it can make speaking even more stressful.

Some children have trouble processing sensory information such as loud noise and jostling from crowds – a condition known as sensory integration dysfunction.

This can make them “shut down” and be unable to speak when overwhelmed in a busy environment. Again, their anxiety can transfer to other people in that environment.

There’s no evidence to suggest that children with selective mutism are more likely to have experienced abuse, neglect or trauma than any other child.

When mutism occurs as a symptom of post-traumatic stress, it follows a very different pattern and the child suddenly stops talking in environments where they previously had no difficulty.

However, this type of speech withdrawal may lead to selective mutism if the triggers are not addressed and the child develops a more general anxiety about communication.

Another misconception is that a child with selective mutism is controlling or manipulative, or has autism. There’s no relationship between selective mutism and autism, although a child may have both.

Risk For Other Disorders

Children with selective mutism tend to have a history of being socially very inhibited, and are also diagnosed with other anxiety disorders like social anxiety disorder, separation anxiety disorder, and specific phobias. Some kids with SM may appear to be oppositional when they’re pressured to speak. Children with SM may also struggle with mood disorders as well as learning disorders; those conditions should be addressed along with SM in the child’s treatment plan.

Diagnosis

Diagnosis should be made by a professional familiar with selective mutism who can rule out other conditions that present similar symptoms. Since young, anxious children have difficulty participating in interviews—particularly if they have SM—the expert making the diagnosis will rely heavily on reports from parents and other adults in the child’s life, to determine a pattern of behavior across situations. They might request home videos of the child’s behavior in her “place of strength” and/or observe her alone with her parents (though a one-way mirror). To be diagnosed with SM a child must be able to speak in some settings but not in others, the condition must have lasted for a month that is not the first month of school, and it must interfere with schooling and social activities.

How is Selective Mutism treated?

Selective mutism is most receptive to treatment when it is caught early. If your child has been silent at school for two months or longer, it is important that treatment begin promptly.

When selective mutism is not caught early, there is a risk that your child will become used to not speaking, and as a result, being silent will become a way of life and more difficult to change.

Treatment for selective mutism may include psychotherapy, medication, or a combination of the two.

The effectiveness of treatment will depend on:

• how long the person has had selective mutism
• whether or not they have additional communication or learning difficulties or anxieties
• the co-operation of everyone involved with their education and family life

Treatment does not focus on the speaking itself, but reducing the anxiety associated with speaking. Treatment approaches should be individualized, but the majority of children are treated using a combination of:

1. Social Communication Anxiety Therapy® (S-CAT®): This is the philosophy of treatment implemented at the Selective Mutism, Anxiety, and Related Disorders Treatment Center (SMart Center). This treatment includes development of an individualized treatment plan that focuses on the whole child and incorporates a TEAM approach involving the child, parent, school personnel, and treating professional. Recommended therapeutic tactics and techniques are implemented to build social comfort and progression of communication comfort (nonverbal and verbal) in various social settings (in and out of school). Because anxiety levels change from situation to situation, and often from one person to the next, methods often change from one social situation to another. Therefore, by lowering anxiety, increasing self-esteem, as well as increasing communication and social confidence within a variety of REAL WORLD settings, the child suffering in silence will develop necessary coping skills to enable for proper social, emotional, developmental, and academic functioning.
2. Behavioral Therapy: Positive Reinforcement and Desensitization techniques are the primary behavior treatments for Selective Mutism, as well as removing all pressure to speak. Emphasis should be on understanding the child and acknowledging their anxiety. Introducing the child to social environments in subtle and non-threatening ways is an excellent way to help the child feel more comfortable, i.e., Parents can take the child into school when few people are around to get the child to practice speaking. Eventually, bring a friend or two to school and allow the children to play when other children are not present. Small groups with only a small number of children are helpful, as well as allowing parents to spend time with the child within the class. After the child is speaking quite normally, the teacher, and then the students are gradually introduced into the group setting. Positive reinforcement for verbalization should be introduced when, and only when, anxiety is lowered and the child feels comfortable and is obviously ready for some subtle encouragement.
3. Play Therapy, Psychotherapy, and other psychological approaches: These can be effective if all pressure for verbalization is removed and emphasis is on helping the child relax and open up. Confronting mutism in a non-threatening way is important. These children are SCARED, and the focus should be to help them identify their level of being scared’ in a particular situation. Helping them to realize that you understand and are there to help them relieves tremendous pressure.
4. Cognitive Behavioral Therapy: CBT trained therapists help children modify their behavior by helping them redirect their fears and worries into positive thoughts. CBT needs to incorporate awareness and acknowledgement of anxiety and mutism. Most children with Selective Mutism worry about others hearing their voice, asking them questions about why they do not talk and trying to force them to speak. The focus should be on emphasizing the childs positive attributes, building confidence in social settings, and lowering overall anxiety and worries.
5. Medication: Studies indicate that the most effective approach to treatment is a combination of behavioral techniques and medication. Often behavioral techniques are used for an indeterminate amount of time prior to the addition of medication. If children are not making enough progress with behavioral therapy alone, medication may be recommended to reduce the anxiety level. Serotonin reuptake inhibitors (SSRIs) such as Prozac, Paxil, Celexa, Luvox, and Zoloft are very effective in the treatment of anxiety disorders. Similar to the SSRIs, there are other drugs that affect one or more neurotransmitters such as serotonin, norepinephrine, GABA, and dopamine, etc. which are also proving to be affective. Examples are Effexor XR and Buspar. Both classes of drugs work well in children who have a true biochemical imbalance. This seems to be the case in the majority of children with Selective Mutism. Very often, we have seen positive effects in as little as a week! Medication is used as a jump start with the hope that, as we lower anxiety via medication, we can implement behavioral techniques more easily and successfully! Goals for the duration of treatment with medication are usually 9-12 months.
6. Self-esteem boosters: Parents should emphasize their childs positive attributes. For example, if your child is artistic, then by all means show off the artwork! Have a special wall to display your childs masterpieces; perhaps you can even have a special exhibition! Have them explain their artwork to family members and close friends. This promotes more verbalization practice, as well as helps with confidence!
7. Frequent socialization: Encourage as much socialization as possible without pushing your child. Arrange frequent play dates with classmates or even small group interactions with individuals the child knows well. The goals is for your child to feel comfortable enough with the classmates so that verbalization will occur. Most children with Selective Mutism will talk to friends in their own home. As the child gets increasingly comfortable speaking to one child, invite another child over, and then have two or three children at a time! Transfer speaking into the school via set tactics/techniques. For some children, Social Skills therapy is necessary and often helpful in accomplishing increased communication.
8. School involvement: Parents need to educate teachers and school personnel about Selective Mutism! You must be an advocate for your child. The school needs to understand that children with Selective Mutism are not being defiant or stubborn by not speaking, that they truly CANNOT speak. Explain to the teacher that a child needs to feel that it is alright for them not to speak. Nonverbal communication is acceptable in the beginning. As the child progresses with treatment, the teacher should be involved in the treatment plan with verbalization being encouraged in subtle, non-threatening ways. An Individualized Educational Plan (IEP) or 504 Plan may be necessary to help accommodate your childs inability to communicate verbally and to help the child progress communicatively as well as build social comfort.
9. Family involvement and parental acceptance: Family members must be involved in the entire treatment process! Very often changes in parenting styles and expectations are necessary to accommodate the needs of the child. Remember, never pressure or force your child to speak this will only cause more anxiety. Convey to your child that you are there for them. Spend one on one time, especially at night, when all pressure is off and engage your child in discussions about their feelings. Allowing your child to open up helps relieve stress. A parents acceptance and understanding is crucial for the child!

It is important to realize that with proper diagnosis and treatment, the prognosis for overcoming Selective Mutism is excellent!

In general, there is a good prognosis for selective mutism. Unless there is another problem contributing to the condition, children generally function well in other areas and do not need to be placed in special education classes.

Although it is possible for this disorder to continue through to adulthood, it is rare and more likely that social anxiety disorder would develop.

Tips for Helping Kids Talk

• Wait 5 seconds: We often don’t give kids enough time to respond. Waiting five seconds without repeating the question or letting anyone answer for a child is a good rule of thumb. It also helps kids learn to tolerate their anxiety.
• Use labeled praise: Instead of just saying “Great job!” be specific: “Great job telling us you want juice!” This way kids know exactly what they’re being praised for, and they feel motivated to keep doing it.
• Rephrase your question: Instead of asking questions that can be answered with a yes or no — or, more often, nodding or shaking her head — ask a question that is more likely to prompt a verbal response. Try giving her choices (“Would you like a puppy sticker or a star sticker?”) or asking more open-ended questions (“What should we play next?”).
• Practice echoing: Repeat or paraphrase what the child is saying. This is reinforcing and lets her know that she’s been heard and understood. For kids who speak very quietly, repeating what they say also helps them participate in bigger groups.
• Be a sportscaster: Do a play-by-play recap of what the child is doing: “You’re drawing a flower” or “I see you’re pointing to the picture in the book.” This helps convey interest in what the child is doing and is a good technique to fall back on when she is being nonverbal.