What is Selective Mutism?
Selective mutism is an anxiety disorder that occurs during childhood, inhibiting the child from communicating and socializing with others in particular settings. Often they can socialize effectively in environments where they feel secure, but generally suffer in public places. Children with this diagnosis experience extreme fear at the thought of speaking and interacting in social situations.
Signs and Symptoms
There is a wide range of symptoms in children who are diagnosed with selective mutism. It is generally noticed and diagnosed before the age of five and does not vary by gender, race, or ethnicity. The longevity of this diagnosis is unknown as more research is needed, but many clinicians report children and adolescents outgrow the symptoms as they age.
Some children are completely mute in certain situations, while others can only whisper or speak a few words. Sometimes the fear is overwhelming and they become frozen in place and expressionless, while other times they look relaxed but have difficulty communicating with their peers. Often the child will not initiate or reciprocate in conversations.
According to the DSM-5, the following symptoms must be met in order to be diagnosed:
- Failure to consistently speak in particular social situations, such as school, but speaks in other social situations, such as at home.
- Education, work, or social communication is inhibited due to social disturbance
- Symptoms last at least one month
- Not knowing the language or a lack of knowledge is not a contributing factor to the failure to speak
- Symptoms are not due to a separate disorder, such as a communication disorder, autism, or a psychotic disorder.
Severe anxiety (such as separation anxiety), clinging, tantrums, sleeping difficulties, shy tendencies from infancy, fear of social embarrassment, withdrawal, nausea, shortness of breath, and changing moods are common additional symptoms.
90% of children diagnosed with selective mutism have another social phobia or anxiety, such as separation anxiety or panic disorder. There may be a genetic predisposition to anxiety disorders or inherited anxious tendencies. Also common are oppositional behaviors, obsessive compulsive disorder (OCD), trichotillomania (pulling at hair or picking at skin) or communication delays. If a child refuses to speak upon immigrating to a country with a different native language, he or she may be diagnosed with selective mutism.
A pediatrician, speech-language pathologist (SLP), psychologist, or psychiatrist may diagnose a child with selective mutism. The child receives multiple evaluations. The speech and language assessment tests for comprehension, expressiveness, and verbal/nonverbal communication skills. The hearing portion is a standard hearing exam. The oral-motor portion examines the coordination and strength of the lips, jaw, and tongue. Academic grades, standardized test scores, and teacher comments are reviewed. Parents and teachers may also be interviewed for environmental factors, history of symptoms, family history, language development (both understanding and expressing language), as well as the situations in which the child does or does not verbally engage in communication.
If you notice symptoms of selective mutism, it is important that you seek a diagnosis and treamtment as soon as possible. Research shows that symptoms are overcome more quickly when treated early, but often take additional lengths of time to overcome if the child receives delayed treatment. Treatment focuses on the anxiety, not the speech.
For Parents and Teachers
Parents can do many things to help their child overcome selective mutism. Most importantly, be sure to convey to your child that you are not anxious about the mutism, that you accept him/her, and that you confidently believe he/she will overcome this. Here are a few more suggestions:
- Support the positive attributes or talents of your child, and encourage him/her to share them confidently with others.
- Don’t avoid social situations. Rather, arrange situations where your child can socialize with peers in comfortable environments.
- Praise your child for speaking when it was difficult for him/her, but do so afterwards in a private setting so you do not embarrass your child.
- Educate your child’s teachers and coaches about selective mutism. Remind them to gradually increase your child’s participation, beginning with nonverbal communication and progressing toward the goal of full integration.
- Be an advocate. Follow through with treatment and stand firm on what is best for your child. Educating others is a great first step in being an advocate.
Teachers can also play a role in helping a child overcome selective mutism within the classroom.
- First, build a relationship with the child; this will lower the student’s anxiety levels and allow you to play a vital role in his/her growth.
- Do not exempt the child from activities, but instead modify them so the student can still participate.
- Encourage interaction with other students. Group work is a great tool for this.
- Promote the student’s independence and encourage his/her self-esteem.
- Keep the end goal in mind. Remember that each tiny step is one movement closer to fully integrating the student in a settings and environments.
Additional advice for parents and teachers is provided here.
The goal of behavioral therapy is to eliminate undesired behaviors by reinforcing desired behaviors using a variety of techniques:
- Positive reinforcement adds a reward when good behaviors (in this case, talking or communicating in selective situations) are performed.
- Stimulus fading is used by gradually adding another person to the conversation with the child until the child is comfortable talking with more, new, or different people.
- Similarly, desensitisation begins with writing, emailing, or messaging someone, then online chatting, then voicemails, phone calls, and eventually in-person communication.
- Shaping involves a progressive interaction by first engaging in making noises, then humming or whispering, until the child can eventually form words and sentences.
- Graded exposure forces the child to rate how anxious certain situations make him or her feel. He/she tackles the task that causes the least amount of anxiety, working up the list to the one that causes the most anxiety. Situations include answering the telephone, asking a stranger what time it is, or giving a presentation in front of a class.
Cognitive Behavioral Therapy
Generally used for older children and adults, cognitive behavioral therapy addresses how one’s perception of him/herself, others, and the world affect personal thoughts and feelings. This includes redirecting negative thoughts about self to positive ones.
If the child has a comorbid speech or language problem, a speech and language therapist can use role play to model appropriate interactions and allow the child to practice. It may also help the child to speak properly in order to reduce anxiety surrounding his/her language or voice.
Medication in combination with a treatment program can increase the progress made in therapy by reducing anxiety in the child. Common medicines for anxiety include serotonin reuptake inhibitors (SSRIs): Prozac, Paxil, Celexa, Luvox, and Zoloft. Other drugs that target neurotransmitters include Effexor OR and Buspar. Generally medication will be given for 9-12 months. In particular, research has shown that fluoxetine (Prozac) may improve selective mutism that is comorbid with other anxiety disorders, and has a high efficacy rate.
Books for Parents
- Helping Your Child With Selective Mutism: Practical Steps to Overcome a Fear of Speaking, by McHolm, Cunningham, and Vanier
- The Selective Mutism Treatment Guide: Manuals for Parents, Teachers, and Therapists: Still Waters Run Deep, by Perednik
Books for Children with Selective Mutism
- Maya’s Voice, by Cheng
- Danny the Duck with No Quack, by Doyle
- Cat’s Got Your Tongue?: A Story For Children Afraid To Speak, by Schaefer and Friedman
- A Home For Bird, by Stead
Books for Family and Friends
- My Friend Daniel Doesn’t Talk, by Longo and Bottomley
- Can I Tell You About Selective Mutism?: A Guide for friends, family and professionals, by Wintgens, Johnson and Gallow