What is Selective Mutism?

Selective mutism (SM) is a severe anxiety disorder where children or adults are unable to speak in certain social settings, such as school, work, or out in the community. People with SM may struggle to speak around relatives they have only met a few times or people they don’t know well. People with SM may appear excessively shy in public, however, when they are at home with their immediate families and loved ones, they are able to speak without issue. SM is more common in girls.

SM is typically diagnosed in childhood and often co-occurs with other anxiety disorders such as social anxiety or separation anxiety. The difference between a person being shy and having SM is a pattern of being unable to speak that persists over time and significantly impacts daily living and normal functioning. Characteristics common to SM are struggling to make eye contact, using non-verbal forms of communication, communicating through another person, and presenting as behaviorally inhibited.

Signs and Symptoms

Selective mutism has several signs, symptoms, and characteristics. These include:

• Speaks freely at home or with loved ones, yet is unable to speak when in certain social settings such as school, work, out in the community, or when around people they don’t know well
• Experiences crippling fear (a freeze response) or shuts down completely when in certain social settings and is unable to speak
• May struggle to make eye contact
• Sudden stillness or frozen facial expression when expected to speak or interact with others in certain social settings
• May communicate in non-verbal ways, such as pointing, nodding, moving objects, drawing, or writing
• Clingy with trusted caregiver
• Socially awkward and nervous
• Stiff or tense
• Poor coordination
• Speaking through a trusted individual (whispering to a parent or friend at school to give an answer or response)
• Struggles to perform or participate in certain aspects of school (trouble focusing, difficulty completing tasks, trouble following instructions, only playing alone)
• Struggles to make friends with peers or classmates their own age, due to an inability to speak in public
• May become stubborn, resistant, angry, or have tantrums at home when questioned or pushed by parents
• Sleep problems
• Physical problems (tummy ache, headache, nausea, vomiting, diarrhea, chest pain, headache, shortness of breath)
• Picky eater
• Bowel or bladder issues

SM is typically noticed and diagnosed in childhood between the ages of 3-8, usually when the child starts to interact with people outside of their family. SM is about more than just shyness. Children and adults with SM do not choose to not speak, rather, they have an inability to speak. If SM is not treated in childhood, it can persist into adulthood. SM exhibits a pattern of verbal inhibition in certain social settings, which is persistent over time, and significantly impacts daily living and normal functioning.

Causes

The exact cause of SM is not always clear, but it is categorized as an anxiety disorder with emphasis on a particular fear (phobia) of speaking with certain people in certain settings. Children with SM tend to be more anxiety prone and may be triggered by separation (or perceived separation) from parents or a caregiver. Loud noises, crowds, or environments that feel overstimulating may also cause the child to shut down and withdraw. 

There are some misconceptions about causes for SM. There is no evidence supporting that children with SM have experienced trauma or abuse. Often, SM develops without any history of trauma. However, some children who have experienced trauma, if the triggers are not addressed, may develop symptoms of SM. There is also no evidence supporting that autism causes SM, although some people with SM also have a diagnosis of autism.

Some children with SM may also have a diagnosis of sensory processing disorder, also known as dysfunction in sensory integration (DSI). This disorder is characterized by difficulty in integrating sensory inputs, which can cause a child to feel overstimulated and overwhelmed in certain situations. Often, with DSI, children may struggle to adapt and regulate sensory input, which can be experienced in the body as a potential threat. The inability in integrating sensory inputs may cause a child to misread or misinterpret social or environmental cues. 

Additionally, some children with SM have subtle speech or language abnormalities or learning disabilities. The abnormalities or delays may heighten the experience of anxiety and become a trigger for SM. It is important to note that many children with SM have no signs of speech or language issues or delays. 

Diagnosis

Diagnosis of SM is usually made between the ages of 3-8, when children interact more outside of the home. To have a diagnosis of SM, a person must exhibit signs of mutism for 1 month or more. It is important for the success of treatment and recovery that children are diagnosed early in life. If SM is left untreated, mutism and the corresponding anxiety and maladaptive coping skills may follow them into adulthood. According to the Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition, to receive a diagnosis of SM, a person must exhibit the 

• Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations. 
• The disturbance interferes with educational or occupational achievement or with social communication.
• The duration of the disturbance is at least one month (not limited to the first month of school).
• The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. 
• The disturbance is not better explained by a communication disorder (e.g., stuttering) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

There are different diagnostic tools, tests, and assessments that a mental health professional may use to determine a selective mutism diagnosis. It is important to have your child evaluated by a mental health professional who understands selective mutism, as it is often misunderstood or misdiagnosed. It is important to take a whole child approach when evaluating, diagnosing, and treating SM. Assessments and interviews may be given to a parent, teacher, and child to get a broader understanding of what is going on. Parents as well as teachers should be included in a treatment plan. Additionally, it may be helpful to have your child evaluated by a speech or language specialist or pediatrician to rule out any other conditions. 

Some key questions to ask a medical or mental health professional if you suspect your child has SM and are seeking treatment are:

• What are your areas of expertise?
• Have you ever treated a child with selective mutism? 
• What are your views on selective mutism regarding why it develops?
• What is your treatment approach to selective mutism?
• What will be my role as a parent? What is the teacher’s role?
• What are your views on medication in treating selective mutism?
• How will you work with my child to help him or her progress communicatively (reducing anxiety and developing coping skills)?

Treatment

It is important in the treatment of SM to take a whole child approach, which requires involvement from caregivers, teachers, mental health professionals, and sometimes speech language pathologists. Research recommends a multi-disciplinary approach including psychotherapy, play-therapy, and speech therapy. Studies have indicated positive effects of combining behavioral techniques and medication.

Typically, a treatment plan will be made, which includes highly individualized strategies and interventions. It is most helpful when parents, teachers and other school personnel, and the child are included in and made aware of the treatment plan and can incorporate some of the strategies and interventions at home and at school. Some specific forms of treatment include:

Psychotherapy

• Behavioral therapy. This type of therapy uses behavior modification and desensitization techniques, as well as positive reinforcement to help a person reduce anxiety, develop healthy coping skills, and eventually develop social comfort and confidence. 
• Play therapy. This is a client-centered approach to therapy that creates a non-threatening environment for children to express thoughts, feelings, and behavior through play, ultimately taking the pressure off verbalization, allowing the child to feel safe, calm and relaxed.
• Cognitive-behavioral therapy. This type of therapy would help a person with SM identify the fears and worries that lead to social inhibition and reframe or replace the maladaptive thought or belief with something more positive or realistic. It also uses behavior modification techniques to help reduce anxiety, as well as working to develop healthy coping skills.

Other forms of treatment

• Parental involvement and acceptance. For best results, parents need to be involved for the entire process of treatment. Often, parents will have to make changes in parenting styles and expectations to accommodate the needs of their child. It is imperative to progress that a parent does not force or pressure their child to speak, as this will induce anxiety and be counterproductive to treatment. 
• School involvement. Parents will need to advocate for their children in school settings with educators and other school personnel. Often, teachers and other school personnel will need to be educated on selective mutism. Getting the school involved and on board with the treatment plan will only help raise the success rate of treatment.
• Bolstering self-esteem. Parents can work to emphasize their child’s positive attributes and find ways to allow their child to share about them.
• Frequent socialization. It is an important part of therapy, that as people with SM get more comfortable with people or more comfortable in certain social settings, to increase the frequency at which they socialize. It is important not to force your child to speak or socialize, but pay attention to their progress and comfort level, and gradually increase the socialization accordingly.

Medication

Research has shown that a combination of behavioral techniques and medication is the most effective form of treatment for SM. Medication is usually supplemented when behavior techniques alone are not enough to make significant progress in reducing anxiety and social inhibitions. Medications that seem to be most effective in treating SM are SSRI’s (they block or inhibit the reuptake of serotonin) and other medications that effect norepinephrine, GABA, and dopamine.