Selective Mutism

Selective Mutism is a mental health condition that most commonly affects children, in which the child can only speak in specific situations or to specific people. However, they are unable to communicate in any social or public setting.

What Is Selective Mutism?

Selective mutism (SM) or situational mutism, is a complex anxiety disorder, mostly observed in children. A child suffering from this condition is unable to speak or communicate in certain social settings, such as with classmates or distant relatives. However, they may speak comfortably in secure and relaxed environments, around close friends and family. The National Institute of Biotechnology Information characterizes Selective Mutism as “the persistent failure to speak in select social settings despite possessing the ability to speak and speak comfortably in more familiar settings.”

The use of the term “selective” was started in 1994 prior to which this disorder was known as “elective mutism”. Even though the name changed from elective to selective, a common misconception remains that the child might be defiant or stubborn. The new DSM-IV-TR diagnosis refers to the disease as “selective mutism,” with “selected” stressing “the selective conditions in which the illness occurs and is defined by failure to speak rather than intentional withholding of speech as the prior term implied.”

The condition usually develops during childhood and may persist in adulthood, when left untreated. The onset of this disorder typically occurs between the ages of three and six and is usually diagnosed between the ages of five and eight after the child enters school.

According to the Anxiety and Depression Association of America (ADAA), SM can prevent children and adolescents from taking part in school, establishing relationships and friendships and even asking for help when necessary. It can also have other serious negative consequences throughout the child’s span of life and can have an impact on their academic and social life, if left untreated.

Prevalence And Comorbidity

About 1 in 140 young children are affected by SM with more girls than boys suffering from this condition. It can also be observed in children who need to learn a second language, especially after moving to a new country. However, it can be difficult to accurately ascertain the prevalence of selective mutism as the condition is relatively rare and due to differences in diagnostic procedures.

Other co-existing mental health issues can be exacerbated by SM. According to research, 20 to 30 percent of children with Selective Mutism have speech and language difficulties, such as repeated speaking, trouble expressing language, and language delays, all of which add stress to circumstances when the kid is required to talk.

Approximately 90% of children with this illness also have social anxiety or phobia. Moreover, research [mfn] Steffenburg, H., Steffenburg, S., Gillberg, C., & Billstedt, E. (2018). Children with autism spectrum disorders and selective mutism. Neuropsychiatric disease and treatment, 14, 1163–1169. https://doi.org/10.2147/NDT.S154966 [/mfn] indicates that “autism spectrum disorder (ASD) might be a comorbid condition in selective mutism (SM),” as well. In most cases, children develop anxiety to speak in social settings which can ultimately develop into selective mutism.

Selective mutism can also be associated with other mental conditions:

• Anxiety
• Depression
• Delays in development
• Language problems
• Obsessive-Compulsive Disorder
• Panic Disorder

Read More About Panic Disorder Here

According to a 2010 scientific review,[mfn] Wong P. (2010). Selective mutism: a review of etiology, comorbidities, and treatment. Psychiatry (Edgmont (Pa. : Township), 7(3), 23–31. [/mfn] “the disorder can occur over a few months and persist over a few years, although the majority of selectively mute children tend to outgrow the disorder spontaneously for unknown reasons”. However, there may be several comorbid conditions associated with this disorder, such as:

• Enuresis
• Encopresis
• Obsessive-compulsive disorder
• Depression
• Premorbid Speech
• Language Abnormalities
• Developmental delays
• Asperger’s Disorder

How SM Affects Children

The National Health Service (NHS) of the United Kingdom states that “a child or adult with selective mutism does not refuse or choose not to speak at certain times; they are literally unable to speak.” When compelled to speak, the child may become frozen and panicked, resulting in a severe case of stage fright. This makes it nearly impossible for them to communicate.

Eventually, they learn to predict situations that may trigger them, making them avoid certain situations altogether. To be diagnosed with this condition, the sufferer must experience substantial impairment in regular functioning in different aspects of life, like educational, social or occupational settings. However, affected children may be able to develop age-appropriate skills successfully.

Children and adults who suffer from this disorder are entirely capable of speech and understanding the language but are physically unable to speak in certain situations. Persistent selective mutism is generally presented in the condition of anxiety disorders[mfn] E. STEVEN DUMMIT, RACHEL G. KLEIN, NANCY K. TANCER, BARBARA ASCHE, JACQUELINE MARTIN, JANET A. FAIRBANKS, Systematic Assessment of 50 Children With Selective Mutism, Journal of the American Academy of Child & Adolescent Psychiatry, Volume 36, Issue 5, 1997, Pages 653-660, ISSN 0890-8567, https://doi.org/10.1097/00004583-199705000-00016. [/mfn].

Moreover, the DSM-5 classifies this disorder as “an anxiety disorder”. The DSM-5 doesn’t link this disorder as a consequence of trauma, neglect, or abuse. However, research [mfn] BRUCE BLACK, THOMAS W. UHDE, Psychiatric Characteristics of Children with Selective Mutism: A Pilot Study, Journal of the American Academy of Child & Adolescent Psychiatry, Volume 34, Issue 7, 1995, Pages 847-856, ISSN 0890-8567, https://doi.org/10.1097/00004583-199507000-00007. [/mfn] indicates that selective mutism may simply be a social anxiety symptom, instead of being a distinct diagnostic syndrome.

The associated features with this disorder are excessive shyness, fear, social embarrassment or withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling behavior. Children suffering from this disorder are almost always given an additional diagnosis of anxiety disorder like a social phobia.

Signs And Symptoms Of Selective Mutism

One of the most common signs of a child suffering from this disorder is when the child is usually talkative at home with his family but changes his speaking tone or words or shows gestures when he or she is in school.

Selective Mutism can be characterized by the following:

• Repeated failure to speak in social situations despite speaking in other situations.
• The distance interferes with daily life in cases of educational or occupational achievement.
• The duration lasts at least a month (not limited to the first month of school).
• The failure to speak in public is not due to a lack of knowledge of the language.
• The disturbance is not better accounted for by a communication disorder (e.g. childhood-onset fluency disorder) and does not occur exclusively in people with autism spectrum disorders or psychotic disorders like schizophrenia.

Here are some of the prominent physical and psychological symptoms of SM:

1. Physical symptoms:

• Nausea & vomiting
• Stomach aches
• Shortness of breath
• Chest pain
• Headaches
• Joint pains
• Diarrhea
• Bowel and bladder issues

2. Psychological symptoms

• Shyness, and social anxiety
• Fear of social embarrassment or social isolation
• Difficulty maintaining eye contact
• Blank expression and reluctance to smile or incessant smiling
• Difficulty in expressing feelings even to their family members
• The tendency to worry excessively than most people of that age
• Sensitivity to noise and crowds
• Feeling nervous or scared
• Avoid social situations or public speaking
• Sensitive to crowds
• Dislikes strong lights or loud sounds
• Heightened senses
• Self-regulation issues like disobedience, inflexible or stubbornness
• Delays in motor, communication & social development

Signs That A Child Doesn’t Have Selective Mutism

Here are a few symptoms that your child may not be suffering from selective mutism and may be affected by some other conditions:

• They have never talked in any situation
• The disturbance only occurred abruptly in every environment after a traumatic event
• Other speech difficulties like stammering are present
• When they are learning a new language, they may go through a silent period until it becomes more confident

Causes For Selective Mutism

Due to limited research and under-diagnosis, the exact causes for developing SM are not yet known and it may be different for every patient. Most sufferers are diagnosed only in their late childhood as mutism starts to affect their education and public speaking skills.

However, as they may function and speak normally at home, it can be difficult for the parents to become aware of the disorder in their children. Selective mutism may be mistaken for ordinary stage fright or shyness by other caretakers, pediatricians, and teachers.

Here are some of the probable factors that may lead to the development of SM:

1. Genetics

Children who are suffering from this disorder often have a genetic predisposition to anxiety disorders. It is highly likely that most of the affected children have an inherited tendency to feel anxious. As a result, these children may exhibit moodiness, separation anxiety, frequent tantrums, sleep issues, crying, and shyness. These are all signs of severe anxiety that have been inherited from one or more family members.

Research [mfn] DENISE A. CHAVIRA, ELISA SHIPON-BLUM, CARLA HITCHCOCK, SHARON COHAN, MURRAY B. STEIN, Selective Mutism and Social Anxiety Disorder: All in the Family?, Journal of the American Academy of Child & Adolescent Psychiatry, Volume 46, Issue 11, 2007, Pages 1464-1472, ISSN 0890-8567, https://doi.org/10.1097/chi.0b013e318149366a. [/mfn] shows that parents of children with SM may have a “history of lifetime psychiatric disorders.” It has been observed that around 37% of parents with SM children tend to have generalized social phobia, while 17.5% of parents have avoidant personality disorder as compared to other parents. Additionally, on the NEO Personality Inventory, these parents have poor openness and high neuroticism. “These findings complement earlier uncontrolled findings of a familial connection between generalized social phobia and SM,” the researchers wrote in their conclusion.

2. Temperament

Most children suffering from SM tend to have intense inhibited temperaments (negative affectivity, behavioral inhibition). Children with ‘shy’ temperaments are believed to be highly prone to anxiety. In fact, the majority of the unique behavioral features of children with Selective Mutism are believed to be caused by their inhibited temperaments, which have reduced their “threshold of excitability” in the area of the brain known as the amygdala.

Studies reveal that the neurological basis in the brain is called the amygdala which receives danger signals from the environment. It also triggers the flight or fight response in the human brain. For SM children, social scenarios, like school, family gatherings, birthday parties, or daily errands, can be fearful.

3. Sensory Integration Dysfunction

Sensory Integration Dysfunction (DSI) [mfn] Guardado KE, Sergent SR. Sensory Integration. [Updated 2021 Aug 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559155/ [/mfn] may be another reason why some children develop Selective Mutism. These children often have difficulty processing certain sensory information. Hence, they may be sensitive to taste, smells, touch, strong lights and loud sounds. Moreover, SM children may have trouble regulating sensory input [mfn] Van Hulle, C. A., Schmidt, N. L., & Goldsmith, H. H. (2012). Is sensory over-responsivity distinguishable from childhood behavior problems? A phenotypic and genetic analysis. Journal of child psychology and psychiatry, and allied disciplines, 53(1), 64–72. https://doi.org/10.1111/j.1469-7610.2011.02432.x [/mfn] and this may influence their mental and emotional responses.

Integration of the senses Because of their dysfunction, children may misunderstand and misinterpret social and environmental cues. This can cause them to become worried, agitated, and rigid, causing them to avoid or withdraw from particular situations. The child may have tantrums or become walled off as a result of the high levels of anxiousness.

4. Environmental factors

Apart from the factors mentioned above, certain social factors, like abuse, neglect, trauma, social inhibition and overprotective parents, may also lead to the development of this disorder. However, research has not found any evidence that abuse [mfn] MacGregor, R., Pullar, A., & Cundall, D. (1994). Silent at school–elective mutism and abuse. Archives of disease in childhood, 70(6), 540–541. https://doi.org/10.1136/adc.70.6.540 [/mfn], neglect or trauma may specifically lead to the development of Selective Mutism

Moreover, a small number of children with SM do not appear to be shy. In fact, these children love getting attention and actively seek it. However, studies have shown these children may develop autism for some other reasons which have not been identified yet. This is why several experts consider selective mutism as a symptom of some other underlying condition.

Diagnosis Of Selective Mutism

According to ADAA, the general age for diagnosis of SM is about 3-4 years. Diagnosis can be made when the child starts school or daycare or when the mutism behavior starts affecting their learning, development and daily functioning. However, some affected children are diagnosed may be properly diagnosed later as their symptoms may be misidentified as extreme shyness by paediatricians.

The child with SM must exhibit substantial impairment in their daily functioning, especially in education. They should also avoid social participation in multiple settings, like in school or family gatherings due to high levels of anxiety and fear of speaking.

If left untreated, selective mutism can lead to social anxiety disorder, low self-esteem, and social isolation, and it can even last into adulthood. This is why early and effective diagnosis and treatment are critical for complete and long-term recovery. “It’s critical that families and schools recognise selective mutism early on so that they can collaborate to reduce a child’s anxiety,” says NHS UK.

Treatment For Selective Mutism

The treatment is most receptive when it is caught early. If your child has been silent at school for more than two months or longer, then it is important to consult a doctor. If this disorder is not caught early there will be a risk of your child becoming used to not speaking and as a result, being silent will become their way of life.

According to the American Speech-Language-Hearing Association, “SLPs (speech-language pathologists) are in an excellent position to coordinate intervention for children who have selective mutism because of their knowledge and skills in effective communication treatments”. The effectiveness of treatment will depend on –

• How long the person is suffering from selective mutism
• Whether there are any additional communication or learning difficulties
• The cooperation of everyone related to the child

Treatment for this disorder includes a combination of psychotherapy and medication.

1. Psychotherapy

A commonly used method to treat patients with selective mutism is the use of psychotherapy. These programs involve desensitization and positive reinforcement that is used both at home and school under the supervision of a doctor. There are several ways to treat this disorder. Some of them are mentioned below:

A. Exposure Based Practice

This therapy involves the child speaking gradually but in increasingly difficult or anxiety-provoking situations. This helps the child to face their anxiety and practice speaking in public. This practice aims to replace anxious feelings with more relaxed emotions and increase the child’s feelings of independence by gradually improving their ability to speak in public.

B. Systematic Desensitization

This program involves the usage of using relaxation techniques along with gradual exposure to anxiety-provoking situations.

C. Stimulus Fading

This involves gradually increasing exposure to a fear-based stimulus (e.g gradually increasing the number of people present in the room while the child is speaking). The process involves rewarding the child when he or she is speaking with someone to whom he or she typically doesn’t speak.

D. Positive Reinforcement

The aim of this therapy is to reward the child when it is able to speak in public. This includes providing positive reinforcement contingent upon verbalization and reinforcing attempts and approximations to communicate until the child learns how to speak in public.

E. Cognitive Behavioral Therapy (CBT)

CBT allows the child to be aware of their thoughts and helps them understand how it influences their behavior. It is usually effective in older children particularly those experiencing social anxiety disorder and adults who have grown up with selective mutism.

However, younger children can also benefit from CBT that is specifically designed for their well-being. For example, talking about their anxiety and understanding how it affects their body language and behavior and learning how to manage and cope with those anxieties.

Read More About Cognitive-behavioral Therapy Here.

2. SLP Treatment Options And Technique

There are a number of SLP treatment options that can help sufferers affected by selective mutism. Some of them include:

A. Augmentative And Alternative Communication

This involves the replacement of natural speech with aided symbols (e.g. pictures, line drawings, tangible objects, and writing). Some children who have been treated with Augmentative and Alternative Communication may temporarily adopt to facilitate classroom communication during the initial stages of intervention. This method is not a long-term solution and it should be carefully monitored in order to replace visual interaction with verbal communication.

B. Augmented Self Modeling

In this session, the child watches a video or listens to audio in one segment where the child is in a comfortable setting and then is gradually moved to a more uncomfortable environment. This allows the child to have a virtual glimpse of being successful in his goal of speaking in situations that may feel uncomfortable to them.

This may also involve creating a video of the child and editing it to portray that they are speaking in an unfavorable or undesirable setting, like the classroom. With everyone present, the child can watch themselves speaking in this social setting and thus feels more positive and confident about speaking in public more frequently.

C. DIR Floortime

DIR (Development, Individual Differences, Relationship-based) Floortime is a developmental and interdisciplinary framework based on functional emotional developmental capacities (FEDCs). It uses a combination of self-regulation, attention, engagement, intentional communication, and problem-solving communication. It incorporates sensorimotor, play-based activities, and instruction regarding anti-anxiety strategies from a social worker or other behavioral health professional. The child works on a gradual process that starts from working on a non-responsive gesture to making sounds and then using verbal communication.

D. Ritual Sound Approach

Ritual Sound Approach is a part of Social Communicative Anxiety Treatment (S-CAT). It is a cognitive and behaviorally based treatment, that teaches sound production from a mechanical perspective. The sound is then given shape to reinforce oral movements which gradually progress into phonemes, syllables, and words.

3. Medicine

Medicine can only be used if the child is older or has reached the appropriate age to consume antidepressants or anxiety-related drugs. Health professionals often recommend using a combination of medicines as well as behavioral therapies to older children in order to treat selective mutism. Serotonin reuptake inhibitors (SSRIs) such as Prozac, Paxil, Celexa have proven to be very effective in treating anxiety disorders. The duration of treatment with medication is between 9 to 12 months.

Advice For Parents With Children Suffering From Selective Mutism

It is always difficult for a parent to see their child suffering from any disease or any disorder. But when your child is suffering from a mental health condition, you need to be supportive and care for your child as they need you the most. Here is some advice for parents with children suffering from this disorder:

• Don’t pressurize or bribe your child to speak in public if he or she doesn’t want to.
• Tell your child that you understand that they are scared to speak and have difficulty speaking sometimes. Tell them that they can take small steps when they feel ready
• Refrain from praising your child publicly for speaking because they may feel embarrassed. Wait until you are alone and appreciate them for making progress.
• Reassure your child that non-verbal communication is okay and they can talk when they are confident.
• Don’t avoid parties or social gatherings since it’s important for your child to get the required environmental changes. This will help the child to get acquainted with new situations.
• It is important to give love, support, and patience to your child along with verbal reassurance.

Your Child Can Recover From Selective Mutism

Children suffering from this disorder should never be pushed to speak where they feel uncomfortable. The right way of treatment for this disorder is to gradually phase it out with therapy and medication.

It is important to have patience because the treatment procedure can be time-consuming. However with a little effort and the right psychotherapy treatment your child may recover and get more comfortable speaking in public.

Selective Mutism At A Glance

1. Selective Mutism is a mental health condition, where the child can normally speak in specific situations or to specific people.
2. The condition usually develops during childhood and may persist in adulthood, when left untreated.
3. The onset of this disorder typically occurs between the ages of three and six
4. Children and adults who suffer from this disorder are entirely capable of speech and understanding the language but are physically unable to speak in certain situations.
5. Children suffering from this disorder should never be pushed to speak where they feel uncomfortable.
6. The right way of treatment for this disorder is to gradually phase it out with therapy and medication.