Understanding Selective Mutism

Selective mutism (SM) is an anxiety disorder in which a child might be very chatty when they feel relaxed but completely unable to speak in a different social setting, like family gatherings or school.

The condition stems from severe fear in certain social circumstances. Selective mutism is often mistaken for shyness in infants and toddlers but is more serious than a timid personality. ^[1][2]

The disorder typically begins in childhood and can have long-lasting effects as life goes on. However, identifying selective mutism and treating it early significantly improves the prognosis. This guide will teach you about selective mutism and the various treatment options. ^[1][2]

What is Selective Mutism?

Selective mutism is a mental health condition causing children (and less commonly teenagers and adults) to fear speaking in select settings. SM is classified as an anxiety disorder, which sometimes overlaps with other anxiety disorders. Over 90 percent of children suffering from selective mutism are also diagnosed with social anxiety disorder or social phobia. ^[1][2]

SM is uncommon, affecting fewer than 1 out of every 140 people. It is more prevalent in females, and symptoms usually start to appear between the ages of 3 and 4, although selective mutism is typically only diagnosed after a child starts attending school. In this social setting, the anxiety of speech is easier to notice. ^[1][3][5]

Children with selective mutism can spend an entire year or longer in class without saying a single word to their teachers or classmates. This silence is often mistaken for a timid personality, as the majority of children with SM are very well-mannered. Speech is not the only challenge for children with SM, and many with the disorder also struggle to communicate non-verbally. ^[2][3]

Those with less severe SM may manage a whisper or feel comfortable speaking to others in a social setting. On the other hand, when the anxiety disorder is severe, it can cause children to freeze physically in social situations in addition to being unable to speak. ^[2]

Selective Mutism Symptoms

The term selective mutism describes how the inability to speak occurs only in select situations. People with SM are often very chatty when feeling relaxed, and it is only when anxiety sets in that the disorder rears its head. Symptoms vary according to the severity of each case, but you can generally expect a combination of: ^[1]

Situational Muteness

This can include talking freely in settings where the child feels comfortable, like home, but not being able to speak in other settings, like at school or with strangers. Additionally, situational muteness can also take the form of being unable to speak to familiar people (like their caretakers or peers) around other less familiar people. ^[3]

Anxiety in Social Situations

The most common symptom of selective mutism is an inability to speak due to overwhelming fear. SM can cause the sufferer to avoid social situations or act out with temper tantrums to avoid talking. In severe cases, those affected will not be able to speak at all, while those with lesser degrees of SM will have slow, short responses or manage to mumble or whisper. ^[1]

Physical Manifestations

Severe SM can cause manifestations such as physically freezing or having a stiff posture in social settings which may be confused for a movement disorder. Other physical symptoms include a shocked or blank expression typical of stage fright. When less severe, a person may use only non-verbal communication, such as gestures, nodding, writing, facial expressions, pointing, or sounds. ^[1]

Causes of Selective Mutism

It is not yet known precisely what causes selective mutism. However, researchers are looking into the potential causes, including genetic factors, environmental influences, and comorbid disorders. ^[1][2][4]

Genetic Factors

Selective mutism is a mental health condition, and so, like other mental disorders, it appears to have a strong genetic link. A family history of anxiety-related disorders is thought to play a role in selective mutism. It has been found that people with SM are likely to have an immediate family member with an anxiety disorder. ^[1][2]

Environmental Influences

Environmental factors are also believed to influence the onset of selective mutism. One theory is that moving to a place where people speak a different language or having a bilingual family might lead to SM. Other theories suggest bullying, abuse, traumatic events, or poor family relationships might be a contributing factor. ^[1][2][4]

Cooccurring Conditions

While other mental health conditions are not proven to be the cause of SM, they have been found more likely to manifest in people with the disorder. This is especially true of social anxiety disorder, with between 75 and 100 percent of SM cases also including this co-occurring condition. Other psychiatric disorders that are thought to be linked to selective mutism include: ^[1]

• Anxiety disorders
• Phobias
• Autism spectrum disorder
• Post-traumatic stress disorder

How Does Selective Mutism Affect Daily Life?

Selective mutism can be challenging for loved ones to watch, as it negatively impacts daily life. The effect SM has on social interactions and academic performance often leads to poor self-esteem. When a child struggles with crippling fear, it can be hard for them to find the motivation for the basic requirements of daily life. ^[3]

Social Interactions

SM causes massive anxiety that can hold children back from taking part in fun activities with their peers. Engaging in play after a child has reached speaking age typically involves verbal communication, which children with selective mutism tend to avoid. As a result, it can be difficult for a child with SM to make friends. ^[1][3]

Academic Performance

Selective mutism can prevent children from asking for help, even when they need it. As a result, the disorder can lead a child to fall behind their peers academically. It can also interfere with curriculum requirements such as answering questions, reading aloud, or speaking in front of the class.

Diagnosis of Selective Mutism

The sooner a child receives treatment for selective mutism, the faster they improve. Keep in mind that if the muteness persists for many years, the behavior can become automatic and, therefore, becomes more difficult to treat. Untreated SM can negatively impact social interactions, academic performance, and emotional stability as follows: ^[2]

• Reduced social interaction leading to feelings of loneliness
• Struggles with self-worth and a diminished sense of ability
• Intensification of anxious thoughts and behaviors over time
• Increased risk of co-occurring mental health conditions, such as depression and anxiety disorders
• School refusal, declining academic performance, and potential dropout
• Underachievement in both academic and professional environments
• Possible reliance on drugs or alcohol to self-medicate
• Emergence of thoughts of self-harm or suicide, with a risk of follow-through

A psychiatrist, psychologist, or other mental health professional usually diagnoses selective mutism using the American Psychiatric Association’s DSM-5 criteria. Speech therapists may also help rule out other conditions. ^[1]

Healthcare professionals will ask about your child’s behavior and any factors that could be causing the issue. They often use questionnaires, checklists, or similar tools to see if the criteria for SM are met, following the guidelines of the DSM-5 seen below: ^[1]

• Consistent inability to speak in specific social situations where speaking is expected (e.g., at school or work). They can, however, speak comfortably in other contexts
• This inability to communicate affects social, educational, or occupational performance
• The condition persists for at least one month and is not restricted to transitional phases, such as the first month of school.
• The difficulty speaking is not due to a lack of understanding or familiarity with the language used
• The inability to speak is not better explained by communication disorders (that may include symptoms such as stuttering), autism spectrum disorder, schizophrenia spectrum, or other psychotic disorders

Treatment for Selective Mutism

Seeking treatment sooner rather than later is crucial, as untreated SM can cause other mental health conditions. Selective mutism treatment in the form of behavioral therapy, cognitive-behavioral therapy (CBT), speech therapy, or medication has been shown helpful. These therapies can help make the symptoms occur less often and feel less intense. ^[1][2][3][6]

Behavioral Therapy

According to the Child Mind Institute, behavioral therapy “is the gold standard for treating selective mutism.” The treatment uses desensitization techniques such as taking a child to school when there are not many people around and getting them to practice speaking in that environment. Results can be achieved in as little as a month. ^[2][3]

Cognitive Behavioral Therapy (CBT)

Therapists specializing in CBT can assist children with selective mutism to manage their anxiety and fear. By developing an awareness of their stress triggers, such as comments about them not speaking, children with SM can learn to shift their focus to their assets. This builds social confidence and reduces anxiety. ^[2]

Speech Therapy

The best way to help children with selective mutism is to combine strategies that lower their anxiety (like the therapies mentioned above) with activities that build their language skills. Speech therapy should start early and focus on describing things, explaining ideas, telling stories, and having conversations. ^[7]

Medication

Research shows that combining therapy and medication yields the best results for treating selective mutism. That said, psychiatrists typically prescribe selective serotonin reuptake inhibitors (SSRIs) to combat the anxiety disorder only if therapies aren’t making the expected progress. ^[2][3]

How to Support Someone with Selective Mutism

According to the Selective Mutism Association, if you have a family member, student, or loved one with selective mutism, there are several ways to help. Progress with SM takes time, but with encouragement and the right strategies, you can make a big difference in helping them find their voice. ^[1][2][5]

Prompt Nonverbal Communication

Encourage nonverbal participation in class or social settings where a child struggles to speak. Facilitate hands-on tasks like playing one-on-one with another child or pointing to answers on the board. Temporarily accept nonverbal responses to ease the child’s stress and gradually encourage verbal interaction.

Communicate Without Expectations

Avoid asking questions initially and make the child’s life easier by using one-sided comments or observations. For example, describe aloud in detail what the child is doing, leaving room for a response. This creates a sense of comfort that can help build the child’s confidence. Slowly transition to simple questions requiring short, specific answers.

Use Forced-Choice Questions

If the child is beginning to communicate more, even in a non-verbal way, you can encourage progress by asking questions with two options. For example, “Do you like blue or pink more?” opens the door to communication beyond yes or no but reduces the pressure of formulating sentences.

Give Them Praise and Encouragement

Avoid scolding, punishing, or using guilt to make a child with selective mutism speak. These children are susceptible to criticism and feel overwhelmed if they think they’re letting someone down. Stay calm, supportive, and encouraging instead. Remember to shower them with praise for effort and not just an outcome.

Key Takeaways

Selective mutism in children can be heartbreaking for a parent to experience. Still, there is hope for young ones suffering from the condition, particularly if they are treated soon after symptoms present.

With a combination of therapies and possibly medication, many, if not all symptoms of SM can improve significantly. There are also ways to support a child with selective mutism at home and in the classroom, helping them to gain confidence and find their voice.