Selective Mutism

Overview

Selective mutism (SM) is an anxiety-based disorder primarily among young children, but also affecting older children and adolescents, who are typically fearful and unable to speak or speak very little. The disorder is primarily characterized as being freely verbal and comfortable at home (with family or close friends), but being mostly nonverbal in social settings (school, birthday parties, to familiar adults or close friends) or in the community.

This fear of speaking causes significant impairment in daily functioning, academic performance and/or social relationships. Children are unable to ask to have their needs met nor communicate when they are in pain or to fully participate in school or social activities.

Anyone can develop SM, but it is typically first diagnosed in early childhood, childhood or adolescence. It affects:

Roughly 7 per 1,000 children; or 1 out of 140 elementary-aged children
Average age of onset is age 5, though parents or teachers often notice signs as early as ages 3-4
Slightly more prevalent among girls than boys

While SM itself is not genetic, some evidence suggests a genetic link between children with SM and anxious parents or family members. Those with the disorder may also be shy and have social anxiety. By avoiding speaking situations, this avoidant behavior gets reinforced over time.

SM can persist for months or years. If left untreated, it is more likely to persist and can have negative consequences on a child’s life, including:

- Social phobia
- Generalized anxiety disorder (GAD)
- Depression
- Poor academic performance
- Risk of substance abuse

With appropriate and early treatment, SM can be overcome. Evidence shows children with SM have a “decreased threshold of excitability in the brain’s amygdala,” which receives and processes potential threats (see Selective Mutism Association or SMA). In addition:

Those with SM have changes in anxiety level and level of functioning from one setting to another.

An inability to speak effectively in some but not other settings does not indicate a deliberate refusal to speak.
It would be inappropriate to punish or withhold privileges for not speaking.

The difference between SM and simple shyness:

Typically, most children will grow out of shyness, a normal personality trait that does not tend to interfere with daily functioning.
In contrast, SM is a diagnosable mental health disorder, requiring treatment to overcome symptoms and function at an adaptable level.

Signs and Symptoms

Children with SM are physically and cognitively able to speak and understand language in low-anxiety situations. Often described as “chatterboxes” at home, in other settings they can be completely mute and unable to speak.

Less severely affected children may be able to speak, whisper or rely on nonverbal gestures to communicate with a select few. Some children are highly anxious, while others appear relaxed when prompted to speak or engage.

To be diagnosed with SM, a child or teen:

- - Fails to speak when expected, interfering with daily functioning at school or work
  - Does not adapt well to social situations, nor communicate effectively with others
  - Consistently fails to speak over a period lasting more than one month
  - Has no other disorders or conditions to better explain the disorder

SM is not due to:

- - Lack of fluency or discomfort with primary language or a different communication disorder
  - Being bilingual, as compared to monolingual speakers
  - Willful or noncompliant behavior
  - Simple shyness, which children outgrow if left untreated

Assessment and Diagnosis

Due to poor understanding of the disorder, most SM cases are not treated. As a result, children and adolescents can go years without speaking and, because their mutism is ingrained, it becomes harder to overcome.

For a child who appears to have SM, parents or other significant persons (such as a medical doctor or schoolteacher) should seek diagnosis and treatment.

- When SM therapy begins early, the response is quicker and greater.
- According to research, those speaking before age 8 in previously mute settings typically become verbal in other settings within one year.
- Older children or teens get more accustomed to nonverbal behavior, making change more difficult.

A comprehensive neuropsychological assessment and diagnosis by experienced professionals are key to assembling the team and forming an early intervention plan. This determines not only whether a child or teen is suffering from SM, but also whether there are other disorders that need addressing, such as

- Generalized anxiety disorder (GAD)
- Speaking and language disorders
- Autism spectrum disorder (ASD)
- Psychotic disorders (schizophrenia)

Treatment for SM

CFI’s Brave Voices Program

The goal of CFI’s Brave Voices Program is to help children and adolescents develop the resources and skills they need to “bravely” get their voices back. This intensive SM intervention adapts a number of cognitive and behavioral treatments in a developmentally age-appropriate manner. The program aims to help children, ages 2-17, deal with underlying anxiety and other co-occurring conditions (comorbidities) to eventually speak outside the home, in school or at social settings and larger family or community gatherings.

A CFI therapist with expertise in SM designs a treatment plan based on the child’s developmental age, the severity and complexity of the disorder and the existence of comorbidities. Treatment starts by gently guiding the child within a safe environment to participate. A wide range of treatments and services can be paired together, including:

Cognitive restructuring: Helps individuals change the way they think, by replacing stress-producing thoughts (cognitive distortions) with more balanced, de-stressing thoughts

Mindfulness and relaxation

Cognitive behavioral therapy (CBT) groups for social anxiety and social skills: Learning skills to manage stress or deal with persistent symptoms

Parent-child interaction therapy for selective mutism (PCIT-SM): An approach adapting the traditional, two-stage PCIT model to improve verbal and non-verbal participation and to reduce parental over-accommodation

Exposure and response prevention (ERP) or exposure therapy: A therapeutic process that gradually exposes children in a safe setting to situations designed to provoke and desensitize fears.

School-based interventions, in coordination with the child’s school

Psychiatry / Medication management

Educational Advocacy & School-Based Interventions

Many children with SM experience the most anxiety and difficulty at school. The therapist-led treatment team can plan and implement school and community interventions, along with in-session therapy.

Most children with SM do not need to be placed in special education classrooms, nor in educational environments with limited opportunities for social interaction. They can perform academic work with minimal or no classroom accommodations.

However, the treatment team can aid in developing an education plan, if needed:

- Behavioral intervention plans (BIP)
- 504 Plans
- Individualized education program (IEP)

Parents and therapists should become familiar with education laws to exercise their rights to support a child or adolescent with SM.

Treatment at Home

Parents should not force a child or teen with SM to speak, but rather help overall communications to be more successful.

This allows the child or teen to be understood and not be taken as stubborn, defiant or shy.

With parental support, goals and reinforcement, children and adolescents can slowly increase their speaking behavior in challenging situations.

Parents and families can build understanding and support for children with SM by learning more about the disorder and by helping identify and share resources and tools with anyone who interacts with their child.

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REFERENCES

Selective Mutism Association

Association for Behavioral and Cognitive Therapies

Growing Minds