Selective mutism

What is selective mutism?

Selective mutism is characterised by consistent selectivity in speaking, such that a child has adequate language ability in specific social situations, typically at home, but has a consistent failure to speak in other situations, typically being unable to speak at school despite speaking in other situations.

For a diagnosis of selective mutism, the disturbance should last for at least one month, not be limited to temporary mutism as part of separation anxiety, and should be of sufficiently severe to interfere with school progress or with social communication.

For a diagnosis of selective mutism to be made, there must also be no other explanation for the symptoms, such as any other mental health problem.

Temporary reluctance to speak at the time of first starting school is common. Selective mutism should only be diagnosed if symptoms persist beyond the first month of schooling.

Children who have come from abroad who may be unfamiliar with or uncomfortable in the official language of their new host country may, for a limited period of time, refuse to speak to strangers in their new environment. This usually resolves quickly with appropriate help and support, and is not the same as selective mutism.

Signs of selective mutism

Selective mutism is usually first diagnosed in childhood. It is estimated that less than 1 in 100 children have selective mutism.

Although the onset of selective mutism typically occurs during early childhood (before age 5), significant impairment of functioning may not occur until entry into school when children experience increased demands to speak publicly (eg, reading aloud) and engage socially.

The symptoms of selective mutism may include:

• Wanting to speak but being held back by anxiousness, fear, or embarrassment.

• Fidgeting, avoiding eye contact, lack of movement or lack of expression when in feared situations.

• Inability to speak in school and other specific social situations.

• Use of nonverbal communication to express needs, such as nodding head or pointing.

• Shyness, fear of people, and reluctance to speak between 2 and 4 years of age.

• Speaking easily in certain situations (eg, at home or with familiar people), but not others (eg, unable to speak at school or with unfamiliar people).

Other children and adults may often feel that the symptoms of selective mutism are deliberate and defiant. This is not the case and the symptoms are only a response to anxiety and fear.

Children with selective mutism experience significant anxiety in social situations and when able to express themselves indicate that they fear criticism, particularly of their speech. It is common for selective mutism to occur along with other mental health problems, such as social anxiety, separation anxiety, and specific phobias.

Selective mutism is associated with severe difficulties with school and social functioning that can present as being unable to complete expected schoolwork, not getting personal needs met, inability to socially interact with other children, or becoming the target of bullying.

Complications of selective mutism

• Selective mutism may worsen anxiety. A child with selective mutism may dread going to school, where their condition makes it hard for them to be accepted by other children.

• Selective mutism can lead to communication problems. An adult who has selective mutism may seem to be judgmental or passive aggressive if people around them don't understand their condition, making coping with the condition even more difficult.

• Someone with selective mutism may withdraw from school, work, or everyday activities and socially isolate themselves. This may lead to further loss of self-esteem and depression.

Causes of selective mutism

Like many mental health problems, it is unlikely that there is just one single cause.

It was once believed that selective mutism was the result of childhood abuse, trauma, or upheaval. However, research now suggests that selective mutism is related to extreme social anxiety and that genetic factors probably play a role. Selective mutism may be more likely if the parents have social anxiety.

Other potential causes include temperament and the environment. Children who are shy and feel inhibited or who have language difficulties may be more prone to developing selective mutism.

Selective mutism also often occurs together with other disorders including:

• Anxiety

• Autism spectrum disorder (ASD)

• Depression

• Developmental delays

• Speech and language problems

• Obsessive-compulsive disorder (OCD)

• Panic disorder

How is selective mutism diagnosed?

The diagnosis of selective mutism is made by a thorough assessment with a mental healthcare professional (such as a child psychologist or child psychiatrist), to explore the nature and severity of symptoms, the difficulties caused by the symptoms, and whether there are any other associated mental health conditions.

Diagnosing selective mutism in children

The main feature required for a diagnosis of selective mutism is a consistent failure to speak in specific social situations (eg, at school), despite speaking in other situations.

In addition to this symptom, children must also display the following:

• Symptoms of selective mutism must have been present for at least one month, and not simply the first month of school.

• The child must understand spoken language and have the ability to speak normally in some situations (usually at home with familiar people).

• The lack of speech must interfere with your child's school or social functioning.

Children who stop talking temporarily after immigrating to a foreign country or experiencing a traumatic event would not be diagnosed with selective mutism.

Diagnosing selective mutism in adults

In some cases, selective mutism persists from childhood to the teenage years, and even into adulthood. In order to be diagnosed with selective mutism as an adult, the following features are usually present:

• Symptoms of selective mutism must have been present for at least one month.

• Symptoms must interfere with functioning at work or in social settings.

Adults with selective mutism often display behaviours similar to those related to social anxiety disorder, such as fearing public spaces or speaking to unfamiliar people.

Selective mutism (and social anxiety) may cause a person to avoiding social situations or withdraw completely, leading to social isolation.

Treatment for selective mutism

The treatment for selective mutism is most effective when the diagnosis is made and treatment started at an early age rather than after a long duration of the disturbance. There is a risk that the child will become used to not speaking, and so being silent will become a way of life and more difficult to change.

Treatment for selective mutism may include self-help, along with therapy, medication, or a combination of the two.

Coping with selective mutism

It is very important not to make your child feel under pressure. Parental acceptance and family involvement are important in treatment, but avoid trying to force your child to speak. Putting pressure on your child will only increase their anxiety levels and make speaking even more difficult. Focus on showing your child support and acceptance.

Reward progress but avoid punishment. Where rewarding positive steps toward speaking is a good thing, punishing silence is not. If your child is afraid to speak, they will not overcome this fear through pressure or punishment.

Talk to the teachers and others who are involved with your child. Teachers can sometimes become frustrated or angry with children who don't speak. It is therefore very important that your child's teacher knows that the behaviour is not intentional and is involved with helping to treat your child's selective mutism.

Therapy

A common and often effective treatment for selective mutism is the use of behaviour therapy. These programs often base the treatment around cognitive behavioural therapy (CBT).

Techniques used in cognitive behavioural therapy for individuals with selective mutism may include:

• Desensitisation: gradually helping to overcome sensitivity to anxiety triggers by gradually increasing experience of these trigger situations.

• Exposure therapy: a psychologist creates a safe space where an individual is exposed to the object of their fear (eg, speaking in front of or directly to a stranger).

• Reinforcement: a therapist may teach how to use positive coping skills to alleviate anxiety when in situations that trigger selective mutism.

• Shaping: the desired behaviour (eg, the child attempts to speak to a teacher or another child) is rewarded with positive reinforcement (but undesired behaviour is not punished).

Medication

Medication to reduce anxiety may be considered, but only in severe or very persistent cases, or when other methods have not been very helpful. The choice of whether to use medication should be made by a specialist (child psychiatrist).

Outlook for selective mutism

Selective mutism can have a number of consequences, particularly if it goes untreated. It may lead to poor progress at school, low self-esteem, social isolation, and social anxiety.

In general, there is a good outcome for most children with selective mutism. Unless there is another problem contributing to the condition, children generally function well in other areas and do not need to be placed in special education classes.

The duration of selective mutism may be as long as 8 years, but may be much shorter. The symptoms then begin to reduce or go away completely. However, even after the symptoms resolve, difficulties related to social communication and anxiety often continue. The outlook is worse when there is a family history of selective mutism.