What is Selective Mutism?
Selective mutism is a severe childhood anxiety disorder wherein a child consistently fails to speak in specific social situations (e.g., at school) despite speaking in others (e.g., at home with parents). The child may speak normally at home but does not speak in other social situations where they may not feel secure, relaxed and comfortable, say with relatives they do not get to meet often or classmates at school. The mutism must impact social or educational functioning for greater than a month in order to meet DSM-5’s diagnostic criteria. These children often have a comorbid anxiety disorder, usually social anxiety. Some professionals consider that selective mutism is a developmental variant of social anxiety.
Selective mutism is not out of choice or refusal to speak in certain situations but literally, they are quite simply unable to speak. The inability to talk cannot be better accounted for by a communication disorder or difficulties in understanding and using spoken language. Lack of speech occurs in social interactions with children or adults. It typically starts in childhood and persists into adulthood if it is not treated.
Selective mutism is a relatively rare disorder with an estimated prevalence of approximately 0.75 to 0.80 percent. The disorder is more likely to manifest in young children than in adolescents and adults, with an onset between the ages of 3 and 5 years. It’s more common in girls and children who are learning a second language, such as new immigrants.
Treatment approaches aim at lowering the anxiety that a child has for speaking in certain situations and increase the contexts in which the child may speak comfortably. Psychotherapy is the first choice of treatment intervention.
Symptoms of Selective Mutism
The child has no difficulty speaking in the home environment. The child often is “overly” talkative at home. The situation in which speaking is most commonly avoided is at school. Children with selective mutism also have difficulty with nonverbal but socially relevant tasks such as eating in front of others, having their picture taken, and communicating nonverbally. It lasts at least one month – not including the first month at school when shyness is common.
They exhibit some of the following signs and symptoms:
- Over 90% of children with selective mutism have social anxiety, displaying symptoms like discomfort with introductions to people, disliking criticism or teasing, not wanting to be the center of attention or drawing attention to themselves, tending to be afraid to make a mistake (perfectionist), and having eating issues (embarrassed to eat in front of others)
- Timid and cautious in unfamiliar or new situations
- Facial expression is frozen when they need to talk to someone who is outside their comfort zone
- Tend to avoid making eye contact
- Nervous, socially awkward, or uneasy
- Mood swings and crying spells
- Rude, sulky or disinterested
- Difficulty in completing tasks
- Clinging to caregivers and shadowing them
- Withdrawn or shy
- Tense and stiff
- May use gestures or nodding or even whisper to get by when the condition is not severe
- May have developmental delays
- May lag behind academically
- Could be assertive, stubborn, domineering, moody, and bossy at home
- Throw temper tantrums upon coming home from school, or become angry when parents ask questions
Causes of Selective Mutism
The exact cause of selective mutism is not known. Most of the children with selective mutism have a genetic predisposition to anxiety, that is, one or more family members may be suffering from one or other forms of anxiety disorder, selective mutism or extreme shyness.
Some of them have trouble processing specific sensory information and may be sensitive to lights, sounds, touch, smells, and taste. It may cause the child to misinterpret social and environmental cues, leading to anxiety, frustration, and inflexibility. This anxiety could cause a child to withdraw or avoid a situation, shut down, or act out, with tantrums and negative behaviors.
Receptive language difficulties could also be a contributory factor. Overprotective or overly controlling parenting is also a risk factor.
Diagnosis of Selective Mutism
DSM-5 lists the following diagnostic criteria for selective mutism (American Psychiatric Association, 2013):
- Consistent failure to speak in certain social situations (e.g., at school) despite speaking in other situations.
- This interferes with educational or occupational achievement or with social communication.
- Symptoms last at least 1 month (not counting the first month at school).
- It is not attributable to a lack of knowledge of, or comfort with, the spoken language.
- It is not better explained by a communication disorder and does not occur only during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.
Treatment of Selective Autism (Sadock, et al., 2017) (Gelder, et al., 2009)
Treatment involves psychotherapy (the first-line intervention strategy) or medication, or some combination of the two, in addition to speech and language therapy.
Psychotherapies that are effective in selective mutism include behavior therapy, play therapy, family therapy, psychodynamic therapy, and group therapy. They all contain a considerable emphasis on the use of behavioral interventions in selective mutism.
Standard behavioral techniques are used for treating selective mutism, such as contingency management (positive reinforcement for speech behavior – from whispering and pointing to verbalizing out loud), stimulus fading (gradually increasing the number of people and places in which speech is rewarded), systematic desensitization (child is gradually exposed to anxiety-producing situations in which speech is expected but are given emotional support and guidance with relaxation exercises to help them work through it), cognitive reframing (child is taught to identify anxious patterns and come up with positive alternative thoughts), and shaping (approximations of the desired behavior are reinforced).
Behavioral approaches use a rank-ordered list of situations in which the child has difficulty speaking. Then, the child is made to mouth speech, make sounds, and whisper in increasingly more difficult situations. With repeated successful attempts, the associated anxiety decreases due to autonomic habituation. Also, when the consequences of speaking that are being feared do not occur, the child’s exaggerated forebodings of harm reduce, which further reduces anxiety. Typically, the child’s behavior is also shaped through positive reinforcement (rewards) when he/she successfully engages in speaking-related behaviors. Audio and video techniques can also be used to self-model behavioral interventions.
Family therapy tries to identify the presence of difficulties in family relationships that could be contributing to the mutism and engages the whole family to create more positive relationships. Psychodynamic approaches try to identify the underlying reasons and help the child resolve the possible unconscious conflicts being experienced, through art therapy and play therapy.
Anti-Anxiety medication may be prescribed from the start, usually if the initial presentation is severe or they have not responded well to psychotherapy. The medication of choice for selective mutism is a selective serotonin reuptake inhibitor (SSRI) antidepressant, such as fluoxetine (Prozac), paroxetine (Paxil), citalopram (Celexa), fluvoxamine (Luvox), and sertraline (Zoloft). Other medications effective in selective mutism are venlafaxine (Effexor XR) and buspirone (BuSpar). Medications are needed to be given usually for 9-12 months.
Speech and Language Therapy
Although speech and language skills are generally good in children with selective mutism, speech and language difficulties such as articulation and expressive and receptive language difficulties can co-occur. Speech and language therapy is a valuable adjunct in such cases. It facilitates communication rather than resolve the underlying causes. The therapist works with the child to desensitize him/her to communicating with others. A gradation of stages is followed from easy to hard speech tasks within easy to hard speaking situations.
American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing.
Gelder, M., Andreasen, N., López-Ibor Jr., J. & Geddes, J. eds., 2009. New Oxford Textbook of Psychiatry. 2nd ed. Oxford: Oxford University Press.
Sadock, B. J., Sadock, V. A. & Ruiz, P., 2017. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 10th ed. Philadelphia: Wolters Kluwer.