Selective Mutism

What is selective mutism?

Selective mutism is a childhood anxiety disorder that is diagnosed when a child consistently does not speak in some situations, but speaks comfortably in other situations. These children are unable to speak in certain social situations where there is a demand to speak, such as at school, at dance class, at soccer practice, or at the corner store. In other situations, these same children may speak openly with others and may even be considered a “chatterbox”.

Selective mutism causes significant impairment in children's lives and can interfere with performance at school and with friends. It can often prevent them from having fun and engaging in regular childhood experiences. It also can keep them from being safe if they are unable to ask for help or get their basic needs met.

 

How do I know if my child has selective mutism?

Your child may have selective mutism if s/he…

  • Speaks in certain settings but stops talking, either completely or almost completely, when other people are around.
  • Looks frozen or paralyzed (like a “deer in the headlights”) or even angry when asked questions by strangers or when s/he feels uncomfortable.
  • Uses gestures like pointing, nodding, or funny facial expressions to get his or her needs met despite knowing how to talk.

And the difficulties speaking…

  • Have occurred for more than one month, not including the first month of school, and are interfering with your child’s life.
  • Are not better explained by another disorder.

 

Facts

  • Most affected children and adolescents function normally in other areas of their lives and are able to learn age appropriate skills despite not speaking in some important situations.
  • Approximately 1 % of the population has selective mutism.
  • Girls are twice as likely to develop this disorder than boys.

 

What causes selective mutism?

There is no single known cause of selective mutism, but there are factors that make it more likely to develop. For example, being slow to warm up to new situations, the tendency to withdraw from new or unfamiliar situations early in life, a family history of an anxiety disorder including selective mutism, English as a second or other language, and speech or language problems. These factors can all play a role in the development of selective mutism.

 

What maintains selective mutism?

Imagine a scene where a mother and her daughter, Suzy, are at the grocery store. The mother runs into a friend that she has not seen in a long time. The friend asks, “Wow who is this little cutie? What’s your name?”  Suzy freezes, looks scared, tearful, and clings to her mother’s arm. She is unable to respond to this seemingly easy question and a few seconds of silence occur. The friend feels horrible. She never meant to scare Suzy. The mother becomes irritated and embarrassed that Suzy is not answering the question and quickly jumps in to rescue her by saying, “Her name is Suzy.” The friend says, “Hi Suzy, so nice to meet you. You’re so cute and shy.” Suzy didn’t have to answer and everyone feels better. This scenario is common for a child with selective mutism and illustrates how not speaking due to anxiety is often reinforced by people in the child’s environment (parents, teachers, peers). The child learns that if s/he keeps quiet that others will talk for her.  For children with selective mutism, this scenario happens multiple times per day. It can happen at school, in extra curricular activities, when running errands, and when relatives come over. With each “rescue” the child temporarily feels better because s/he is relieved from the anxious feelings. However, very quickly a cycle of anxious avoidance takes hold.

 

Within a few short months this cycle becomes an engrained habit for the child, and for the close adults in his or her life, which becomes harder and harder to break with each passing day.

 

How is selective mutism diagnosed and treated?

If you think that your child might have selective mutism talk to your family doctor or pediatrician to make sure that there are no developmental issues (e.g., hearing or speech delays). The next step is to ask your doctor to refer you to a psychologist or psychiatrist who will help confirm a diagnosis of selective mutism by specifically looking at where your child is verbal and non-verbal as well as evaluating for any other mental health diagnoses that may be present (e.g., other anxiety disorders.)

The main treatment for selective mutism is behavior therapy. Behaviour therapy involves gradually exposing a child to increasingly difficult speaking tasks in the context of a supportive relationship. Practice begins with easier steps, and gets progressively harder – like climbing a ladder. Children are asked to complete tasks that they will meet with success. Success is rewarded with praise and small prizes. In time, children learn that the anxiety they feel when they are asked to speak decreases without having to avoid the situation in order to feel better.

Sometimes, medication plays a role in successful treatment. Behavioural therapy should be the first choice of treatment, but some kids might benefit from a medication called a SSRI (or selective serotonin reuptake inhibitor). A psychiatrist is the best person to talk to about whether medication is right for your child. Your child might need medication in therapy if s/he is making very slow progress despite good behaviour therapy and/or s/he is older and has multiple disorders. Usually children do not stay on medication long-term. After they achieve success talking in a variety of situations and the gains are maintained for a period of time, they are gradually taken off of medication under the supervised care of a medical doctor.

 

Selective mutism in adolescence

As children get older, selective mutism becomes harder to treat because they become better practiced at anxiously avoiding situations that involve talking. The longer children miss out on important academic and social learning opportunities, the more likely they are to be impacted. Specifically, older children and teens may have difficulties with peer relationships, additional anxiety disorders such as social or generalized anxiety disorder, or depression. Older teens may also start to self-medicate with alcohol or drugs in order to ease anxious feelings. Despite the fact that it is harder and more complicated to address, excellent help can still be available. Older children and teens may need:

  • Prescribed medication to help them participate in therapy.
  • Intensive and robust behavior therapy.
  • Some evidence suggests that cognitive behavior therapy can be helpful with older kids with SM.
  • Specific interventions aimed at social skill development.
  • Interventions to address other disorders, such as generalized anxiety disorder and depression, which are unlikely to go away on their own.

Click here for My Anxiety Plan (MAP)

Stories of children with selective mutism

Audrey’s Story
Jill’s Story
The Jones’ Story

Audrey is a 5-year-old girl who lives with her parents and older brother. At home, Audrey is a happy and fun-loving child where she loves playing games and putting on plays for her brother and parents. However, at school and in the community, Audrey is a completely different child and becomes completely silent when required to speak. When Audrey entered school, she was excited to go, and eager to participate, however she would completely shut down any time the teacher asked her a question, acting as if her teacher were a tiger coming to attack her! When she is not required to speak, Audrey willingly communicates using nonverbal gestures with her classmates and teachers. At school, Audrey’s best friend Hannah will speak for her and answer any questions on her behalf. Audrey’s needs are met despite the fact that she uses nonverbal gestures to communicate in the classroom.

Jill is a 12-year-old girl who does not speak at school. When Jill was three years old, her parents moved from China to Canada. Jill picked up English fast, but hesitated to speak in her Kindergarten classroom.  Jill only answered questions when she was asked directly by her teacher. In elementary school she had one friend. She never wanted to be the center of attention. She wouldn’t eat in school for fear that someone might watch her. She also would not go to the bathroom the whole day, and would sometimes have accidents. By Grade two, Jill no longer answered her teacher’s questions verbally. The teachers would assess her by having her point at answers. An individualized education plan was developed which allowed her to communicate completely non-verbally and allowed her to have a modified program. Recently, her lack of verbal communication became a safety issue when Jill tripped at school and broke her ankle; she went the entire day in pain because she did not tell anyone what had happened.

Lizzie Jones was born at 26 weeks. She was in the neonatal intensive care unit for a very long time until she was discharged. Those early years were very hard for the Jones’. They attended countless doctor’s appointments for various health problems. Lizzie had vision difficulties, gross motor delays and was slow at acquiring speech. At age five, Lizzie still had some difficulties speaking clearly, but was otherwise progressing at the same rate as her peers. Halfway through Grade one, Lizzie transferred schools because Mr. Jones was relocated to a job on the other side of the country. When Lizzie arrived at her new school, she did not speak to anyone. Months later she stopped speaking to people in the community as well. Lizzie’s mom knew something was wrong and took her to the pediatrician. The doctor told Mrs. Jones that Lizzie was adjusting to a new situation and would grow out of this stage with a little time. That was two years ago and Lizzie is still not talking in school or in new places.