Selective Mutism

Therefore, it’s important to fully understand the nature of selective mutism and how to best treat it. This article provides an overview of selective mutism, including the signs and symptoms, causes, consequences, and appropriate treatment and intervention plans.

What is Selective Mutism?

Selective mutism is a type of anxiety disorder. It is primarily characterized by an inability to speak in social situations where speaking is expected, despite being able to talk in other situations, such as at home with family. It is predominantly found in children and most often begins in early childhood between age three and six.^[1][2]

It is a relatively rare disorder, with estimated prevalence rates between 0.2 and 1.6% of the population. Some studies suggest that it is more common in girls than boys, although other research points to non-significant gender differences. Selective mutism also appears to be slightly more common in immigrant children, children with speech and language delays, and children who speak a minority language.^[1]

How is Selective Mutism Connected to Anxiety Disorders?

Selective mutism is strongly connected to anxiety disorders, especially social anxiety disorder. Individuals with selective mutism are very often diagnosed with social anxiety disorder, with some studies suggesting as high as 69 to 80%. Individuals with selective mutism display many social anxiety symptoms and have very similar fears and thought processes as those with social anxiety and other anxiety disorders. As a result, it is predominantly their anxiety that causes them to not speak.^[3]

Causes of Selective Mutism

There is no single cause of selective mutism. A combination of psychological, genetic, environmental, neurodevelopmental, and personality factors all seem to play roles in the development of this disorder. These include:^[1][4]

• Genetic and hereditary components

• Environmental factors, such as childhood experiences and parenting styles

• This also includes patterns of reinforcement for behavior

• Neurodevelopment, especially related to speech and language

• Nervous system responses

• Psychological and personality-based factors, such as neuroticism and timidness

Who is at Risk of Developing Selective Mutism?

Based on the above factors, there are many individuals who are at a greater risk of developing selective mutism.

Firstly, individuals are at greater risk if they have parents or other immediate family members with a history of selective mutism, shyness, social anxiety, and related concerns.^[1]

Children who grew up with little to no social contact are also at greater risk. Other environmental risk factors include early traumatic experiences, inconsistent parenting, and having parents or other authority figures who reinforce silent behaviors.^[1][4]

In addition, selective mutism is more likely to occur in children who are shy, timid, and anxious. Some research indicates that up to 80% of individuals with selective mutism have another anxiety disorder, especially social anxiety, but also generalized anxiety and separation anxiety.^[1][5]

Children who have speech and language difficulties may also be at greater risk. These problems can increase anxiety and fear surrounding speaking, such as fear of being teased for mispronouncing words or sounding different. In general, children with any developmental delays or neurodevelopmental disorders are at a higher than average risk.^[4]

Can Selective Mutism Occur in Adults?

Selective mutism is more common in children than adults, although it can occur in adults too. Adults experience similar symptoms as children, such as a desire to speak but inability to do so due to intense anxiety.

If this disorder progresses into adulthood, it may also cause the individuals to self-identify as non-verbal, which further entrenches these behaviors. In addition, some adults may not end up speaking because they think it won’t lead to any benefits.^[1]

Symptoms of Selective Mutism

There are several identifiable symptoms in selective mutism, all of which generally center around an inability to speak in specific social situations due to anxiety. These include:

• Difficult speaking to extended family members, family friends, or other non-immediate family

• Inability to speak with family when others are present or when outside of the home

• Intense anxiety when asked to speak, such as by teachers or relatives

• May lead to a blank or “frozen” expression

• Inability to speak with teachers, classmates, or others in social or educational settings

• Inability to respond verbally or nonverbally when spoken to

• Such as when asked a question

• Difficulty or inability to initiate conversations

• Use of nonverbal communication methods in more comfortable situations

• Physical symptoms of anxiety, such as rigidness, minimal to no eye contact, rapid heart rate, flushing, etc.

• Tantrums or withdrawal in response to anticipated speaking situations

• Refusal to leave home or go to school

Diagnosing Selective Mutism

Diagnosing selective mutism as early as possible is important because it leads to prompt and effective treatment. The diagnostic process involves a comprehensive, multifactorial assessment involving medical history, behavioral observations, interviews with parents and teachers, and a structured diagnostic interview.

An important first step is to review the child’s medical history, especially to screen for neurodevelopmental delays or speech and language difficulties. A doctor may implement certain tests to rule out other causes for the behavior. Examples include an audiology test to ensure there is no hearing impairment, as well as a neurological exam to rule out neurological disorders. Academic and psychoeducational tests may also be implemented to test for cognitive ability.^[4]

After these steps, a comprehensive assessment is initiated. This includes direct observation of the individual’s behavior in home, social, and educational settings by a psychiatrist, psychologist, or other mental health professional. Parents and teachers may also be interviewed to detail more information about the child’s communication and other relevant behaviors. Parents may also be asked to record videos of their child’s behavior.^[1][4]

In addition, a speech and language pathologist is often employed to analyze the child’s speech and language development and overall ability, such as language comprehension, ability to express themselves, and communication abilities across various contexts.^[1]

A very important piece of diagnosis is a comprehensive psychiatric evaluation using a structured diagnostic interview. This allows health professionals to compare symptoms with the diagnostic criteria in theDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5). The diagnostic criteria are:^[3]

• Consistent inability to speak in specific social situations where speaking is expected, despite speaking in other situations

• These disturbances interfere with school or work achievement or with social communication

• Symptoms last for at least one month (excluding the first month of school)

• The inability to speak is not caused by lack of knowledge or comfort with the language

• Symptoms are not better explained by a communication disorder and do not occur exclusively during autism spectrum disorder, schizophrenia, or another psychotic disorder

Treatment for Selective Mutism

There are a number of beneficial treatments for selective mutism. Early intervention is important as it increases the likelihood of symptom resolution and helps to prevent the issues from getting worse over time.

Treatment for selective mutism often involves behavioral and cognitive-behavioral strategies, which address the learned behavior aspects of mutism. Other treatments include medication, family therapy, and speech therapy, among others.^[1]

Ongoing Management for Selective Mutism

Ongoing management for selective mutism is essential, given that it takes time to develop new behaviors and reduce or eliminate old ones. Therefore, treatment should not be viewed as a “one and done” approach, but rather as an intensive process lasting several months (or even years) with many sessions.

Behavioral and cognitive-behavioral strategies are based around the idea that selective mutism is a learned behavior. These strategies implement a variety of techniques to decrease mutism and promote speaking in various contexts. Examples of these strategies include:^[1][4]

• Contingency Management, Positive Reinforcement, & Shaping: Contingency management involves the use of positive reinforcement, in which verbal behavior is rewarded and mutism behaviors are ignored. Within this, the therapist also rewards attempts to communicate until the child actually speaks, which is a process called shaping.

• Exposure-Based Practice: The child is exposed to gradually difficult or anxiety-provoking situations where they are asked to speak.

• Techniques such as systematic desensitization are used along with this to help reduce anxiety and promote feelings of independence and confidence.

• Stimulus Fading: Gradually increasing the level of anxiety while a child is speaking. For example, if a child is talking with one student in the room, they may bring in another student. If they continue talking, the process is continued with another student, and so on.

• Self-Modeling: This involves a child watching a video or hearing an audio tape where they were speaking in a comfortable situation, such as at home. These are then edited to show them speaking in uncomfortable situations, such as at school. This may also be paired with positive reinforcement.

Certain medications may also be used for selective mutism, such as selective-serotonin reuptake inhibitors (SSRIs), which is a type of antidepressant. Despite the name, it also has anti-anxiety effects, which is mainly why it’s used in cases of selective mutism.^[4]

Lastly, family therapy may be implemented, especially if family issues are deemed to play a role in the child’s current behaviors. This form of therapy focuses on building cooperation and communication between parents and siblings of children with selective mutism, which is designed to help with anxiety and avoidance.

School Support for Children with Selective Mutism

Schools also play an essential role in selective mutism treatment. Research points to three overarching roles that schools play when helping children with selective mutism. These are:^[6]

• Understanding and Identifying

• Greater understanding leads to more appropriate responses

• Enhanced knowledge helps to avoid responses that only make the issues worse

• With enhanced knowledge, school workers can identify selective mutism earlier, thus promoting sooner intervention

• Planning and Collaborating

• Teachers and school psychologists can collaborate with health professionals and parents to share essential information, which helps plan effective treatments

• Communication amongst teachers and school workers helps develop appropriate lesson plans and any necessary modifications

• Adapting and Supporting

• Schools are often a place to carry out treatments, such as systematic desensitization and exposure therapy

• Teachers can implement specific strategies/modifications in the classroom to help the child adapt more easily and lessen anxiety (e.g. non-verbal communication strategies)

Final Thoughts

Selective mutism makes it difficult for children to function well, especially at school and areas outside of the home. And without proper identification and treatment, symptoms may persist into adolescence and adulthood.

Fortunately, this disorder has a very high chance of being resolved, especially with early identification, appropriate professional intervention, and school and family support.