Selective Mutism

What is Selective Mutism (SM)?

Selective mutism (SM) is a complex childhood anxiety disorder characterized by a child’s inability to communicate in specific social situations, but has the capability to communicate in settings or environments where he or she feels comfortable, assured or relaxed. For example, a child with SM may not be able to communicate with communication partners including peers or relatives in social settings such as school or outdoor places. However, the same child is able to speak effectively with their familiar communication partners or close family members at home.

According to Muris and Ollendick (2021), a child is diagnosed with SM if his or her non-verbal behaviours in certain social situations are not inhibited by factors such as insufficiency of knowledge of the conversation topics, or unpleasantness with the spoken language required in the social situation. The duration of SM behaviour is required to be present for at least one month. However, the behaviours should not be limited to the first month if the child enrols in a new school. The non-verbal issues have to interfere with the child’s academic or job-related achievements which attribute to consistent failure of social communication in school or work. Moreover, “the disturbance is not better explained by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively during the course of Autism Spectrum Disorder (ASD), schizophrenia, or another psychotic disorder” (Muris and Ollendick, 2021).

SM appears to be slightly more common in females than in males, and SM behaviours usually start in early childhood, between ages of two and four (Driessen, et al, 2020). However, the child’s selective speaking behaviours may not be noticeable until the child attends school, where verbal communication and peer interaction are required for rapport building. SM is therefore considered a rare psychiatric disorder that may lead to isolation, low self-esteem and may persist into adolescence and even adulthood if left untreated.

Causes of Selective Mutism

The following are some possible risk to developing selective mutism:

• An anxiety disorder
• Family history of anxiety disorders
• Speech and language disorder (e.g., stuttering)
• Poor family relationships
• Low self-esteem and having feelings of anxiety or embarrassment before others (e.g., fearful of making mistakes before others, being afraid of criticism due to poor articulations)
• Experienced a traumatic event
• Difficulty processing sensory information such as loud noise

Signs of Selective Mutism

People with SM may show signs of selective speaking behaviours since early childhood. Parents or caregivers may take note of the signs or symptoms presented and provide appropriate early intervention to support the child. The following are some signs or symptoms of SM:

• Appears extremely verbal at home but consistently fails to communicate in typical social or school situations such as having difficulty answering teachers’ questions, initiating or joining in a conversation with peers as well as performing in front of the others during extracurricular activities (e.g., sport or musical events).
•  Appears extremely shy in public, may have blank facial expression, stiff or rigid body posture and seem uncomfortable in situations such as when being introduced to unfamiliar people, being teased or criticised and when being the centre of attention
• Shows avoidance or withdrawal behaviours such as turning his or her head away, avoiding eye contact, clinging to parents, withdraws from a group and appears more interested in playing alone when there is an expectation for speaking
• Predominantly whispers or uses non-verbal communication such as nodding, gesturing or pointing when expressing thoughts
• May refuse to follow adults’ instructions, and appears to be oppositional and defiant
• Selective speaking behaviours persist for at least a month (not including to the first month when enrolling into new school)
• Avoids eating in public or feels anxious to use the public restroom

Outcome

SM is different from being shy. A child who is shy tends to warm up to new situations and unfamiliar people over time. In addition, shyness does not prevent a child from thriving in his or her endeavours. However, SM is an anxiety disorder that can interfere with a child’s academic performance and in later life adversely affect his or her career pursuits. In many circumstances, parents will utilise the ‘wait and see’ approach in the hopes that their child will outgrow his or her mutism. However, most children do not outgrow SM without appropriate intervention. For example, the child with SM might not have any interaction or social communication with the others as he or she grows up.

If the child with SM is left untreated, the non-verbal behaviours can become a conditioned response.  Over time, it can have negative consequences of untreated anxiety throughout the child’s life. The following are some possible outcomes if the child with SM is left untreated:

• Worsening anxiety over time leading to depression when he or she continues to live in fear and is consistently isolated from people outside of the home setting
• Social isolation and withdrawal as a result of not communicating with the people outside of the home environment for long time
• Low self-esteem and self-confidence as a result of growing up without learning the appropriate social skills to communicate and interact with people around
• Poor academic performance and the possibilities of quitting school due to the fear of being in situations with the expectation to speak (e.g., answering questions in class, buying food from the school canteen, completing teamwork assignments)
• Underachievement in the work place due to the fear of approaching colleagues for assistance when work challenges arise, unable to join in or initiate a conversation with colleagues about work-related matters

Treatment of Selective Mutism

According to the American Speech-Language-Hearing Association (2022), early intervention plays an important role as a child with SM is most receptive to treatment when intervention starts early. The following are some possible treatments that are commonly used for a child with SM:

• Collaboration with different professionals such as teachers in different settings:
  • Parents should inform teachers regarding the child’s unintentional non-speaking behaviours so that both parties can collaborate to better facilitate the child’s communication and learning. Together you can offer praise and reinforcements for the desired behaviours such as greeting or interacting with peers or teachers in the classroom. You will need to acknowledge the child’s non-verbal behaviours if the child remains silent during communication as the pressure of being forced to speak may worsen his or her fear to speak. 
  • Avoid speaking for the child. Instead, teachers or other professionals such as therapists may arrange one-on-one time with the child so that he or she will be able to seek assistance quietly rather than in front of the peers.
  • Parents or teachers should not force the child to engage in social situations or activities that demand spoken communication as this may increase their anxiety level to speak verbally. Roe (2011) stated that the most common response to tell others about SM is “I want to talk but can’t and don’t know why. It’s not a conscious choice” (as cited in Hipolito and Johnson, 2021). Instead, teachers or parents can choose activities that do not involve speech such as reading, art, or doing puzzles in order to minimize the child’s selective speaking symptoms. Parents and teachers can then gradually seek communication opportunities to reinforce small improvements in the child’s verbal communication or interaction with peers.
• Behavioural therapy: The main goal of behavioural therapy is to reduce the child’s anxiety, increase his or her self-esteem and social confidence while communicating with others.
  • A child with SM should start to communicate with people that he or she is feeling comfortable with such as family members, when nobody else is present. Then, parents may gradually introduce the child to new communication partners while the parents or familiar communication partners gradually withdraw from the conversation. When the child becomes comfortable with the social conversation, the conversation may be expanded to a new social situation. However, do not force the child to do this all at once as this may increase his or her anxiety to communicate.
  • Positive reinforcements such as verbal praises or tangible rewards should be awarded when the child with SM manages to speak in various social situations (e.g., continues his or her conversation in the presence of unfamiliar people or speaks in more anxiety-provoking situations such as giving a speech in front of a an unfamiliar audience).

• Play-based therapy or other psychological intervention:
  • Acknowledges the child’s feelings of anxiety and fear to speak verbally with unfamiliar communication partners. Emphasizes on understanding the child’s anxious feelings while communicating with the others and help the child to feel more comfortable in a conversation with the others.

• Cognitive Behavioural therapy (CBT):
  • A CBT trained therapist may help the child with SM to modify his or her behaviour by redirecting feelings of anxiety into positive thoughts. Most children with SM are sensitive about others hearing their voices, forcing them to speak or asking them why they are not talking. In order to emphasize on the child’s positive attributes, building his or her social confidence and reduce the overall anxiety, desensitization can be an effective technique to reduce the child’s sensitivity to other people hearing his or her voice in person. For example, the child may exchange voicemail messages to unfamiliar people as a method to communicate before having direct face-to-face conversations
• Pharmacological treatment:
  • In consultation with a medical doctor, medication may be considered for older children or more severe cases where the other methods are not effective to relieve the signs and symptoms of SM in the child.

• The effectiveness of the treatment will depend on:
  • The duration that the child has had SM
  • The possibilities of underlying communication or learning difficulties or anxieties other than SM
  • The social support system where individuals are involved to support the child’s SM behaviours

Adolescents and Adults with Selective Mutism

According to the American Speech-Language-Hearing Association (2022), adolescents and adults with SM since early childhood who did not receive any intervention, may eventually choose not to speak as they do not see the advantage of speaking. Despite the fact that the treatment can still be effective for adolescents and adults, the process of intervention might be more challenging and might take longer as the selective speaking behaviours have become deep-seated over time.

Tips for parents

As parental acceptance and family involvement are important in intervention, parents should not pressure the child to speak. Forcing the child to speak may increase his or her fear which can make the speaking goals more difficult to achieve. The following are some tips for parents to support the child with SM:

• Do not show that you are anxious because he or she is not speaking as this may increase his or her anxiety level of pressure to speak
• Acknowledge the child’s anxiety of speaking and reassure the child that talking will be easier when he or she takes small steps to relieve the fear of being unable to speak in front of the public
• Concentrate on having fun even though it is a non-speaking activity (e.g., arts or music)
• Praise the child even if there is only minimal improvement (e.g., when the child makes efforts to join in and interact with others by passing and sharing the toys, nodding, smiling and pointing during a conversation)
• Do not express surprise when the child speaks as this bring attention to the child and having the child feel embarrassed
• Do not avoid parties or family visits, but consider modifying the environment to make the situation more comfortable for the child (e.g., you may start the conversation with the child and one familiar communication partner, and then gradually withdraw from the conversation once the child feels comfortable in communicating with the other communication partner)

Generally, there is a good prognosis for SM if the child receives appropriate treatment and diagnosis. If you suspect that a child might have SM, you should consult a speech language therapist (SLT) for a comprehensive evaluation.

References

Driessen, J., Blom, J. D., Muris, P., Blashfield, R. K., & Molendijk, M. L. (2020). Anxiety in children with selective mutism: a meta-analysis. Child Psychiatry & Human Development, 51(2), 330-341.

Muris, P., & Ollendick, T. H. (2021). Current Challenges in the Diagnosis and Management of Selective Mutism in Children. Psychology research and behavior management, 14, 159–167. https://doi.org/10.2147/PRBM.S274538

Muris, P., & Ollendick, T. H. (2021). Selective mutism and its relations to social anxiety disorder and autism spectrum disorder. Clinical child and family psychology review, 24(2), 294-325.

Selective Mutism – A comprehensive overview. https://selectivemutismcenter.org/whatisselectivemutism/

Selective Mutism. https://www.nhs.uk/mental-health/conditions/selective-mutism/#:~:text=Selective%20mutism%20is%20a%20severe,untreated%2C%20can%20persist%20into%20adulthood.

Selective Mutism. https://www.cedars-sinai.org/health-library/diseases-and-conditions—pediatrics/s/selective-mutism.html#:~:text=There%20is%20no%20single%20known,Poor%20family%20relationships

What is Selective Mutsim? https://www.verywellmind.com/what-is-selective-mutism-3024702

Hipolito, G., & Johnson, M. (2021). Selective Mutism. In Handbook of Pragmatic Language Disorders (pp. 247-281). Springer, Cham.

Selective Mutism Treatment. https://www.priorygroup.com/mental-health/selective-mutism-treatment

Complete Guide to Selective Mutism (2022). https://childmind.org/guide/parents-guide-how-to-help-a-child-with-selective-mutism/#block_281f74f8-2905-4c87-afb0-c311dc4f33b2