Selective Mutism

Selective mutism disorder is a type of severe anxiety disorder in children that causes them to be unable to talk or communicate in specific situations. In most cases, the problem is diagnosed in childhood. The disorder causes difficulties in talking in specific social settings, such as at school or with relatives they do not see often. If left untreated, the disorder can persist into adulthood.

Selective mutism disorder is a complex anxiety disorder characterized by the inability to speak and communicate effectively in certain social settings, sometimes extending to an inability to communicate non-verbally. Clients are only able to speak and communicate normally in comfortable and secure environments. The client is not refusing to talk in these social situations; they cannot speak as they are overwhelmed with fear and anxiety, which triggers a freeze response. When clients frequently experience this type of anxiety, they start to anticipate the situations that could trigger this response and will begin to avoid them entirely. This causes them to experience anxious feelings before and during the situation, leading them to become more isolated as time passes.  

There is a difference between selective mutism disorder and traumatic mutism disorder. Selective mutism disorder involves an inability to speak in specific settings due to the anxiety arising from expectations in social settings. If left untreated and due to the negative consequences of their mutism, their symptoms may further develop in other settings and become more generalized. This could affect their academic performance, self-esteem, and social life. Traumatic mutism disorder, on the other hand, involves a sudden and complete loss of communication after a traumatic event, such as witnessing the death of a loved one.  

Symptoms

  • Consistent failure to speak in specific social situations where they are expected to speak, even though they can speak in other situations.  
  • The impairment hinders academic or occupational performance, as well as social communication.  
  • The failure to talk is not due to a lack of familiarity with or comprehension of the spoken language required in the social environment.  
  • The failure to speak is not related to a lack of knowledge of, or comfort with, the spoken language required in the social situation.  
  • The disturbance is not better explained by a communication disorder (e.g., childhood-onset fluency disorder). It is not due to a diagnosis of autism spectrum disorder, schizophrenia, or another psychotic disorder.

Signs of selective mutism disorder:  

Aside from the main diagnostic symptoms, there are other signs of selective mutism disorder.  

  • Awkward body language and avoiding eye contact  
  • Appearing nervous, shy, or withdrawn  
  • Cautious and restrained behavior in new or unfamiliar situations  
  • Physical symptoms of anxiety (nausea, headaches, chest pains, shortness of breath)  
  • Chance of developmental delay  
  • Becoming stubborn, moody, or irritable  
  • Has difficulties with transitions and may be uncomfortable with change  
  • A desire to speak that is hindered by anxiety and fear  
  • Fidgeting or displaying a lack of movement and expression  

Prevalence

About one in every 140 young children suffers from selective mutism disorder. It is more common in girls and children learning a second language, such as those who have just moved away from their home country.

Prognosis

The onset of selective mutism is usually before the age of five, but it may only be recognized once the child enters school, when there is an increase in social interaction and performance duties, such as reading aloud. The persistence of the disorder is variable. Although clinical findings imply that many people "outgrow" selective mutism, the disorder's long-term outcome is uncertain. Selective mutism may disappear in most cases, but symptoms of social anxiety disorder commonly persist unless there is a therapeutic intervention

When to seek help

Taking note of the child's developmental milestones and age-appropriate behavior can help identify whether the child should seek an assessment to find out if help should be sought. If you notice signs of selective mutism disorder in your child, seek early intervention, as it's important to start a treatment plan as soon as possible.

Treatment

Treating selective mutism disorder does not target the child's ability to speak; it tackles the anxiety associated with the disorder. This first involves absolving the child from the pressure to speak and creating a more positive and supportive environment for them. Then, they are gradually encouraged to be more relaxed in the social contexts in which they are unable to speak. The most common treatment methods for selective mutism disorder are cognitive behavioral therapy (CBT) and behavioral therapy (BT).  

 

Psychotherapy:    

  • Cognitive behavioral therapy helps clients change their thoughts, feelings, and behavior. It also changes their perspective on themselves and those around them. It tackles their perceptions about their fear of communication. CBT is generally used with older children, adolescents, and adults who grew up with selective mutism disorder. Some younger children may also benefit from certain CBT techniques including anxiety management and coping strategies.  
  • Behavioral therapy. Instead of tackling clients' thoughts and core beliefs, behavioral therapy teaches them to develop desired behaviors through reinforcement and replace inadequate habits with adaptive ones.  

 

Techniques:  

A few common techniques are applied from cognitive behavioral therapy and behavioral therapy to tackle selective mutism disorder. These techniques should be supervised and guided by a mental health professional.  

  • Graded exposure:

Professionals using this technique gradually expose clients to anxiety-provoking situations and may combine this exposure with relaxation techniques. As clients become accustomed to the least anxiety-provoking situations, they move on to situations that may make them more anxious.  

  • Stimulus fading:  

The client starts to communicate with a person they feel comfortable with (e.g., a parent), with no one else present. Then another person is introduced, and the first person gradually withdraws when the client is at ease. Then more people are introduced in the same way, until the behavior (i.e., communication) is more generalized.  

  • Shaping:

Shaping teaches clients to gradually develop the desired behavior that is close to what they are already capable of. For example, a client would begin by reading something aloud, then take turns with someone else. Afterward, they would move to interactive reading games, structured talking activities, and finally, two-way conversation.  

  • Positive and negative reinforcement:  

This technique consists of praising the client's verbal communication and ensuring not to reinforce or encourage any avoidance behavior. Those around should not put much pressure on clients diagnosed with selective mutism disorder to communicate, as they will experience a sense of relief after communicating while the pressure is off.  

  • Desensitization:  

Using desensitization helps to reduce the client's anxiety regarding communication instances by encouraging them to be accustomed to hearing other people talking to them. This could be applied by encouraging them to exchange voice messages instead of texting to communicate, for example.  


Medications:  

In more severe cases, medications can be used to treat selective mutism disorder. The decision to use medication should be made with the supervision of a doctor with experience in prescribing anxiety medication to children. Medications, however, should not be used as a substitute for behavioral changes and environmental adjustments. In adults with selective mutism, doctors may opt for a combination of medication and behavioral therapy. Antidepressants can also be used in a treatment plan to reduce clients' anxiety levels, especially if there is difficulty in engaging in psychotherapy.  

There are things one can do to help your child manage their condition in addition to seeking therapy.  

  1. Teachers and others who work with the child should be informed. Teachers can grow upset or angry when their students refuse to communicate. Parents can assist by ensuring the child's teacher knows the behavior is not deliberate.  
  1. Choose activities that are appropriate for their abilities. Don't push your child into social situations or hobbies that require verbal communication. Instead, engage in non-verbal activities such as reading, drawing, or puzzle solving.  
  1. Encourage progress but avoid punishments. Punishing silence is not as beneficial as rewarding positive steps toward speaking. If the child is scared to speak, no amount of pressure or punishment will help them overcome their fear.  
  1. Don't use pressure. Acceptance from parents and family participation are crucial aspects of treatment, but one should avoid forcing their child to speak. Putting pressure on the child will only raise their anxiety levels and make it more difficult for them to talk. Concentrate on showing the child that they are cared for and accepted for who they are.