Selective Mutism and How It Is Presented
Selective Mutism (SM) is an anxiety disorder characterized by a persistent failure to speak in one or more social situations for at least one month, despite speaking at home or in other settings.
How is Selective Mutism presented in children?
Children usually develop SM before the age of 5. Still, it may not be diagnosed until school age, when the disturbance becomes more noticeable. Children with SM have the ability to speak and are often described by immediate family members as ‘chatty’ when observed at home and in other select environments.
Therefore, children with SM typically exhibit a consistent refusal to speak in specific social situations in which there is an expectation for speaking (e.g., at school), despite doing so in other situations (e.g., at home with family members) and their silence or reluctance has a negative impact on their daily life.
Selective Mutism is not synonymous with complete silence in specific settings either. Older children, who often have a long history with SM, may be more effective at communicating through nonverbal behaviors, such as nodding or shaking their head, pointing or gesturing, writing, and using inaudible, whispered, or abbreviated speech. Some children also make sounds and noises (e.g., grunts, mumbles, animal sounds) and utterances (e.g., um, uh-huh) instead of intelligible words.
Selective Mutism is a serious disorder. Left untreated, it may lead to academic problems, low self-esteem, social isolation and anxiety, reduced quality of life, and interference with family, school, and peer functioning.
How is Selective Mutism presented in teens and adults?
When people speak about Selective Mutism, they often refer to children. But without treatment, SM generally does not “go away” on its own. With the misconception that SM only occurs in childhood, it is not uncommon for teens with SM to be mislabelled as “defiant” or for adults with SM to be labeled as “rude.”
Teens with SM often have deep-rooted patterns of avoidance and ineffective coping skills for managing anxiety. Adults with Selective Mutism face additional unique stressors. Their disorder can render them incapable of adapting to situations like job interviews and work interactions, leading to financial setbacks and underdeveloped social lives.
It is worthy of note that given the increased social pressures one faces as one ages, teens and adults with SM are at increased risk for using substances such as alcohol or drugs to self-medicate for their anxiety.
How is it different from
Shyness: Selective Mutism is a diagnosable mental health disorder and shyness is a common personality trait. Shyness is marked by a tendency to withdraw from people, particularly unfamiliar people; however, shy people can function adequately in society. By contrast, people with a mental health disorder like SM do not adapt well to social situations, nor can they communicate effectively with others.
Social anxiety: More than 90% of children with Selective Mutism also have social phobia or social anxiety. So, they are two different diagnoses, but they often occur together. Children and adolescents with Selective Mutism have an actual fear of speaking and of social interactions where there is an expectation to speak and communicate. The anxiety that they experience is more situation-specific than the anxiety experienced in social anxiety alone.
Autism: Another misconception is that a child with selective Mutism is on the autism spectrum. Autism is a developmental disorder, and selective Mutism is an anxiety disorder. If a child is mute because of autism, they are not diagnosed with selective Mutism.
Traumatic Mutism: When Mutism occurs as a symptom of post-traumatic stress, it follows a very different pattern. The child suddenly stops talking in environments where they previously had no difficulty. An example would be a child who witnesses the death of a grandparent or another traumatic event, and cannot process the event and becomes mute in all settings.
How to Support someone living with Selective Mutism
Parents, teachers, school counselors, psychologists, and sports coaches are key players in helping children overcome their selective Mutism. Parents are encouraged to share information about SM with other adults that their child does not speak to and help them understand that this is a manifestation of anxiety rather than defiance. It is also strongly encouraged to collaborate and ensure that behavioral strategies and interventions are delivered consistently at school, at home, and after school. Patience and consistency are vital in supporting a child to overcome it.
Supporting someone with selective mutism across any setting:
There is a variety of ways to support somebody with SM, and you can apply the following across any setting:
- Always praise verbal behavior and be specific! “Thank you for asking to use the restroom,” or “I liked how you asked Sara to borrow a crayon.”
- Wait 5-10 seconds for their answer. Do not immediately jump in to respond. Give the child an opportunity to respond. Show that you are comfortable with a few seconds of silence.
- Rephrase your questions. Use forced-choice questions (‘is this red, blue, or something else?’) instead of yes/no questions (‘is this red?’) or open-ended questions (‘what color is this?’). Children with SM are likely to respond to yes/no questions by nodding or shaking their heads and freeze in response to open-ended questions.
- Choose activities suited to their current skills. Don’t force the child to engage in social situations or activities that demand spoken communication. Instead, choose activities that don’t involve speech, such as reading, art, or doing puzzles.
- Reward progress but avoid punishment. Where rewarding positive steps toward speaking is a good thing, punishing silence is not. If your child is afraid to speak, they will not overcome this fear through pressure or punishment.
- Don’t pressure your child. Putting pressure on your child will only increase their anxiety levels and make speaking all that more difficult. Focus on showing your child support and acceptance.
School or workplace accommodations
Individuals with Selective Mutism may qualify for school-based or work-based accommodations, such as an Individualized Education Plan (IEP) in grade school, college, or the workforce. Just like someone with a learning disability, if someone’s academic or vocational work is negatively impacted by their SM diagnosis, they may qualify for special accommodations to help them succeed in that environment.
- In grade school or college, one common accommodation is alternative methods of presentation (e.g., written paper instead of a presentation, video recording from home, presenting to teacher/professor one-on-one, or small group presentation).
- In the workplace, standard accommodations include the option for written communication, limited involvement in a role that requires speaking, the assistance of a job coach, or involvement of the individual’s clinician while conducting graduated exposure activities to increase speaking in the workplace.
Supporting your child with selective mutism:
As a parent, you will play a determining role in your child’s progress. If your child has selective Mutism, they need your support to build speaking skills and confidence. There are many things you can do as you embark on this journey with them:
- Acknowledge your child’s anxiety about speaking. Tell them they won’t get in trouble if they don’t speak when they’re away from home or you.
- Model positive and confident behaviors in social situations. For example, smile at people, say hello, and ask how people are when you meet them.
- Talk to your child about times you felt anxious and how you managed it with calm breathing, positive self-talk, and giving things a go. This will help your child understand that talking about anxious feelings is OK.
- Read books with your child that are about nervous, scared, or shy feelings or that have characters who overcome their speaking problems. These can help your child understand their feelings and problems and give them ideas about how to overcome them.
- Focus on your child’s efforts to speak, be patient with their progress, and try to keep any frustration to yourself.
- Instead of answering for your child, encourage them to use non-verbal communication so they can be part of conversations.
- Help your child practice communicating in places outside your home, and make sure your expectations match their abilities.
Familiarizing the child with new environments and people is fundamental. If possible, parents should have the child visit the new classroom before the beginning of the school year. Similarly, have the child meet their teacher before the first day of school. The goal is not necessarily to have the child speak, but it should be an opportunity for them to start feeling comfortable with a new adult.
Behavioral Conceptualization of Selective Mutism
It is possible to look at selective Mutism through a behavioral lens. SM behaviors may result from a long series of negatively reinforced interactions. Negative reinforcement is when a behavior increases due to removing an unwanted feeling/behavior. When the anxiety of speaking is taken away due to an adult rescuing the person from the expectation to speak, the person’s nonverbal behavior is reinforced.
As a result, the person concludes that avoidance behaviors are effective coping strategies for reducing anxiety levels. The more times this cycle repeats, the more reinforced the person is to avoid speaking.
Positive reinforcement is when a behavior increases due to the addition of a reward. So, when the anxiety of speaking is reduced by an adult providing the person with support to speak, the person’s verbal behavior is reinforced.
As a result, the personlearns that speaking leads to rewarding responses and reduces anxiety levels. In addition, people often need to recognize how SM interferes with something important to them (e.g., academic performance, peer relationships) to increase motivation to change, which is much more likely to happen when others limit their use of “rescue” behaviors
How Selective Mutism is Treated
With appropriate handling and treatment, most children can overcome Selective Mutism.
The main goals of treatment should be to lower anxiety, increase self-esteem and increase social confidence and communication. Emphasis should never be on getting a child to talk. With reduced pressure, confidence, and appropriate techniques, communication will increase as the child progresses from nonverbal to verbal communication. Treatment approaches should be individualized, but most children are treated using a combination of:
Social Communication Anxiety Therapy® (S-CAT®): This treatment focuses on the whole child and incorporates a team approach involving the child, parent, school personnel, and treating professionals.
- Graded exposure: situations causing the least anxiety are tackled first until the anxiety associated with these situations decreases to a manageable level.
- Stimulus fading: the person with selective Mutism communicates at ease with someone when nobody else is present. Another person is introduced into the situation, and once they’re included in talking, the initial person withdraws. The new person can introduce more people in the same way.
- Shaping: this involves using any technique that gradually enables the person to produce a response closer to the desired behavior.
- Systematic desensitization: traditionally involves the use of relaxation skills along with gradual exposure to successively more anxiety-provoking situations.
- Contingency management: this technique uses rewards systems to celebrate brave behaviors and limit attention to problem behaviors.
Cognitive Behavioral Therapy: CBT-trained therapists help children modify their behavior by helping them redirect their fears and worries into positive thoughts. The focus should be on emphasizing the child’s positive attributes, building confidence in social settings, and lowering overall anxiety and concerns.
Medication: Medicine should never be prescribed as an alternative to environmental changes and behavioral approaches. If children are not making enough progress with behavioral therapy alone, a qualified practitioner may recommend medication to reduce their anxiety level.
Living with or raising someone who struggles with Selective Mutism is difficult. It can feel disempowering to witness others communicate with apparent facility while being unable to do so. It is important to remember that recovery is possible, and learning adaptive behaviors can be achieved overtime with the proper support and treatment, leading to a balanced and fully enjoyable life.