Selective mutism is a childhood anxiety disorder characterized by a child’s inability to speak and communicate effectively in social situations. Children with selective mutism do not initiate speech or respond reciprocally when spoken to by others in social settings. This can occur in settings that involve both children and adults.

Children with selective mutism are able to communicate clearly and effectively in settings where they feel comfortable, secure, and calm. These children will speak at home in the presence of immediate family members or with close friends.

Selective mutism usually begins before a child is five-years-old, but may not come to clinical attention until the child enters school, where there is an increase in social interactions and performance tasks. Children with selective mutism struggle with reading out loud, speaking in front of the class, or working in large groups. This can make school feel like an exercise in survival on a good day.

Symptoms of selective mutism

Selective mutism is characterized by lack of speech in certain situations and can interfere with social and academic functioning:

  • Consistent failure to speak in specific social situations in which there is an expectation for speaking, despite speaking in other situations.
  • Interferes with educational or occupational achievement or with social communication.
  • Lasts at least one month – not limited to the first month of school.
  • Failure to speak is not due to lack of knowledge about or comfort with the spoken language. 1

Other symptoms of selective mutism can include the following:

  • excessive shyness
  • social isolation
  • fear of embarrassment in front of a group
  • clinging to caregivers
  • temper tantrums
  • oppositional behavior
  • compulsive traits
  • negativity.

Prevalence

Selective mutism is a relatively rare disorder. According to the DSM-5, the occurence of this condition ranges between 0.03% and 1%, depending on the setting.2 Selective mutism is more likely to appear in children than adults, but does not seem to vary based on gender or race/ethnicity. The average age of onset is before five years old, but many children are not diagnosed until they enter school.

Causes of selective mutism

Given that selective mutism is fairly rare, the risk factors are not well known. There are a few triggers that can be linked to the disorder:

  • Temperamental factors: Watch for behavioral inhibition, negative affect, and parental history of shyness, social isolation, and social anxiety. Children diagnosed with selective mutism might also have receptive language difficulties.
  • Environmental issues: Parents who exhibit social inhibition model the behavior for children. Overly controlling or overprotective behavior on the part of the parents can also be a risk.
  • Genetics: Due to the overlap with social anxiety, there might be a shared genetic component between the two disorders. 3

Co-morbidity with other disorders

The most common co-morbidity for selective mutism is with other anxiety disorders, including social anxiety disorder, separation anxiety disorder, and specific phobia.

Functional consequences of selective mutism

Selective mutism can negatively impact children in a number of ways, as children with this disorder struggle to engage in reciprocal social interactions, participate in classroom discussions and activities, and fail to assert their needs outside of the home.

Selective mutism can result in the following functional impairments:

  • Academic problems: When kids with selective mutism fail to speak up about their struggles or lack of understanding in the classroom (or with homework), they can fall behind academically.
  • Social isolation: Kids with selective mutism struggle to engage in reciprocal social interactions in some situations, and this makes it difficult to make and maintain friends.
  • Low self-esteem,
  • Social anxiety.

Treatment of selective mutism

Treatment of selective mutism can involve a combination of psychotherapy and medication, though psychotherapy is generally the first recommendation. Some children with selective mutism have a co-occurring speech and language disorder. Although this is not always the case, it is a good idea to get a speech and language assessment to rule out communication disorders.

Behavioral strategies and Cognitive Behavioral Therapy (CBT) are the most widely supported therapeutic treatments for selective mutism. Using a wide variety of strategies aimed at reducing the anxiety beneath the behavior, these therapeutic interventions help kids learn to gradually engage in more speaking behaviors.

Behavioral interventions should be tailored to the specific child, but examples can include the following:

  • Contingency management – positive reinforcement for verbal behavior working from whispering and pointing to verbalizing out loud
  • Shaping – reinforcement is provided for approximations of the desired behavior
  • Stimulus fading – gradually increasing the number of people and places in which speech is rewarded
  • Desensitization – Kids are gradually exposed to anxiety-producing situations in which speech is expected but are given emotional support and guidance with relaxation exercises to help them work through it
  • Cognitive reframing – kids are taught to identify anxious although patterns and come up with positive alternative thoughts
  • Social skills – in both groups and in individual work, kids can practice social interaction skills to reduce anticipatory anxiety related to engaging in reciprocal interactions. Examples include slipping in and out of groups, entering a group at play, and using and understanding nonverbal communication (e.g. eye contact, body language.)

Building self-esteem through talk therapy and engaging in areas of interest can also benefit children with selective mutism. It’s important to follow the child’s lead and find groups and classes that interest. In doing this, kids will feel greater comfort in a new environment.

Although it might sometimes feel like the behavior of children with selective mutism is willful in nature, it is driven by anxiety. Early treatment can help kids with selective mutism learn to speak up more frequently and improve their academic and social outcomes as a result.

 

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Last Updated: Oct 3, 2017