What is selective mutism

Selective mutism is a consistent failure of children to speak in certain situations, such as school, even when they can speak in other situations, such as at home with close family members. Selective mutism can interfere with school, work and social functioning. Selective mutism affects about 1 in 140 young children. Selective mutism is more common in girls and children who are learning a second language, such as those who’ve recently migrated from their country of birth.

Selective mutism is a severe anxiety disorder where a person is unable to speak in certain social situations, such as with classmates at school or to relatives they don’t see very often. However, people with selective mutism are able to speak freely to certain people, such as close family and friends, when nobody else is around to trigger the freeze response.

Selective mutism usually starts during childhood and, left untreated, can persist into adulthood. A child or adult with selective mutism doesn’t refuse or choose not to speak, they’re literally unable to speak.

If your child has selective mutism, you may notice that:

• She will not speak at times when she should, like in school. This will happen all of the time in that situation. Your child will talk at other times and in other places.
• Not speaking gets in the way of school, work, or friendships.
• This behavior lasts for at least 1 month. This does not include the first month of school because children may be shy and not talk right away.
• Your child can speak the language needed at that time. A child who does not know the language being used may not talk. This is not selective mutism.
• Your child does not have a speech or language problem that might cause her to stop talking.

The expectation to talk to certain people triggers a freeze response with feelings of panic, rather like a bad case of stage fright, and talking is impossible. In time, the person will learn to anticipate the situations that provoke this distressing reaction and do all they can to avoid them.

Associated features of selective mutism may include excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling or oppositional behavior, particularly at home. There may be severe impairment in social and school functioning. Teasing or scapegoating by peers is common. Although children with this disorder generally have normal language skills, there may occasionally be an associated communication disorder (e.g., phonological disorder, expressive language disorder, or mixed receptive-expressive language disorder) or a general medical condition that causes abnormalities of articulation.

Anxiety disorders (especially social phobia), mental retardation, hospitalization, or extreme psychosocial stressors may be associated with the disorder.

Immigrant children who are unfamiliar with or uncomfortable in the official language of their new host country may refuse to speak to strangers in their new environment (which is not considered selective mutism).

Selective mutism seems to be rare, being found in fewer than 0.05 percent of children seen in general school settings. Selective mutism is slightly more common in females than in males.

Left untreated, selective mutism can lead to isolation, low self-esteem and social anxiety disorder. It can continue into adolescence and adulthood if not tackled.

However, a child can successfully overcome selective mutism if it’s diagnosed at an early age and appropriately managed.

It’s also possible for adults to overcome selective mutism, although they may continue to experience the psychological and practical effects of years deprived of social interaction or not being able to reach their academic or occupational potential.

It’s therefore important for selective mutism to be recognized early by families and schools so they can work together to reduce the child’s anxiety. Staff in early years settings and schools may receive training so they’re able to provide appropriate support.

If parents suspect their child has selective mutism and help isn’t available, or there are additional concerns – for example, their child struggles to understand instructions or follow routines – they should seek a formal diagnosis from a qualified speech and language therapist.

You can contact a speech and language therapy clinic directly or speak to a health visitor or doctor, who can refer you. Don’t accept the assurance that you or your child will grow out of it, or you or they are “just shy”.

Treating selective mutism involves behavior changes. The child’s family and school should be involved. Certain medicines that treat anxiety and social phobia have been used safely and successfully.

Incidence and Prevalence of selective mutism

The incidence of selective mutism refers to the number of new cases identified in a specified time period. Prevalence is the number of individuals who are living with selective mutism in a given time period. Accurate population estimates of selective mutism have been difficult to ascertain due to the relative rarity of the condition, differences in sampled populations, variations in diagnostic procedures (e.g., chart review, standardized assessment), and the use of different diagnostic criteria ¹.

• Recent prevalence estimates for selective mutism primarily range between 0.47% and 0.76% ², although rates as low as 0.02% ³ and as high as 1.9% ⁴ have also been reported.
• Selective mutism appears to affect more females than males by a ratio of about 1.5–2.5:1 ⁵. However, equal ratios among girls and boys have also been reported ⁶.
• Selective mutism affects approximately 1% of children being seen in behavioral health settings ⁷.
• Higher prevalence rates have been noted in immigrant children and in language-minority children than in nonimmigrant children. Accurate diagnosis of selective mutism in these populations can be difficult due to the initial nonverbal stage (i.e., “silent period”) common to second language learners ⁸.

Can my child have both selective mutism and autism?

Children with selective mutism, when they are feeling anxious, often react with lack of eye contact, a blank expression, and other behaviors that may look like an autism spectrum disorder. However, selective mutism is fundamentally different from autism; while children with autism lack social and communication skills, children with selective mutism are severely inhibited in speaking in certain situations. Selective mutism and autism can’t be diagnosed together, though some of the treatment is similar. It’s not technically possible under current American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed) ⁹ criteria to be diagnosed with both selective mutism and autism. But experts know diagnoses aren’t perfect, and it isn’t unusual for diagnoses to change as children develop. At one developmental stage a child may not look that different from his peers. At age 3, subtle differences in communication are not that easy to pick out, especially in high-functioning kids. It’s only when children are older, and start to miss developmental milestones for social behavior, social appropriateness, social connectedness, that they start to more clearly look different from their peers. Kids with selective mutism are different from those with autism spectrum disorder; in comfortable situations, selective mutism kids interact just fine, with a full range of emotion, and awareness of social interpretation. It’s only when they become uncomfortable that they fall silent. Kids on the autism spectrum disorder have a qualitative difference in how they understand and interact socially. Kids on the autism spectrum disorder have a hard time interpreting subtleties of social interaction, whether or not they’re in comfortable or uncomfortable settings. Interestingly though, in this case, the treatment that experts recommend for selective mutism isn’t that different, in approach, from what’s recommended for kids on the autism spectrum disorder, called applied behavior analysis (ABA). Applied behavior analysis is really about helping kids develop by giving positive rewards for small behaviors, broken down step-by-step. For selective mutism experts do exactly the same thing- they help kids find their voices by giving them labeled praise for small behaviors broken down into small steps they call “brave talking.” Though, to be clear, experts expect that children with those different diagnoses respond differently to treatments, and the goals and expectations are always tailored to the child’s specific strengths and challenges. So while there are a lot of parallels, the difference is in the assumptions of what kids understand or feel socially, and the expectations and goals for them. A child with autism who’s not talking may not be thinking or feeling the same thing as child with selective mutism, who is typically afraid of being judged or being ashamed. Autism makes a person think differently, you have to try to understand how a child is viewing the world in order to help him get the tools to do what he needs to do. A child on the autism spectrum may need a more explicit kind of instruction in social interaction, translation of what may be understood by others, a different kind of coaching to get him on the best possible trajectory.

Selective mutism associated difficulties

It’s important to understand how selective mutism can affect a child’s education and development, and the impact it can have on a young person’s or adult’s everyday life.

A person with selective mutism will often have other fears and social anxieties, and they may also have additional speech and language difficulties in childhood.

They’re often wary of doing anything that draws attention to them because they think that by doing so others will expect them to talk.

For example, a child may not do their best in class after seeing other children being asked to read out good work, or they may be afraid to change their routine in case this provokes comments or questions. Many have a general fear of making mistakes.

Additional difficulties can also arise from the inability to start a conversation.

Accidents and urinary infections may result from being unable to ask to use the toilet and holding on for hours at a time. School-aged children may avoid eating and drinking throughout the day so they don’t need to excuse themselves.

Children may have difficulty with homework assignments or certain topics because they’re unable to ask questions in class and seek clarification.

Teenagers may not develop independence because they’re afraid to leave the house unaccompanied. And adults may lack qualifications because they’re unable to participate in college life or subsequent interviews.

Selective mutism causes

Experts regard selective mutism as a fear (phobia) of talking to certain people. The cause isn’t always clear, but it’s known to be associated with anxiety.

The child will usually have inherited a tendency to experience anxiety and have difficulty taking everyday events in their stride.

Many children become too distressed to speak when separated from their parents and transfer this anxiety to the adults who try to settle them.

If they have a speech and language disorder or hearing problem, it can make speaking even more stressful.

Some children have trouble processing sensory information like loud noise and jostling from crowds – a condition known as sensory integration dysfunction.

This can make them “shut down” and be unable to speak when overwhelmed in a busy environment. Again, their anxiety can transfer to other people in that environment.

There’s no evidence to suggest that children with selective mutism are more likely to have experienced abuse, neglect or trauma than any other child.

When mutism occurs as a symptom of post-traumatic stress, it follows a very different pattern and the child suddenly stops talking in environments where they previously had no difficulty.

However, this type of speech withdrawal may lead to selective mutism if the triggers aren’t addressed and the child develops a more general anxiety about communication.

Another misconception is that a child with selective mutism is controlling or manipulative, or has autism. There’s no relationship between selective mutism and autism, although a child may have both.

The following factors may coexist and play a role in selective mutism:

• Associated anxiety disorders, such as social phobia, separation anxiety, and obsessive compulsive disorder ¹⁰.
• Hereditary or genetic component with a significant overlap between selective mutism and social anxiety disorder ².
• Familial links coupled with environmental factors, such as reduced opportunities for social contact, observing anxious behaviors, or reinforcing avoidance behaviors ².
• Shy or timid temperament ¹¹.

Selective mutism symptoms

Selective mutism is a type of anxiety disorder whose main distinguishing characteristic is the persistent failure to speak in specific social situations (e.g., at school or with playmates) where speaking is expected, despite speaking in other situations.

Selective mutism usually starts in early childhood, between the ages of two and four. Selective mutism is often first noticed when the child starts to interact with people outside their family, such as when they begin nursery or school.

The main warning sign is the marked contrast in the child’s ability to engage with different people, characterized by a sudden stillness and frozen facial expression when they’re expected to talk to someone who’s outside their comfort zone.

Individuals with selective mutism may present with social anxiety and social phobia. They may avoid eye contact and appear:

• nervous, uneasy or socially awkward
• rude, disinterested or sulky
• clingy
• shy and withdrawn
• stiff, tense or poorly co-ordinated
• stubborn or aggressive, having temper tantrums when they get home from school, or getting angry when questioned by parents

Symptoms of social anxiety and social phobias may include the following ¹²:

• Lack of eye contact
• Clinging to parents
• Hiding
• Running away
• Crying
• Freezing
• Tantruming if asked to speak publicly
• Avoidance of eating in public
• Anxious when having picture or video taken
• Anxious to use public restrooms

In addition to these features of social anxiety, children with selective mutism avoid initiating and participating in conversations. If they are able to express themselves, they may rely on gesturing, nodding, pointing, or whispering. They may have fears of being ignored, ridiculed, or harshly evaluated if they speak.

More confident children with selective mutism can use gestures to communicate – for example, they may nod for “yes” or shake their head for “no”.

But more severely affected children tend to avoid any form of communication – spoken, written or gestured.

Some children may manage to respond with a word or two, or they may speak in an altered voice, such as a whisper.

Few people see the child or young person as they really are – a sensitive, thoughtful individual who’s chatty, outgoing and fun-loving when relaxed and unaffected by their selective mutism.

Selective mutism diagnosis

Selective mutism interferes with educational or occupational achievement or with social communication, and in order for it to be diagnosed, it must last for at least 1 month and is not limited to the first month of school (during which many children may be shy and reluctant to speak). Selective mutism should not be diagnosed if the individual’s failure to speak is due solely to a lack of knowledge of, or comfort with, the spoken language required in the social situation. It is also not diagnosed if the disturbance is accounted for by embarrassment related to having a communication disorder (e.g., stuttering) or if it occurs exclusively during a pervasive developmental disorder, schizophrenia, or other psychotic disorder. Instead of communicating by standard verbalization, children with this disorder may communicate by gestures, monosyllabic, short, or monotone utterances, or in an altered voice.

Older children may also need to see a mental health professional or school educational psychologist.

Adults will ideally be seen by a mental health professional with access to support from a speech and language therapist or another knowledgeable professional.

The clinician may initially want to talk to parents without their child present, so they can speak freely about any anxieties they have about their child’s development or behavior.

They’ll want to find out whether there’s a history of anxiety disorders in the family, and whether anything is causing distress, such as a disrupted routine or difficulty learning a second language. They’ll also look at behavioral characteristics and take a full medical history.

A person with selective mutism may not be able to speak during their assessment, but the clinician should be prepared for this and be willing to find another way to communicate.

For example, they may encourage a child with selective mutism to communicate through their parents, or suggest that older children or adults write down their responses or use a computer.

Selective mutism is diagnosed according to specific guidelines. These include observations about the person concerned as outlined:

• they don’t speak in specific situations, such as during school lessons or when they can be overheard in public
• they can speak normally in situations where they feel comfortable, such as when they’re alone with parents at home, or in their empty classroom or bedroom
• their inability to speak to certain people has lasted for at least a month (two months in a new setting)
• their inability to speak interferes with their ability to function in that setting
• their inability to speak isn’t better explained by another behavioral, mental or communication disorder

Selective mutism falls within the category of Anxiety Disorders ¹³. According to the fifth edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) ¹⁴, the diagnostic criteria for selective mutism are as follows:

• The child shows consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school), despite speaking in other situations.
• The disturbance interferes with educational or occupational achievement or with social communication.
• The duration of the disturbance is at least 1 month (not limited to the first month of school).
• The failure to speak is not attributable 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., child-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

These behaviors are a method of self-protection during an experience of intense anxiety but may appear deliberately oppositional ¹⁵.

Selective mutism test

There is no test for selective mutism. Diagnosis is based on the person’s history of symptoms.

Teachers and counselors should consider cultural issues, such as recently moving to a new country and speaking another language. Children who are uncertain about speaking a new language may not want to use it outside of a familiar setting. This is not selective mutism.

The person’s history of mutism should also be considered. People who have been through trauma may show some of the same symptoms seen in selective mutism.

Selective mutism treatment

With appropriate management and treatment, most children are able to overcome selective mutism. But the older they are when the condition is diagnosed, the longer it will take.

The effectiveness of treatment will depend on:

• How long the person has had selective mutism
• Whether or not they have additional communication or learning difficulties or anxieties
• The co-operation of everyone involved with their education and family life

Treatment doesn’t focus on the speaking itself, but reducing the anxiety associated with speaking.

This starts by removing pressure on the person to speak. They should then gradually progress from relaxing in their school, nursery or social setting, to saying single words and sentences to one person, before eventually being able to speak freely to all people in all settings.

The need for individual treatment can be avoided if family and staff in early years settings work together to reduce the child’s anxiety by creating a positive environment for them.

This means:

• Not letting the child know you’re anxious
• Reassuring them that they’ll be able to speak when they’re ready
• Concentrating on having fun
• Praising all efforts the child makes to join in and interact with others, such as passing and taking toys, nodding and pointing
• Not showing surprise when the child speaks, but responding warmly as you would to any other child

As well as these environmental changes, older children may need individual support to overcome their anxiety.

The most effective types of treatment are behavioral therapy and cognitive behavioral therapy (CBT). These are described below, along with some commonly used techniques to overcome anxiety.

Behavioral therapy

behavioral therapy is designed to work towards and reinforce desired behaviors while replacing bad habits with good ones.

Rather than examining a person’s past or their thoughts, it concentrates on helping combat current difficulties using a gradual step-by-step approach to help conquer fears.

Several of the techniques below can be used at the same time by individuals, family members and school or college staff, possibly under the guidance of a speech and language therapist or psychologist.

Stimulus fading

In stimulus fading, the person with selective mutism communicates at ease with someone, such as their parent, when nobody else is present.

Another person is introduced into the situation and, once they’re included in talking, the parent withdraws. The new person can introduce more people in the same way.

Positive and negative reinforcement

Positive and negative reinforcement involves responding favorably to all forms of communication and not inadvertently encouraging avoidance and silence.

If the child is under pressure to talk, they’ll experience great relief when the moment passes, which will strengthen their belief that talking is a negative experience.

Desensitization

Desensitization is a technique that involves reducing the person’s sensitivity to other people hearing their voice by sharing voice or video recordings.

For example, email or instant messaging could precede an exchange of voice recordings or voicemail messages, leading to more direct communication, such as telephone or online conversations.

Shaping

Shaping involves using any technique that enables the person to gradually produce a response that’s closer to the desired behavior.

For example, starting with reading aloud, then taking it in turns to read, followed by interactive reading games, structured talking activities and, finally, two-way conversation.

Graded exposure

In graded exposure, situations causing the least anxiety are tackled first. With realistic targets and repeated exposure, the anxiety associated with these situations decreases to a manageable level.

Older children and adults are encouraged to work out how much anxiety different situations cause, such as answering the phone or asking a stranger the time.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) works by helping a person focus on how they think about themselves, the world and other people, and how their perception of these things affects their thoughts and feelings. CBT also challenges fears and preconceptions through graded exposure.

Cognitive behavioral therapy (CBT) is carried out by mental health professionals and is more appropriate for older children, adolescents – particularly those experiencing social anxiety disorder – and adults who’ve grown up with selective mutism.

Younger children can also benefit from cognitive behavioral therapy-based approaches designed to support their general wellbeing.

For example, this may include talking about anxiety and understanding how it affects their body and behavior, and learning a range of anxiety management techniques or coping strategies.

Medication

Medication is only really appropriate for older children, teenagers and adults whose anxiety has led to depression and other problems.

Medication should never be prescribed as an alternative to the environmental changes and behavioral approaches described above.

However, antidepressants may be used alongside a treatment programme to decrease anxiety levels and speed up the therapy process, particularly if previous attempts to engage the individual in treatment have failed.

How to help a child with selective mutism

You may find the advice below helpful if your child has been diagnosed with selective mutism.

• Don’t pressurize or bribe your child to encourage them to speak.
• Let your child know you understand they’re scared to speak and have difficulty speaking at times. Tell them they can take small steps when they feel ready and reassure them that talking will get easier.
• Don’t praise your child publicly for speaking because this can cause embarrassment. Wait until you’re alone with them and consider a special treat for their achievement.
• Reassure your child that non-verbal communication, such as smiling and waving, is fine until they feel better about talking.
• Don’t avoid parties or family visits, but consider what environmental changes are necessary to make the situation more comfortable for your child.
• Ask friends and relatives to give your child time to warm up at his or her own pace and focus on fun activities rather than getting them to talk.
• As well as verbal reassurance, give them love, support and patience.

Getting help and support

It’s only relatively recently that selective mutism has been properly understood and effective treatment approaches have been developed.

The body of expertise among healthcare professionals, educational psychologists and teaching staff is growing, but those seeking help need to be prepared for the fact that professionals in their area may not have up-to-date knowledge or experience of working with selective mutism.

If this is the case, you should seek out teachers and healthcare professionals who are willing to listen, learn and develop their specialist knowledge to provide appropriate support.

Teenagers and adults with selective mutism can find information and support at iSpeak (http://www.ispeak.org.uk/) and Finding Our Voices (https://findingourvoices.co.uk/).

The following organizations are good resources for finding professionals for treating selective mutism:

• American Speech-Language-Hearing Association (https://www.asha.org/profind/)
• Selective Mutism Association (https://www.selectivemutism.org/)
• The Royal College of Speech and Language Therapists (https://www.rcslt.org/speech-and-language-therapy)
• The Association of Speech and Language Therapists in Independent Practice (https://beta.helpwithtalking.com/)

Selective mutism prognosis

Children with selective mutism can have different outcomes. Some may need to continue therapy for shyness and social anxiety into the teenage years, and possibly into adulthood.

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