How to Help a Child with Selective Mutism

Does your child chatter away at home but is quiet in school? Chances are, you may already have had a diagnosis of selective mutism (SM). 

Do not be worried. This isn’t something you have done wrong, nor, contrary to what you may read, it is not a sign of abuse. 

There is a range of efficacious therapies currently available for you and your child to take part in. With help, the condition is totally reversible.  

We can walk you through all the terminology surrounding the issue and help you find the best treatments for your little one. 

What Is Selective Mutism?

Selective mutism (SM) is one of the anxiety disorders [1]. In this case, the person chooses not to speak in particular situations or to specific people if certain trigger conditions are met.

It is an induced stress response to a perceived trigger or triggers that may exist only in the individual's mind. Care must be taken not to trivialize whichever issue(s) are responsible. 

Children with selective mutism commonly present concomitantly with social anxiety disorder,  complex childhood anxiety disorder, or other anxiety disorders [2].

Individuals with selective mutism are perfectly capable, biologically, of speaking and understanding spoken language. They simply exhibit a consistent failure to speak in certain groups/situations or, in severe cases, at all. 

Selective Mutism in Toddlers

This condition may occur when the child is starting to interact with people outside of the family unit, perhaps at two or three years of age. They are essentially outside of their comfort zone and enter a fight or flight mode. 

SM is a panic response, not unlike severe stage fright. It can be expressed in a variety of forms [3]:

• Your toddler or child can appear nervous, uneasy, or socially awkward. They may avoid eye contact.
• The child struggles in certain situations; they may suddenly become shy and withdrawn and have fixed facial expressions. 
• You may notice in their body language that they seem tense, unusually awkward, or stiff.
• The particular child may resort to nonverbal communication.
• The child speaks in a whisper or not at all. 
• They may suddenly seem poorly coordinated. 
• When they get home from school, they may become stubborn or aggressive, have temper tantrums, or get angry when questioned by you. 
• They may seem rude, disinterested, or sulky in company.
• Most children suddenly become clingy in public and show separation anxiety.

Children with selective mutism show normal language development and may well be perfectly vocal in comfortable social settings, at home, for instance. They may happily converse with family members when outside of the home. 

The condition arises when the child is in a new situation or a situation where he or she does not feel comfortable or may even feel threatened. 

It is possible that some form of nonverbal communication may be possible, a nod or shake of the head for a yes or no answer. The child may also exhibit altered speech patterns, such as only speaking in a whisper [3].

It can be possible that the child has issues processing sensory information and may suffer from a sensory overload. This can be as a result of a presentation of autism spectrum disorder [2]. 

Selective Mutism in Adults 

In adults, selective mutism is diagnosed as a severe anxiety disorder. It is usually observed as an extreme form of social anxiety disorder that is brought on by specific triggers [4]. It usually leads to social isolation.

Most people will be aware of feeling ‘stage fright’ when having to perform any sort of social speaking function, perhaps at work or at a wedding. 

Selective mutism in adults was known as ‘elective mutism’ until 1994. This is due to the previous view that selective mute people actively choose mutism in certain situations, 

The actual truth is people do wish to speak but are just unable to communicate verbally. The change was to highlight the involuntary nature of the condition.

Signs of Selective Mutism 

Selective mutism anxiety research has shown the diagnostic criteria for selective mutism as laid out by the DSM, The Diagnostic and Statistical Manual of Mental Disorders [5]:

• Not speaking in certain settings. During school lessons is common or when they can be overheard in public in general.
• Social isolation.
• Speaking normally in situations where they feel comfortable. This can be when they're alone with parents at home, for example.
• The child’s inability to speak to certain people has lasted for at least 1 month (2 months in a new setting).
• The inability to speak interferes with their ability to function in that particular setting.
• The inability to speak is not better explained by another communicational, behavioral, or mental disorder.

Affected children may also show some typical behavioral strategies. It is possible that the child develops separation anxiety disorder, obsessive-compulsive disorder, or signs of low self-esteem as a response to anxiety [1]. 

Risk factors are common, such as suddenly being confronted with unexpected social settings. The child’s facial expression may freeze. This mask-like appearance is typical of children with selective mutism. 

If the child is with parents and suddenly triggered, the child may become unusually clingy, show social phobia, even hiding behind the parents to avoid the situation. 

Confusingly, other children with selective mutism may have a blank expression, a reluctance to smile, or even display incessant smiling. These are all, individually, indicators of possible selective mutism. 

What Causes a Child to Be a Selective Mute?

There are a range of causes that can lead to selective mutism, including:

• Shyness.
• Sensory Processing Disorder.
• Language or communication disorders.
• Anxiety.
• Traumatic Selective Mutism.

The causes of selective mutism are not well understood [6]. It is a broad category for otherwise well-developed children who are unable to communicate verbally when certain conditions are met. 

One of the risk factors for most children is a genetic predisposition to heightened anxious feelings and SM. They exhibit inhibited temperaments, which, it is thought, results from an over-excitability in an area of the brain called the amygdala.

The amygdala is the part of the brain that is responsible for processing threat stimuli, the ‘fight or flight response’. It is hypothesized that this is activated by the trigger or triggers the child feels to cause SM. 

Shyness 

There is a clear difference between a child being ‘shy’ and children diagnosed with selective mutism. It is very important not to conflate the two. 

A child who is shy can, if asked, speak in class or social settings. A child with SM can not. A child who is shy can effectively grow out of it as they gain more confidence. A child with SM will not spontaneously recover. 

Selective Mutism and Autism

SM is not linked to autism. A child with autism may, however, exhibit SM-like symptoms or develop SM as a response to sensory processing issues [7]. 

Sensory Processing Disorder

Many children who present with selective mutism will also have sensitivities with their sensory channels. They can meet the criteria for SPD (Sensory Processing Disorder). SPD can be an underlying reason for developing SM and SM-like behavior [8].

Your pediatrician can assess your child and see if sensory integration dysfunction is an underlying reason for the SM. 

Language or Communication Disorders 

It is important to have your child assessed for language problems or a communication or language disorder. SM and a physical disorder can occur but should be ruled out as soon as possible [9].  

A communication disorder will be apparent in all situations, whereas symptoms of SM are only noticeable in trigger situations.

Anxiety  

A child's anxiety is a key feature of SM. A large part of the various treatments revolves around anxiety and the child managing triggering situations. 

Social Anxiety Disorder (SAD) and Social Mutism 

SM is one of the types of anxiety disorders. It is commonly seen alongside social anxiety disorder [10].

Studies link SM to a progression of SAD. It is theorized that SM is a coping or avoidance strategy of children with SAD to avoid trigger situations. 

Traumatic Selective Mutism 

Traumatic selective mutism (TSM) is sudden onset mutism. It is different from selective mutism in that it has a specific trigger event. The mutism is a response to that specific event [11]. 

In SM, the child may be vocal in certain situations, among family members or peers, for example. In TSM, the onset of mutism is usually sudden and total. There is usually no vocalization in any setting. 

Events that can trigger TSM are usually a traumatic event in the child’s life but not limited to events such as the death of a parent or sibling (or similar figure), involvement in a serious accident, or abuse. 

Selective Mutism Test: Who Can Diagnose Selective Mutism? 

If you suspect SM in your child, then take them, initially, to your family health provider or talk to a therapist online at BetterHelp. They will then recommend an appointment with an appropriately qualified family physician or pediatrician or an appointment with a psychiatrist or a therapist [5].

Selective Mutism in Kids: How to Help a Child with Selective Mutism 

How is selective mutism treated? In children, it is highly treatable, and excellent results are seen with early intervention with a number of treatment plans: 

• Treating speech or hearing disorders.
• Social Communication Anxiety Therapy (S-CAT).
• Other forms of therapy.
• Medication.
• Encouraging socialization.
• Involving the child’s teachers, family, and other caregivers.
• Support without pressure.

Early intervention is key. Without prompt treatment, SM tends to be self-reinforcing. It can lead to developmental problems later in life, educational underachievement, problems with social relationships, anxiety issues, and depression in later life. 

• Model appropriate language when interacting with the child. Use positive reinforcement.
• Visit a speech language pathologist to have the child's speech behavior assessed and for language assessment and language evaluation.
• Do not pressure the child to talk on-demand in triggering environments (in school or with strangers).
• Ensure there is always space and time to communicate effectively in trigger environments.
• Encourage the use of non-verbal communication, such as sign, Picture Exchange Communication System (PECS). This helps reduce stress.
• Do not comment on the child’s selective mutism or otherwise bring attention to it.

Listed below are a selection of forms of therapy. 

Treating Speech or Hearing Disorders

If SM is found to be part of an issue relating to a speech or hearing disorder, then the underlying condition should be addressed. 

Any social issues can then be addressed with the appropriate form of speech therapy. Once the initial physical cause has been removed, then progress is typically rapid. 

Social Communication Anxiety Therapy (S-CAT)

S-CAT or Social Communication Anxiety Therapy is a new, integrated approach to SM. It consists of components of cognitive-behavioral therapy (CBT), behavioral therapy, and an insight-oriented approach. 

The aim is to increase social communication and promote social confidence and self-esteem. It employs tactics such as systematic desensitization, modeling, fading, and positive reinforcement.

It allows children to develop social skills that have been lost due to SM. The child can then start to learn to communicate in a measured, step-by-step manner.

Other Forms of Therapy 

There is a range of therapeutic approaches to selective mutism [12]:

• Self modeling: Many children with SM can benefit from watching videos of their own positive interactions and receive praise when doing so
• Cognitive-behavioral therapy (CBT): This type of psychotherapy or talk therapy has shown to be effective in follow-up studies.
• Mystery motivators: An envelope with the child’s name contains a treat. When the child asks for the envelope, the treat is received. 
• Stimulus fading: With a child present in a comfortable environment, stressors are slowly introduced (adults, peers). A slow exposure is less triggering. 
• Desensitization: The child is encouraged to communicate with an individual they are not comfortable with indirectly by such means as email, instant messaging, or video.
• Shaping: Practice speaking by saying certain sounds such as the sound of each letter of the alphabet. Then moving on to words, then whispering, and finally, conversing. 
• Spacing: Interventions are spaced out over time to reduce anxiety and increase the efficacy of treatment

There are online resources that can be effective such as BetterHelp and TalkSpace. Check out our BetterHelp review and TalkSpace review for more information on this type of therapy.

Medication

As selective mutism is similar to other anxiety disorders such as generalized anxiety disorder, similar drugs are used in the treatment [13]. Some evidence indicates anxiolytics to be helpful in treating children with selective mutism. They are used to reduce anxiety levels and hasten the recovery process.

Medication is generally for older children, teenagers, or adults. This is when the anxiety has led to depression and other anxiety problems and mood disorders.

Treating selective mutism with prescribed medication should never be considered the entire treatment for a person with childhood anxiety or communication disorder or SM.

Encouraging Socialization

A valid part of therapy and a way to overcome anxiety one thing that every parent can do is slowly encourage socialization. As a graduated introduction to social stressors, the parent can introduce a single peer or adult into the child’s comfort zone.

The introductee can play no part in socialization nor interact with the child. As the child gets used to the presence of the introductee, the adult can converse within earshot of the child. 

Over time, the child can be gently introduced into the conversation. The process can be repeated until the child is comfortable. 

Involving Teachers, Family, and Other Caregivers

As with the previous point, extended family, the child’s teachers, and other caregivers can be used to gradually introduce other people into the child’s comfort zone. Family involvement is key. 

If it is done in a non-triggering way, it can be a valuable addition to help someone with anxiety. 

Support Without Pressure 

A key feature of anxiety is its self-propagating nature. Parents must make sure that they do not exert undue pressure on the child to ‘perform’ [12]. This can have adverse effects. 

It is essential to use a low-key approach and reward any positive behavior with praise and encourage repetition of each goal. The child can then associate verbal communication with rewards and positive feelings rather than anxiety. 

FAQ

Here is a selection of the most commonly asked questions regarding selective mutism and associated mental disorders.

Is Selective Mutism a Voice Disorder?

No. There is no physical component to SM. The child is perfectly capable of talking but has difficulty speaking from the condition. 

Is Selective Mutism a Form of Autism?

No. Selective mutism is not a form of autism. Some children on the autism spectrum may, however, exhibit selective mutism. 

Do Selectives Mutes Talk?

Yes. Children with selective mutism do talk when they feel comfortable. It is a myth to think that all children with selective mutism are non-vocal. 

How Does a Child Get Selective Mutism?

The causes are largely unknown. It is thought that the amygdala, a part of the brain that processes information, may be hyperstimulated, resulting in selective mutism. 

It is also hypothesized that there may be a genetic component, some family medical history to a predisposition to selective mutism.

What Triggers Selective Mutism?

The triggers are stress and anxiety. Selective mutism is strongly linked to social anxiety disorder and childhood anxiety disorder. The individual triggers, however, will differ from child to child, as will the presentation of selective mutism. 

How Do You Treat a Child with Selective Mutism?

There are now a range of excellent treatments and therapies available for selective mutism based on your child's ability. You can speak to your pediatrician or online therapist about which is the most suitable for your child. 

There is a breakdown of some of the treatments available in this article. 

Conclusion

Children with selective mutism can pose quite a challenge, especially with younger children. It can seem that little or no progress is being made, and this can be very frustrating as a parent. 

It can not be overstressed that you should not display your anxiety as your child will pick up on and feed off your emotions from an early age.

The treatments available are very effective. They will take some hard work and dedication on your part. Be rest assured that every step forward, no matter how small, is a victory. 

Don’t worry. You can do this together! 

Citations 

1. Wong, Priscilla. “Selective mutism: a review of etiology, comorbidities, and treatment.” Psychiatry (Edgmont (Pa. : Township)) vol. 7,3 (2010): 23-31. https://pubmed.ncbi.nlm.nih.gov/20436772/
2. Driessen, J., Blom, J.D., Muris, P. et al. Anxiety in Children with Selective Mutism: A Meta-analysis. Child Psychiatry Hum Dev 51, 330–341 (2020). https://doi.org/10.1007/s10578-019-00933-1
3. Muris P, Monait N, Weijsters L and Ollendick TH (2021) Symptoms of Selective Mutism in Non-clinical 3- to 6-Year-Old Children: Relations With Social Anxiety, Autistic Features, and Behavioral Inhibition. Front. Psychol. 12:669907. doi: 10.3389/fpsyg.2021.669907 https://www.frontiersin.org/articles/10.3389/fpsyg.2021.669907/full
4. Aaron S. Walker & Jane Tobbell (2015) Lost Voices and Unlived Lives: Exploring Adults’ Experiences of Selective Mutism using Interpretative Phenomenological Analysis, Qualitative Research in Psychology, 12:4, 453-471, DOI: 10.1080/14780887.2015.1054533 
5. Letamendi, A. M., Chavira, D. A., Hitchcock, C. A., Roesch, S. C., Shipon-Blum, E., & Stein, M. B. (2008). Selective Mutism Questionnaire: measurement structure and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 47(10), 1197–1204. https://doi.org/10.1097/CHI.0b013e3181825a7b
6. Koskela, M., Chudal, R., Luntamo, T. et al. The impact of parental psychopathology and sociodemographic factors in selective mutism - a nationwide population-based study. BMC Psychiatry 20, 221 (2020). https://doi.org/10.1186/s12888-020-02637-6 
7. Steffenburg, H., Steffenburg, S., Gillberg, C., & Billstedt, E. (2018). Children with autism spectrum disorders and selective mutism. Neuropsychiatric disease and treatment, 14, 1163–1169. https://doi.org/10.2147/NDT.S154966
8. Teresa Tavassoli, Lucy Jane Miller, Sarah A. Schoen, Jennifer Jo Brout, Jillian Sullivan, Simon Baron-Cohen,Sensory reactivity, empathizing and systemizing in autism spectrum conditions and sensory processing disorder,Developmental Cognitive Neuroscience,Volume 29,2018,Pages 72-77,ISSN 1878-9293, https://doi.org/10.1016/j.dcn.2017.05.005.
9. Sharon L. Cohan, Denise A. Chavira, Elisa Shipon-Blum, Carla Hitchcock, Scott C. Roesch & Murray B. Stein (2008) Refining the Classification of Children with Selective Mutism: A Latent Profile Analysis, Journal of Clinical Child & Adolescent Psychology, 37:4, 770-784, DOI: 10.1080/15374410802359759
10. Poole, K.L., Cunningham, C.E., McHolm, A.E. et al. Distinguishing selective mutism and social anxiety in children: a multi-method study. Eur Child Adolesc Psychiatry (2020). https://doi.org/10.1007/s00787-020-01588-3
11. Anyfantakis, D., Botzakis, E., Mplevrakis, E. et al. Selective mutism due to a dog bite trauma in a 4-year-old girl: a case report. J Med Case Reports 3, 100 (2009). https://doi.org/10.1186/1752-1947-3-100
12. Oerbeck, B., Overgaard, K.R., Stein, M.B. et al. Treatment of selective mutism: a 5-year follow-up study. Eur Child Adolesc Psychiatry 27, 997–1009 (2018). https://doi.org/10.1007/s00787-018-1110-7
13. Manassis, K., Oerbeck, B. & Overgaard, K.R. The use of medication in selective mutism: a systematic review. Eur Child Adolesc Psychiatry 25, 571–578 (2016). https://doi.org/10.1007/s00787-015-0794-1