What Is Selective Mutism?

Selective mutism affects children.

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What Is Selective Mutism?

Selective mutism (SM) is a childhood anxiety disorder characterized by an inability to speak or communicate in certain settings. The condition is usually first diagnosed in childhood. Children who are selectively mute fail to speak in specific social situations, such as at school or in the community.

It is estimated that less than 1% of children have selective mutism. The first described cases date back to 1877 when German physician Adolph Kussmaul labeled children who did not speak as having "aphasia voluntaria."

Selective mutism can have a number of consequences, particularly if it goes untreated. It may lead to academic problems, low self-esteem, social isolation, and social anxiety.

Symptoms 

If you believe that your child may be struggling with selective mutism, look for the following symptoms:

  • Expression of a desire to speak that is held back by anxiousness, fear, or embarrassment
  • Fidgeting, eye contact avoidance, lack of movement or lack of expression when in feared situations
  • Inability to speak in school and other specific social situations
  • Use of nonverbal communication to express needs (e.g., nodding head, pointing)
  • Shyness, fear of people, and reluctance to speak between 2 and 4 years of age
  • Speaking easily in certain situations (e.g., at home or with familiar people), but not others (e.g., at school or with unfamiliar people)

While these behaviors are self-protective, other children and adults may often perceive them as deliberate and defiant.

Diagnosis 

Although selective mutism is believed to have its roots in anxiety, it was not classified as an anxiety disorder until the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published in 2013.

The use of the term "selective" was adopted in 1994, prior to which the disorder was known as "elective mutism." The change was made to emphasize that children with selective mutism are not choosing to be silent, but rather are too afraid to speak.

The primary criterion for a diagnosis of selective mutism is a consistent failure to speak in specific social situations in which there is an expectation of speaking (e.g., school), despite speaking in other situations.

In addition to this primary symptom, children must also display the following:

  • Symptoms of selective mutism must have been present for at least one month, and not simply the first month of school.
  • Your child must understand spoken language and have the ability to speak normally in some situations (usually at home with familiar people).
  • Finally, a lack of speech must interfere with your child's educational or social functioning.

Children who stop talking temporarily after immigrating to a foreign country or experiencing a traumatic event would not be diagnosed with selective mutism.

Causes

Because the condition tends to be quite rare, risk factors for the condition are not fully understood. It was once believed that selective mutism was the result of childhood abuse, trauma, or upheaval.

Research now suggests that the disorder is related to extreme social anxiety and that genetic predisposition is likely. Like all mental disorders, it is unlikely that there is one single cause.

Kids who develop the condition:

  • Tend to be very shy
  • May have an anxiety disorder
  • Fear embarrassing themselves in front of others

Other potential causes include temperament and the environment. Children who are behaviorally inhibited or who have language difficulties may be more prone to developing the condition. Parents who have social anxiety and model inhibited behaviors may also play a role.

Selective mutism also often co-occurs with other disorders including:

  • Anxiety
  • Depression
  • Developmental delays
  • Language problems
  • Obsessive-compulsive disorder (OCD)
  • Panic disorder

Treatment

Selective mutism is most receptive to treatment when it is caught early. If your child has been silent at school for two months or longer, it is important that treatment begin promptly.

When selective mutism is not caught early, there is a risk that your child will become used to not speaking, and as a result, being silent will become a way of life and more difficult to change.

Treatment for selective mutism may include psychotherapy, medication, or a combination of the two.

Psychotherapy

A common treatment for selective mutism is the use of behavior management programs. Such programs involve techniques like desensitization and positive reinforcement, applied both at home and at school under the supervision of a psychologist.

Medication

Medication may also be appropriate, particularly in severe or chronic cases, or when other methods have not resulted in improvement. The choice of whether to use medication should be made in consultation with a doctor who has experience prescribing anxiety medication for children.

Coping

In addition to seeking appropriate professional treatment, there are things that you can do to help your child manage their condition.

  • Inform teachers and others who work with your child. Teachers can sometimes become frustrated or angry with children who don't speak. You can help by making sure that your child's teacher knows that the behavior is not intentional. Together you need to encourage your child and offer praise and rewards for positive behaviors. 
  • Choose activities suited to their current skills. Don't force your 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. Parental acceptance and family involvement are important in treatment, but you should avoid trying to force your child to speak. 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.

In general, there is a good prognosis for selective mutism. Unless there is another problem contributing to the condition, children generally function well in other areas and do not need to be placed in special education classes.

Although it is possible for this disorder to continue through to adulthood, it is rare and more likely that social anxiety disorder would develop.

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Article Sources
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  1. Kotrba A. Selective Mutism: A Guide for Therapists, Educators, and Parents. Eau Claire, WI: PESI Publishing and Media; 2015.

  2. Hua A, Major N. Selective mutismCurr Opin Pediatr. 2016;28(1):114‐120. doi:10.1097/MOP.0000000000000300

  3. American Speech-Language-Hearing Association (ASHA). Selective mutism.

  4. Wong P. Selective mutism: A review of etiology, comorbidities, and treatmentPsychiatry (Edgmont). 2010;7(3):23‐31.

Additional Reading
  • American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.

  • Freeman JB, Garcia AM, Miller LM, Dow SP, Leonard HL. Selective Mutism. In: Morris TL, March JS, eds. Anxiety Disorders in Children and Adolescents. New York: Guilford; 2004.
  • Selective Mutism Foundation. Understanding Selective Mutism