Understanding Selective Mutism

Selective mutism is a disorder usually first diagnosed in childhood. The first described cases date back to 1877 when German physician Adolph Kussmaul labeled children who did not speak as having "aphasia voluntaria."

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 suffer from selective mutism.

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

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 criteria 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.

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, 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.

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

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

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.

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 the disorder is not caught early, there is a risk that your child will become used to not speaking—that being silent will become a way of life and more difficult to change.

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.

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. 

Whereas rewarding positive steps toward speaking is a good thing, punishing silence is not. If your child is afraid to speak, she will not overcome this fear through pressure or punishment.

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.

In general, there is a good prognosis for this disorder. Unless there is another problem contributing to the selective mutism, 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.

_Sources:

_{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.}