Selective mutism: causes, symptoms, and treatments
Table of content
- What is selective mutism?
- What are the causes of selective mutism?
- What are the symptoms of selective mutism?
- What can I expect from selective mutism?
- What are the available treatments for selective mutism?
Selective mutism is a type of anxiety disorder where a patient is unable to speak in certain settings or around specific people. For example, they may be talkative with their family, but can’t speak around strangers, distant relatives, or in school and crowded places. A child or adult isn’t selectively mute because they choose to stay silent, but they literally can’t speak in that specific situation.
The causes of selective mutism include childhood abuse, trauma, upheaval, anxiety disorder, poor family relationship, and self-esteem problems.
Symptoms of selective mutism, in addition to the inability to speak, include anxious, unease behavior and being awkward around others, unpleasant, apathetic, moody behavior, and clingy. Other symptoms of selective mutism are shyness and reclusiveness, being stiff and disorganized, and aggressive and stubborn behavior.
Treatment for selective mutism involves a combination of cognitive-behavioral therapy, stimulus fading, family therapy, positive reinforcements, and antidepressants.
What is selective mutism?
Selective mutism (SM) is a mental illness characterized by the inability to speak in certain social situations such as with colleagues in schools or the community, but being able to speak in other settings such as at home.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by the American Psychiatric Association categorizes selective mutism as one of the types of anxiety disorders. Before DSM-5, selective mutism was among “Disorders of childhood and adolescence.” Different categorizing of selective mutism caused two major changes in the interpretation of the symptoms of this mental illness. Since selective mutism is considered a type of anxiety disorder, its anxious etiology is highlighted and also opens the possibility of diagnosing the disorder in adults, according to a review by J. Holka-Pokorska et al. in the April 2018 issue of Psychiatria Polska.
Selective mutism tends to start in childhood, but it can persist into adulthood if left untreated. Selective mute means the patient doesn’t simply refuse or choose not to speak. They are literally unable to speak in certain situations. At that moment, the expectation to talk triggers a freeze response that leads to panic and anxiety, making talking impossible.
German physician, Adolph Kussmaul, was the first to describe selective mutism. In 1877, Kussmaul described cases of children who voluntarily didn’t speak in certain situations. He named the disorder aphasia voluntaria. In the 1930s, the disorder was renamed into elective mutism, thereby emphasizing the voluntary or elective nature of the inability to speak. With the release of DSM-4 in 1994 and DSM-4-TR (text revision) in July 2000, the condition was described as selective mutism. The term “selective” was chosen to emphasize the select situations indicated by failure to speak as opposed to intentional withholding of speech that previous terms implied, explained Dr. Priscilla Wong of the Department of Pediatrics at Madigan Army Medical Center in Tacoma, Washington in her paper from March 2010 issue of Psychiatry. That definition of selective mutism is still used today.
Since selective mutism involves the inability to speak in certain social situations, it is important to make a distinction from social anxiety disorder (SAD). The symptoms of the two disorders can overlap, but they are not the same. Social anxiety disorder is indicated by anxiety in social situations, whereas selective mutism involves being nonverbal or unable to speak around strangers or at school. A patient with selective mutism is unable to speak in front of others, whereas someone with SAD fears new things. A patient with SM may fidget or avoid eye contact, but a person with SAD fears talking to others even though they can. Patients with selective mutism can speak at home or with familiar people, but a person with SAD has fear of negative comments, Very Well Mind explained.
How common is selective mutism?
Selective mutism is a rare disorder that affects approximately 1% to 2% of children, according to a June 2021 paper that Dr. Christopher A. Kearney and Prof. Melanie Rede of the Department of Psychology at the University of Nevada published in Frontiers in Psychology. In an August 2002 study that R.L. Bergman et al published in the Journal of the American Academy of Child and Adolescent Psychiatry, 0.71% (16/2256) of school children had selective mutism.
The prevalence of selective mutism tends to be higher in immigrant children and kids with speech and language delays. Another study from the abovementioned journal, carried out by Prof. Yoel Ellizur and psychologist Ruth Perednik from The Hebrew University in Jerusalem found that the general prevalence of selective mutism was 0.76%, but the rate among immigrant children was 2.2%. A comparative study by K. Manassis et al, published in the journal Depression and Anxiety, showed children with selective mutism had language impairments relative to children with social phobia.
According to the American Speech-Language-Hearing Association (ASHA), accurate population estimates regarding selective mutism have been difficult to establish. The reason for data discrepancies is the rarity of the condition, differences in sampled populations, variations in diagnostic procedures, and the use of different diagnostic criteria. For example, in a 2009 paper from Clinical Psychology Review, A.G. Viana et al. reported that prevalence estimates of selective mutism range between 0.47% and 0.76%, but Brown & Lloyd in 1975 suggested rates as low as 0.02%, ASHA explained. On the flip side, Kampulainen et al. found that the prevalence of selective mutism was 2% among second-graders, according to the results they published in the March 1998 issue of European Child and Adolescent Psychiatry. The same study found that selective mutism was more prevalent in girls. The UK’s NHS reports that selective mutism affects one in 140 young children.
Selective mutism can persist well into adulthood, but it is unclear how many adults have this condition. Interestingly, less than one in five adults (15%) have ever heard of selective mutism, according to a January 2017 online survey that The Harris Poll carried out in partnership with The Selective Mutism Association (SMA). They conducted the survey among 2204 U.S. adults. The same survey also showed that three in 10 (32%) of the respondents personally know a child or adolescent that fits the diagnostic criteria for selective mutism.
What are the causes of selective mutism?
The causes of selective mutism are not fully understood due to the rarity of the condition. ASHA reported that selective mutism is a multifactorial condition meaning multiple causes could play a role rather than a single one. For example, associated anxiety disorders such as a social phobia or separation anxiety, heredity or genetics, and environmental factors could coexist and contribute to the development of selective mutism. The most significant causes of selective mutism are listed below:
- Childhood abuse
- Anxiety disorder
- Poor family relationship
- Self-esteem problems
1. Childhood abuse
Childhood abuse is defined as any intentional harm or mistreatment of a child under 18 years old. Child abuse has many forms such as physical, sexual, emotional, medical abuse, and neglect. Mayo Clinic reports that in many cases child abuse is done by a person that a child knows or trusts such as a parent or relative. Childhood maltreatment increases the risk of mental illnesses and is associated with earlier age of onset and more severe clinical course or poorer treatment response, according to a paper by E. T. C. Lippard and C. B. Nemeroff in the January 2020 issue of the American Journal of Psychiatry. Childhood abuse can have a major impact on the mental health of an individual and may cause selective mutism.
It is unclear how childhood abuse causes selective mutism as more research on this subject is necessary. One of the older pieces of evidence on this subject, published in the June 1994 issue of Archives of Disease in Childhood by R. MacGregor et al, showed a clear relationship between child abuse and SM. In the study, five of 18 (28%) children definitely suffered abuse. Researchers described it as a high proportion. Children were mainly victims of sexual abuse. Scientists explained sexual abuse is psychologically more traumatic and is more associated with secrecy. These findings show that selective mutism could occur as a reaction to a traumatic event.
Childhood abuse is a cause of selective mutism because it is a traumatic experience and may lead to anxiety. An article by L. Guo et al from the June 2021 issue of Translational Psychiatry revealed childhood maltreatment may influence anxiety symptoms and coping styles. Only in participants with negative coping styles, emotional, physical, and sexual abuse in childhood was associated with anxiety symptoms. Therefore, selective mutism could be a consequence of the inability to cope with abuse that a child had endured.
Trauma is defined as an emotional response to a distressing experience or a terrible event such as a natural disaster, sexual abuse, or an accident. According to the American Psychological Association, typical short-term reactions to trauma are shock and denial, but long-term reactions are unpredictable emotions, flashbacks, strained relationships, and physical symptoms such as nausea or headaches. Trauma makes a person more susceptible to mental health problems and may directly cause post-traumatic stress disorder (PTSD), which is a type of anxiety disorder, according to the Mental Health Foundation from the UK. Trauma is one of the causes of selective mutism, as well.
Trauma causes selective mutism through the inability to cope with a traumatic experience. In the previous section, it was stated that a negative coping style after exposure to trauma was associated with anxiety symptoms. Selective mutism, as an anxiety disorder, may be a consequence of difficulty processing trauma. Here it is important to make a distinction between traumatic mutism and trauma-induced selective mutism. Healthline explains that a person with traumatic mutism is unable to speak in all situations or settings following a trauma, but trauma-induced SM involves the inability to speak in certain situations only. For example, a person may not be able to talk in presence of their abuser or in settings that resemble the circumstances under which the trauma had occurred.
Trauma is a cause of selective mutism because it can cause PTSD. According to a paper by Dr. Priscilla Wong in the journal Psychiatry, PTSD with dissociative features has been linked to selective mutism. Children with PTSD can also exhibit avoidance symptoms such as avoiding thoughts or feelings associated with the trauma. As a result, they may experience problems such as selective amnesia, reduced interest in activities, and loss of previously acquired developmental skills such as communication skills. The cessation of speech could be an internal coping mechanism for the traumatic event.
Upheaval is defined as a sudden change or disruption in one’s life. It can be a positive thing such as starting a new job or moving into a bigger apartment, or upheaval can be a negative thing, such as a chronic or terminal illness in the family. Upheaval can generate a wide range of emotions, such as anger, excitement, and a sense of losing control, but a person can also experience apathy and anxiety. Changes in life can affect a person’s mental health and well-being, WebMD reports. Upheaval can also contribute to the development of selective mutism.
Upheaval causes selective mutism because negative life changes can cause trauma. Traumatic experience, as seen above, can contribute to the development of SM due to inadequate coping mechanisms. Trauma is also associated with PTSD, which can lead to communication problems.
Upheaval is a cause of selective mutism because major changes in life can be difficult to process. Negative experiences that change the course of a person’s life can act as trauma. When a person can’t deal with trauma properly, it can affect the way they think or behave. That is why a person can develop communication-related problems such as SM.
4. Anxiety disorder
Anxiety disorder is a term that refers to mental health conditions characterized by persistent and excessive fear, worry, or panic that interferes with daily activities. There are different types of anxiety disorders, such as generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD), social anxiety disorder, separation anxiety disorder, and selective mutism.
Anxiety disorder causes selective mutism because anxiety disorders are often comorbid with one another in addition to their co-occurrence with other mental health conditions like depression, according to a paper by B.W.J.H. Penninx et al from the July 2022 issue of The Lancet. In their paper from the June 2021 issue of Clinical Child and Family Psychology Review, Dr. P. Muris of Maastricht University in the Netherlands and Dr. Thomas H. Ollendick of the Virginia Polytechnic Institute and State University from the US reported that 80% of children with SM also meet the diagnostic criteria for another anxiety disorder such as social anxiety disorder (SAD). Children with selective mutism, according to the same paper, also exhibit fears of making mistakes, language-related fears, and voice-related fears, all of which are indicative of social anxiety too.
Anxiety disorder is a cause of selective mutism because it can affect thinking patterns and coping mechanisms. As mentioned above, PTSD can be a precursor of selective mutism ,suggesting the role of the inability to process a traumatic experience. The relationship between other anxiety disorders, such as GAD or OCD, with selective mutism requires further research.
5. Poor family relationship
Poor family relationship refers to a dysfunctional family where misbehavior, conflict, neglect, and abuse occur continuously or regularly. Healthy family relationships provide resources that help a person cope with stress or engage in healthier behaviors, enhance their self-esteem, and improve overall well-being. On the flip side, a poor family relationship is a stressor that takes a toll on a person’s well-being, according to a paper by Dr. P. A. Thomas et al. in the November 2017 issue of Innovation in Aging. Bad family relationships can contribute to the development of mental illnesses, including selective mutism.
The poor family relationship causes selective mutism because parental behaviors can influence children’s selective mutism symptoms by either reinforcing or discouraging their verbalization, explained Shira Richards-Rachlin, a research associate in her paper from Applied Psychology Opus for NYU Publishing. Poor quality of relationships within the family can cause stress and trauma, which can also contribute to the development of selective mutism.
Poor family relationship is a cause of selective mutism because exposure to an unhealthy environment, such as parental conflict, can lead to the development of anxiety and depression, as per November 2022 paper from Research on Child and Adolescent Psychopathology published by N.M. Morelli et al. Bad family relationships can contribute to anxiety disorders, which tend to co-occur with one another. They may also lead to upheaval due to negative events such as divorce. All these things can make it difficult for a person or child to process the major stressors and thereby affect their communication skills.
6. Self-esteem problems
Self-esteem problems refer to low self-esteem or not holding oneself in high regard. Self-esteem is the way people think about themselves and the values they place upon themselves. People have low self-esteem when they lack confidence about who they are or what they can do and tend to judge themselves negatively. Low self-esteem isn’t an illness, but there is a clear link between the way an individual thinks of themselves and mental health, according to the National Alliance on Mental Illness (NAMI). For example, NAMI explained low self-esteem can contribute to anxiety and depression. It can contribute to selective mutism development, too.
Self-esteem problems cause selective mutism because it plays a role in social anxiety disorder. Selective mutism and social anxiety disorder can be connected as many children with SM have symptoms of the other anxiety disorder, as explained above in this post. A child or person with selective mutism may be afraid of making mistakes or being judged negatively, which could further aggravate their condition.
Self-esteem problems are a cause of selective mutism because they may occur due to poor family relationships or trauma, similar to SM. More precisely, low self-esteem and selective mutism have a lot in common. However, further research is vital to elucidate all the mechanisms behind this relationship.
What are the symptoms of selective mutism?
Symptoms of selective mutism are usually first noticed when a child starts interacting with people outside their family, such as when they start kindergarten or school. The telltale sign of selective mutism is a significant contrast in the child’s ability to engage with different people. The child may be talkative with their family but exhibit sudden stillness or frozen facial expression when speaking to a person they don’t know e.g. a teacher, distant relative. The main symptoms of selective mutism are listed below:
- Anxious, uneasy, or awkward around others
- Unpleasant, apathetic, or moody
- Shy and reclusive
- Stiff, tight, or disorganized
- Aggressive or stubborn, throwing fits when kids return home from school, or becoming irate when parents question them
1. Anxious, uneasy, or awkward around others
Being anxious or uneasy is defined as experiencing mental distress due to fear of danger or misfortune. An anxious person is greatly worried and apprehensive. On the flip side, a person who is awkward around others feels uncomfortable, nervous, and easily embarrassed. People or children feel anxious and uneasy for many reasons, mainly stress and trauma. Awkwardness tends to result from anxiety. Anxiousness or uneasiness and awkwardness can be symptoms of selective mutism.
Anxious, uneasy, or behavior such as being awkward around others becomes a symptom of SM because the expectation to speak to certain people such as strangers triggers a freeze response that leads to anxiety and panic. A child or adult with selective mutism feels uncomfortable in that situation, which leads to anxiousness that people can notice.
Anxiousness, uneasiness, or being awkward around others is a symptom of selective mutism because it’s a reaction that a patient can’t control. A child or adult with SM doesn’t pick and choose situations where they don’t speak, they literally can’t speak. One way they react to that specific situation is through anxious behavior and being noticeably awkward.
Anxious, uneasy, or awkward around others, as a symptom of selective mutism, is identified through nervousness, restlessness, a sense of impending doom, hyperventilation, and difficulty concentrating. They may worry about embarrassing themselves and display fear when interacting with strangers. These symptoms are present in situations that trigger selective mutism, such as events where a patient doesn’t know anyone.
2. Unpleasant, apathetic, or moody
Unpleasant refers to behavior that is not friendly whereas apathetic behavior indicates a lack of care and interest. Moody behavior refers to frequent changes in feelings, attitudes, and behaviors in a way that a person becomes depressed, anxious, or angry without any warning. Unpleasant, apathetic, or moody behavior occurs due to a wide range of reasons including not knowing people in one’s presence, not understanding the situation, stress, and even trauma and anxiety. Selective mutism can also cause these behaviors.
Unpleasant, apathetic, or moody behavior becomes a symptom of selective mutism because the disorder has a direct influence on behavioral patterns due to high levels of anxiety. Discomfort in situations that cause SM can lead to unpleasant behavior, loss of interest in what’s happening, and mood changes.
Unpleasant, apathetic, or moody behavior is a symptom of selective mutism because it is a person or child’s reaction to their environment in situations that cause an inability to speak. That is their response to negative stimuli and they are unable to control it.
Unpleasant, apathetic, or moody behavior, as a symptom of selective mutism, is identified through a lack of politeness, feeling indifferent to spending time with people, lack of motivation, and quick mood changes. These symptoms show up in the presence of a trigger of selective mutism. For example, a child who experiences SM with strangers isn’t interested in participating in activities where they may encounter people they don’t know. They may become unpleasant and moody when that situation is involved.
Clingy behavior is a tendency to stay highly close or dependent on another person (parent, sibling, spouse, etc) for emotional support and a sense of security. Attachment insecurities are associated with a wide range of mental illnesses including clinically significant anxiety, OCD, and PTSD, according to a February 2012 paper from World Psychiatry by Prof. Mario Mikulincer of Interdisciplinary Center Herzliya in Israel and Prof. Philip R. Shaver of the University of California at Davis from the U.S. In a study of 320 children and adolescents, 37% of subjects with mental illness experienced clinginess, reported N. Racine et al. in a paper from the October 2020 issue of Psychiatry Research. The tendency for clingy behavior can be a sign of a mental illness like anxiety disorder; it can also occur as a symptom of selective mutism.
Clingy behavior becomes a symptom of selective mutism because a child or adult feels uncomfortable in the situation that causes their mutism. As a result, they may become clingy or overly dependent on a person or people with whom they feel comfortable speaking. Patients with selective mutism have fears and social anxieties as well as additional speech and language difficulties. They may be cautious and stick to people they feel comfortable with.
Clingy behavior is a symptom of selective mutism because it is a natural response to situations that cause anxiety and discomfort. Individuals who feel insecure in social situations may become clingy to people that provide a sense of security.
Clingy behavior, as a symptom of selective mutism, is identified as refusal to stay alone, being reluctant to socialize or participate in social activities, constantly looking to a parent or family member that provides security for approval, and children crying when their parents leave the room.
4. Shy and reclusive
The shy person feels fear or discomfort when around people, particularly in new situations or among strangers. Reclusive behavior refers to a tendency for seclusion and privacy. Shyness occurs due to self-consciousness, negative self-preoccupation, fear of judgment and rejection, and low self-esteem, according to Psychology Today. Reclusiveness can also occur due to various causes such as PTSD. People with selective mutism can become shy and reclusive.
Shy and reclusive behavior becomes a symptom of selective mutism because people and children with this disorder feel uncomfortable in situations that trigger their mutism. Being around people with whom they can’t speak makes a person feel easily embarrassed, especially when attention is on them and they are expected to talk. They may develop reclusive behavior and refuse to socialize.
Shy and reclusive behavior is a symptom of selective mutism because underlying causes of SM such as trauma can affect communication skills. When confronted by a stranger, a patient with selective mutism may withdraw. Discomfort being around people they don’t know leads to shyness and avoidance, which may turn into reclusiveness.
Shy and reclusive behavior, as a symptom of selective mutism, is identified as nervousness, timid and insecure demeanor, blushing, shaking, shortness of breath, and social isolation. A person with selective mutism can be outgoing and fun when around people they know such as their family, but they tend to become shy and reclusive when they are around strangers or when expected to participate in activities where they may interact with strangers.
5. Stiff, tight, or disorganized
Stiff or tight behavior is when a person is not relaxed and has a hard time adjusting to change. Disorganized behavior refers to lacking order and planning. A disorganized person lacks coherence and structure in life. People become stiff or tight due to major stress, anxiety, and mental illnesses such as depression. Disorganized behavior occurs due to mental illnesses such as schizophrenia, but may also occur due to anxiety and stress. Selective mutism can make a person stiff, tight, or disorganized.
Stiff, tight, or disorganized behavior becomes a symptom of selective mutism because patients with this disorder are overly cautious and it becomes difficult for them to feel comfortable and relax around people they don’t know. Selective mutism can lead to self-regulation difficulties that make a person or child inflexible. Self-regulation can also lead to disorganized behavior.
Stiff, tight, or disorganized behavior is a symptom of selective mutism because they are behaviors that an insecure person can’t control. Selective mutism changes the way a person or child behaves. They may appear flexible or disorganized because they don’t feel comfortable in a setting where they are unable to speak.
Stiff, tight, or disorganized behavior, as a symptom of selective mutism, is identified as hard time adjusting to changes, rejecting ideas that go against a person’s preferences, failing to keep up with tasks or homework and being easily distracted, procrastinating.
6. Aggressive or stubborn, throwing fits when kids return home from school, or becoming irate when parents question them
Aggressive behavior refers to any act or behavior aimed at harming a person or animal or producing damage to physical property. Stubborn behavior refers to the refusal to change the opinion or mind once the decision is made. Aggressiveness occurs due to multiple reasons including fear, stress, anxiety, trauma, and impaired communication skills, according to the Crisis Prevention Institute. Stubbornness occurs due to insecurities and even aggression. Both aggressive and stubborn behavior can be symptoms of selective mutism.
Aggressive or stubborn behavior becomes a symptom of selective mutism because anxiety-provoking situations cause behavioral problems. Patients with selective mutism display stubborn and controlling behavior, argumentativeness, oppositionality, and temper tantrums, as per the previously mentioned June 2021 paper from Frontiers in Psychology published by Dr. C.A. Kearney and Dr. M. Rede.
Aggressive or stubborn behavior is a symptom of selective mutism because it can occur as a part of a fight or flight response. When a person with SM comes into contact with a stranger or a person with whom they can’t speak, their autonomic nervous system (more precisely the sympathetic nervous system) is activated with a fight or flight response, according to Counseling Today. Although fight or flight response doesn’t necessarily cause fighting, it involves a higher release of adrenaline, which leads to more aggressive behavior, explained Calm Clinic.
Aggressive or stubborn behavior, as a symptom of selective mutism, is identified as throwing fits when getting home from school, getting angry when questioned by parents, becoming bossy, assertive, and domineering at home, crying spells, and acting out negatively in school or at home, according to Selective Mutism Center.
What can I expect from selective mutism?
People with selective mutism display a major difference in the way they engage with people they don’t feel comfortable with. More confident patients with selective mutism may use gestures to communicate, but those with severe SM avoid any form of communication including nonverbal communication such as nodding for “yes” or shaking their head for “no”. It’s also possible that persons with selective mutism manage to respond with a few words or speak in an altered voice such as whispering.
Selective mutism doesn’t occur because a person refuses to speak with someone e.g. a person they dislike. An individual with selective mutism can’t speak in a specific setting or when around people they don’t feel comfortable around e.g. strangers.
The NHS explains that patients, mainly children, with selective mutism may experience associated difficulties. These difficulties include fear of making mistakes, accidents, and urinary infections resulting from the inability to ask to use the toilet and holding on for hours. School-age children may fail to eat or drink throughout the day so they avoid communicating to excuse themselves. Since a child with selective mutism may be unable to ask questions in class, due to their mutism, they tend to experience difficulties with homework.
Selective mutism affects the quality of life among adolescents and adults, too. They may not be able to become fully independent or they lack qualifications due to their inability to participate in college life and job interviews.
Anxiety in people with selective mutism is often reinforced by people in the patient’s environment. For example, a mother and child with selective mutism are in a mall and encounter the mom’s old friend. The friend asks a child what their name is, but the child can’t speak to the stranger. The child is unable to respond, which prompts a mother to answer for her. When that happens regularly, according to Anxiety Canada, the child learns that if they keep quiet, others such as parents will take care of the problem i.e. speak for them. For patients with selective mutism, such a scenario may occur several times a day. Every time they are “rescued” by another person such as a parent, they feel better and their anxiety symptoms relieve. However, a cycle of anxious avoidance ensues. After a while, this cycle may become an ingrained habit, which is difficult to break.
Characteristics of a person with whom a patient with SM is unable to speak include low familiarity, lack of distance (getting too close), authority characteristics (fear component), external characteristics (male, old age), and not being focused on needs of a child, according to April 2021 study by C. Schwenck et al. in European Child and Adolescent Psychiatry. The same study also revealed characteristics of a place or setting where a patient with selective mutism may not be able to speak. These characteristics include unknown place i.e. place that is new for the child, crowded places, places where the child has already had a negative experience, and places with high volume or much noise. Activities that may induce anxiety in patients with SM include new activities, motor activities to be learned/require courage, activities that a child can’t do or is afraid of failing, activities where attention could be on that child, and activities that involve communicating with other people or speaking in front of them.
Who is at risk for selective mutism?
Children between two and four years of age are at a higher risk for selective mutism. Anxiety disorder also puts a person at a higher risk of selective mutism. In addition to anxiety, communication delays and immigration or bilingualism are also implicated in a person’s susceptibility to developing selective mutism, according to a review by A. Hua and N. Major of Yale University in the February 2016 issue of Current Opinion in Pediatrics.
Untreated psychological issues such as trauma and PTSD may also increase the risk of selective mutism. Other risk factors, according to Cedars-Sinai, include problems with sound processing, speech and language problems such as stuttering, and a family history of anxiety disorders.
The risk of selective mutism increases when parents have a psychiatric disorder, according to a study by M. Koskela et al. in the May 2020 issue of BMC Psychiatry. The scientists found that if both parents had any psychiatric disorder, the odds of having a child with SM tripled. Fathers older than 35 years of age were more likely to have children with selective mutism. The same study revealed that an offspring of a single mother had a two-fold higher risk of selective mutism than children born to mothers who were in a relationship or married.
Relationships with parents may play a role in the development of selective mutism. A study by S. Melfsen et al. in the November 2022 issue of Children (Basel) showed that relationships with fathers scored lower in subjects with selective mutism compared to their counterparts who didn’t have this disorder. There was no significant difference in relationships with mothers between the two groups. Children and adolescents with selective mutism reported less emotional closeness, physical contact, and support by their fathers compared to their counterparts from the other group. The father’s model function was less pronounced, which led to a child or adolescent’s lack of confidence in their decision. Scientists explain that their findings confirm that the relationship between a child with SM and a mother is close, but their relationship with a father is passive or peripheral.
How is selective mutism diagnosed in children?
Healthcare professionals rely on multiple tests and evaluations to diagnose selective autism in children, but it all starts with questions about a child’s medical history and the symptoms they experience. A healthcare professional may ask a parent or caregiver questions about a child’s speech and language development. They may want to observe a child at school, and home, or parents may be asked to record videos.
The doctor performs a medical exam first. Medical evaluation includes an exam of a child’s ears, jaws, lips, and tongue. Neurological exams and hearing tests may be necessary as well. One of the main goals is to rule out other potential causes of symptoms that a child experiences, such as schizophrenia.
The diagnostic process may involve other healthcare professionals, such as a speech-language pathologist (SLP) or a psychiatrist and psychologist. The main purpose of involving an SLP is to evaluate a child’s ability to understand and use language, whereas a psychiatrist or psychologist can determine whether emotional problems cause symptoms.
During the evaluation, a child with selective mutism may not be able to speak to healthcare professionals. However, clinicians are prepared for this scenario and find another way for a child to communicate. For instance, a child can communicate through their parents.
How is selective mutism diagnosed in adults?
The process of diagnosing selective mutism in adults is similar to the diagnosis of SM in children. A comprehensive assessment is necessary, which involves speech and language evaluation or other healthcare professionals such as psychologists or psychiatrists.
A healthcare professional will diagnose selective mutism in children and adults when they meet the diagnostic criteria from DSM-5. These criteria include consistent difficulty speaking in situations when talking is expected despite having the ability to speak, difficulty speaking that isn’t due to lack of knowledge or comfort with the language, or trouble speaking that isn’t better explained by a communication, behavioral, or mental disorder. Symptoms need to last for at least one month in order to meet diagnostic criteria for selective mutism.
What are the available treatments for selective mutism?
Available treatments for selective mutism depend on the severity of symptoms and their impact on a person’s quality of life. Their effectiveness depends on the duration of SM, the presence of additional communication or learning difficulties, and the cooperation of everyone involved. The available treatments for selective mutism are listed below:
- Cognitive behavioral therapy
- Stimulus fading
- Family therapy
- Positive reinforcement
1. Cognitive behavioral therapy
Cognitive-behavioral therapy (CBT) is a type of talk therapy that helps people manage their mental problems by changing the way they think and behave. It is a structured and goal-oriented type of therapy. Cognitive behavioral therapy can be used to help people with depression, substance abuse, eating disorders, and other mental illnesses, including anxiety disorders. It is among the most significant approaches for the management of selective mutism in children and adults.
Cognitive-behavioral therapy helps treat selective mutism by helping a patient focus on how they think about themselves, other people, and the world. Patients with SM learn how their perception of people and the world around them affects their thoughts and feelings. The main goal of CBT is to help a patient identify unrealistic or irrational thoughts and replace them with more realistic alternatives. Thoughts influence emotions and behaviors. Changing the thinking pattern could positively influence emotions and behaviors, thereby reducing the severity of symptoms. In this case, it could help a patient with selective mutism talk.
Cognitive-behavioral therapy is one of the best treatments for selective mutism because it also involves exposure to situations that are less distressing to a patient and gradually work up to the more anxiety-provoking situation. The main purpose of exposure is to reduce the severity of anxiety that a patient experiences in specific settings. What makes CBT a practical treatment approach is that patients learn skills that improve their daily functioning, such as communication skills, and at the end of each session, they get homework. The homework is to practice the skills they learned during that specific session until the next appointment.
The effectiveness of cognitive-behavioral therapy for the management of selective mutism is scientifically confirmed. A review by Dr. Kasper Rud Østergaard of Aarhus University Hospital in Denmark, published in the May 2018 issue of the Nordic Journal of Psychiatry, found that 53 out of 60 children treated with CBT experienced an improvement in symptoms of selective mutism. Additionally, a case study by E. T. Reuther et al, published in the Journal of Clinical Child and Adolescent Psychology, reported that an eight-year-old Caucasian boy with selective mutism experienced improvements after 21 sessions of modular CBT for childhood anxiety disorders. After completing treatment, the child no longer met the diagnostic criteria for selective mutism. The improvements were maintained at follow-up after a month and six months. Even web-based CBT can improve speech and reduce the severity of selective mutism, according to a paper by Y.P. Ooi et al. in the July 2012 issue of Singapore Medical Journal.
When it comes to the efficacy of CBT, it is important to mention the findings that D. Cornacchio et al. published in the August 2019 issue of the Journal of Consulting and Clinical Psychology. They found that Intensive Group Behavioral Treatment (IGBT) for children with selective mutism was effective and associated with high satisfaction and low perceived barriers to treatment participation. IGBT is an intensive group CBT program that focuses on gradual exposure to verbal communication.
The specific number of sessions depends on the severity of the conditions. People generally need six to 20 CBT sessions to experience the best results. More than 20 sessions may also be necessary. For example, a girl with SM received 33 sessions of cognitive-behavioral therapy but started speaking after the 12th session, according to a post from Cognitive Behavioral Play Therapy. The typical duration of a CBT session is 30 to 60 minutes once or twice a week.
2. Stimulus fading
Stimulus fading is a behavioral technique that involves gradual exposure to feared stimuli. It is commonly used for the treatment of anxiety in children, especially selective mutism.
Stimulus fading helps treat selective mutism by gradually increasing the number of people and situations in which the child speaks. It uses shaping and contingency management (CM) in the process, according to Association for Behavioral and Cognitive Therapies (ABCT). The term shaping refers to enabling a patient to gradually produce a response closer to the desired behavior. More precisely, the patient with SM communicates at ease with someone e.g. a parent, when nobody else is present in the room. The therapist gradually introduces another person to the situation. This is called fade-in. Once the person is included in talking, the parent withdraws i.e. they’re instructed to leave the room. The new person uses the same way to introduce other people.
Stimulus fading is one of the best treatments for selective mutism because it “trains” a patient how to behave or react in situations or settings where they can’t speak. By gradually increasing the number of people in the setting, children learn to improve their response which lessens their anxiety and may help them talk.
Stimulus fading is an effective treatment approach for SM, but more research on this subject is necessary. A case study by M. Wilbert et al, published in the Fall 1973 issue of the Journal of Applied Behavior Analysis, found that stimulus fading helped a six-year-old girl with SM to improve her symptoms. Stimulus fading was found to be a necessary component of treatment for selective mutism. It worked well in combination with contingency management. Effective treatment package for selective mutism, including stimulus fading, video self-modeling, and behavioral reinforcement techniques for eight weeks, led to improvement of verbal communicative behavior, according to a paper by P. Bork and S. Bennett of Brock University in Canada, published in April 2020 issue of Clinical Child Psychology and Psychiatry.
A study by C. Rodrigues Pereira et al. in the August 2020 issue of Contemporary Clinical Trials Communications found that behavioral techniques that involve shaping and gradual exposure have an advantage in the treatment of children with SM. The main advantage is that the treatment takes place at school, where selective mutism tends to be present the most. Scientists explain that the theory is that once a child is able to speak at school, it becomes easier to generalize speaking behavior to other social settings (e.g., speaking to distant family members). Behavioral techniques are particularly effective among children who are too young to benefit from cognitive elements in the treatment of selective mutism.
The exact number of sessions for stimulus fading is unclear because it depends entirely on the patient and how they react to the introduction of new people. Each session lasts a few minutes only.
3. Family therapy
Family therapy is a type of therapy that helps family members resolve conflicts and improve their relationships. It may include all family or just members who are willing to participate. Mayo Clinic explains that family therapy teaches skills that deepen family connections and help overcome stressful or difficult times. Patients with selective mutism benefit from family therapy.
Family therapy helps treat selective mutism by enabling a patient and their family to work on emotional issues that underlie the anxiety symptoms and mutism. During therapy sessions, family members understand the loved one’s anxiety. They learn more about selective mutism and why their loved one is unable to speak in certain situations or around specific people e.g. strangers. Family therapy sessions also serve to empower and encourage the family to learn how to interact without reinforcing anxious habits and behaviors.
Family therapy is one of the best treatment approaches for selective mutism because a patient with this condition is comfortable speaking to their closest relatives and may rely on them for “rescue” in situations when they are unable to speak. Additionally, family therapy could be helpful for people whose selective mutism is associated with dysfunctional family dynamics and a history of abuse.
Research on the effectiveness of family therapy for the treatment of selective mutism is lacking. However, a review by P. Goger and V.R. Weersing from the January 2022 issue of the Journal of Marital and Family Therapy found that family-based interventions are a good alternative for the treatment of anxiety disorders in youth. Similar were the findings of a paper by M.W. Lippert et al. published in Innovations in CBT for Childhood Anxiety, OCD, and PTSD. They found that family-based cognitive-behavioral therapy is at least as effective as a child-focused treatment for anxiety disorders. These results indicate that family therapy could be as effective as individual therapy for anxiety disorders; selective mutism is a type of anxiety disorder.
Family therapy is usually short-term and takes around 12 sessions. The typical duration of each session is 50 minutes to an hour. Keep in mind the therapist recommends the most suitable number of sessions based on specific cases i.e., each patient and their needs.
4. Positive reinforcement
Positive reinforcement is the introduction of a pleasant or desirable stimulus after a behavior. One of the most significant forms of positive reinforcement is contingency management, a behavioral technique that reinforces or rewards an individual for evidence of positive behavior. Positive reinforcement is an important treatment approach for patients with selective mutism.
Positive reinforcement helps treat selective mutism because it encourages speaking while making sure a patient doesn’t perceive it as a negative behavior. When a patient with selective mutism is under pressure to speak, they will feel relief once the moment is over. This reinforces their belief that talking is a negative experience and may worsen their condition. Positive reinforcement rewards verbal behavior, but may initially include reinforcement of nonverbal communication like whispering or pointing. The main objective is to encourage and empower a patient with SM to open up to communication and reward their effort to make a positive step forward. The therapist may also choose to reward speaking only, not nonverbal communication.
Positive reinforcement is one of the best treatments for selective mutism because it can involve several methods, and the therapist can choose the best option for the specific needs of each patient. In the beginning, the therapist chooses a reward that is appealing to the patient. For a patient to receive the reward, they need to complete a specific speech task. These tasks become more demanding each time until a patient is speaking freely in a setting that causes their selective mutism.
The effectiveness of positive reinforcement for selective mutism calls for further research. However, it’s useful to mention a study by P.A. Kusuma Wijayanti and M. Murtini from the October 2021 issue of Gadjah Mada Journal of Professional Psychology, which found children with SM communicate more when they have a stimulus i.e., reward. The study found a significant increase and communication with stimulus as opposed to communication without stimulus. Frequent verbal communication occurs when a child receives more stimuli or reinforcement.
How soon a patient notices improvements with positive reinforcement depends on the severity of the condition. There is no specific number of sessions or length of a program.
Antidepressants are medications created specifically to treat major depressive disorder (MDD). In addition to MDD, doctors may prescribe antidepressants to manage other mental illnesses, such as anxiety disorders.
Antidepressants help treat selective mutism by managing depression, this condition may cause and by reducing anxiety levels. According to the NHS, medications such as antidepressants are more appropriate for older children, adolescents, and adults whose anxiety causes depression. They may help alleviate anxiety, especially in cases when a patient with selective mutism has already tried treating their condition without much success. The mechanism of action through which antidepressants work depends on the type of these medications. For example, selective serotonin reuptake inhibitors (SSRIs), the most frequently prescribed antidepressants, work by increasing levels of the neurotransmitter serotonin in the brain. Serotonin participates in many functions ranging from sleep and digestion to regulating mood. Low serotonin levels are associated with depression and anxiety disorders.
Antidepressants are among the best treatments for selective mutism because they work well in combination with therapy. Medications such as antidepressants are never the main treatment approach for patients with selective mutism. Doctors prescribe them as an adjunct to therapy. For example, in October 2022, researchers at Uppsala University in Sweden, Olof Hjorth, and Tomas Furmark, found that SSRIs are particularly effective in combination with CBT. The combination of the two treatments can lead to significant changes in the brain.
Antidepressants are effective in managing selective mutism, and current evidence confirms their potential. For instance, treatment with SSRI paroxetine (Paxil) was well-tolerated by an eight-year-old girl with separation anxiety disorder and selective mutism, according to findings of a case study by Dr. Robert B. Lehman from the March 2002 issue of the Journal of Psychiatry and Neuroscience. Within two to three weeks, the patient experienced recovery of SM and made significant progress in the number of episodes and severity of anxiety attacks.
In their review from the June 2016 issue of European Child and Adolescent Psychiatry, K. Manassis et al. revealed that there is evidence of symptomatic improvement of selective mutism with antidepressants, especially SSRIs, but more research is necessary. They also emphasized the importance of further studies regarding optimal dosage. The need for more research is also highlighted in a review that Y. Kaakeh and J.L. Stumph of Purdue University published in the February 2008 issue of Pharmacotherapy. They reported that patients with selective mutism might respond to therapy with SSRIs and added that fluoxetine (Prozac) is the most studied antidepressant for this condition.
It is necessary to take antidepressants for one to two weeks before benefits start to kick in. Antidepressants such as SSRIs may take four to eight weeks to exhibit their full effects. The doctor recommends the most suitable dosage based on the severity of the symptoms.
How to prevent selective mutism?
There is no bulletproof method to prevent selective mutism. The exact causes are still unclear and the condition itself is complex, which is why there is no surefire strategy to prevent it. However, it is important to establish a safe environment where a child can develop and thrive.
Children may develop selective mutism due to family conflicts, abuse, trauma, or situations when they do not feel safe. Difficulty processing stressful or traumatic events may contribute to selective mutism. For that reason, it is important to ensure a child is growing up in a safe and functional environment or that they receive professional help and guidance following exposure to traumatic events. Children and adults with a history of abuse or trauma may need therapy so that they can learn to cope in a healthy manner.
How to reduce selective mutism?
In order to reduce selective mutism and alleviate anxiety, it is necessary to follow the tips listed below:
- Adhere to the treatment: the most important thing for children and adults with selective mutism is to adhere to the treatment and stay motivated during therapy sessions or behavioral programs. Parents may want to stay closely involved with their child’s therapy for the best outcome.
- Be patient: parents need to be patient with their children and give them time to choose their words and speak when they feel comfortable. It is also important to encourage others (e.g., distant relatives who are visiting) to do the same. Adults with SM also need to exercise patience and give themselves time to establish verbal communication in a setting where they don’t feel comfortable.
- Consider environmental adjustments: a patient with selective mutism should avoid sources of stress because they could reinforce avoidance behavior. For instance, instead of avoiding family gatherings entirely, a child or an adult with SM should meet family members first individually so they can feel comfortable around them. This strategy can work in other types of settings, such as classes.
- Avoid pressure: people with selective mutism should not be pressured to speak because it can worsen their anxiety. Parents, friends, and colleagues may want to avoid putting too much pressure on a child or adult with SM because it can be counterproductive.
- Avoid praising in public: while positive reinforcement can help a patient with selective mutism, praising them in public can cause embarrassment. This can be particularly difficult for people who already have social anxiety. Always praise a person or child’s progress in private.
- Try a different way of communication: adults with selective mutism may want to try communicating via text or email until they feel more comfortable around a person they just met.
- Take part in fun activities: if a patient with SM finds it difficult to communicate, it could be useful to do an enjoyable activity together instead. This is particularly helpful when a patient with SM is a child. Doing so takes the focus off of communication, reduces the risk of anxiety, and provides an opportunity for a child to bond with you.
- Learn: the more a person knows about selective mutism, the easier it becomes to understand the condition and anxiety they experience. Adults may want to educate themselves about selective mutism so they can gain a better understanding of how to overcome it and why sticking to the treatment is so important. The same applies to parents whose children have SM; they can use their knowledge to help their children understand why they feel the way they do.
- Inform teachers: parents whose children have SM may want to inform teachers about their child’s condition, so they can know the inability to speak is not intentional.
Is selective mutism an anxiety disorder?
Yes, selective mutism is an anxiety disorder because a patient with SM feels anxiety when exposed to settings or people that cause their mutism. Before DSM-5, this disorder was in the category of childhood diseases. In DSM-5, selective mutism is among other anxiety disorders such as GAD because adults can have this condition too.