Selective Mutism

Selective mutism is a childhood anxiety disorder where a child cannot speak in almost all social situations despite being able to. Most children with selective mutism are believed to have an inherited predisposition to anxiety, and there can be a variety of additional contributing causes.

What causes selective mutism?

Doctors are not always sure what causes some children to develop selective mutism although it is thought to occur as the result of anxiety. Most children with selective mutism are believed to have an inherited predisposition to anxiety. There can be some other contributing factors. Some children may have sensory integration dysfunction (trouble processing some sensory information) which causes anxiety, making them “shut down” and unable to speak. Many children may have some auditory processing difficulties, and many have speech or language disorders that add stress to situations in which they are expected to speak. Some children develop the condition as the result of some sort of psychological trauma. Selective mutism usually begins in children under five years of age, though it may only become noticeable when a child begins school. A common misconception is that a selectively mute child is defiant or stubborn.

What are the signs and symptoms of selective mutism?

Children with selective mutism are unable to speak in specific social settings. These children are often able to verbalise appropriately for their age in settings in which they are comfortable, such as in the family home, but lose the ability to do so in other settings. They may speak easily with parents and close friends but “clam up” at school or nursery. Very often the child finds their inability to communicate highly frustrating and embarrassing. This can serve as a vicious circle only serving to make the problem worse.

How is selective mutism normally diagnosed?

Selective mutism needs to be formally diagnosed by a qualified child mental health professional. If there are have concerns that a child is displaying signs of the condition, a GP can advise and refer if necessary. Selective mutism must be diagnosed according to specific guidelines. These include observations that:

  • the child does not speak in specific settings
  • the child can speak normally in alternate settings
  • their inability to speak interferes with their ability to function in the setting
  • the child’s inability to speak has lasted for at least six months
  • the child’s inability to speak is not related to another behavioural, mental or communication disorder

How is selective mutism normally treated?

Selective mutism should be diagnosed and treated as quickly as possible. Treatment focuses on lowering the anxiety that the child has for speaking in a particular setting. Treatment does not focus on the speaking itself. The most common forms of treatment for this condition are behavioural therapy, cognitive behavioural therapy and play therapy.

Behavioural therapy is an approach to psychotherapy designed to reinforce desired behaviours and eliminate undesired behaviours. It does not examine a child’s past, or concern itself much with their thoughts. Instead, it concentrates on eradicating the difficulty practically. This is usually done in a step-by-step approach giving a person techniques and exercises which help them conquer their fears.

Cognitive behavioural therapy works by helping a person talk about how they think about themselves, the world and other people and how their perception of these things affects thoughts and feelings.

Play therapy is generally used with children aged three to 11. It provides a way for them to express their experiences and feelings through a natural, self-guided, self-healing process. As children’s experiences and knowledge are often communicated through play, it becomes an important vehicle for them to know and accept themselves and others.

Another technique used to treat selective mutism is called stimulus fading. In this technique, the patient is brought into a controlled environment with someone with whom they are at ease and can communicate. Gradually another person is introduced into the situation involving some small steps.

Desensitisation is another approach. This works by encouraging the child to communicate via indirect means – such as email, instant messaging (either text, audio, and/or video), online chat or voice or video recordings. The child can continue to build up relationships this way until they feel ready to try more direct communication.

Another technique is called shaping. Here a child is encouraged to interact nonverbally before being slowly coaxed into trying sounds – clicks and hums, then whispering and gradually trying a word or two.

Some doctors use medication as a way to treat selective mutism. This may include trying some antidepressants which are used to decrease anxiety levels to speed the process of therapy. However, medication is more often used for older children and teenagers whose anxiety has led to depression and other problems.

Family therapy can also be helpful. Relatives and friends of children diagnosed with selective mutism can have a major impact on the success of treatment for this disorder. A child needs love, support and patience as well as verbal and emotional encouragement.

At no time should a child suffering from this condition be expected or prompted to talk. Instead, attention should be focused on making the child feel comfortable and confident in social settings.

What next?

This condition can be debilitating – preventing children from interacting normally and from learning normally at school. If left untreated it tends to get worse. However, it is not impossible for a child with selective mutism to ‘unlearn’ their fears, and begin to speak again.

Credit: The Child And Adolescent Mental Health Service, Great Ormond Street Hospital For Children, August 2013.