Selective Mutism

What is it?

Selective mutism (SM) is an anxiety disorder in which a child is unable to speak in some settings and to some people. A child with SM may talk normally at home or when alone with her parents, but cannot speak at all, or speak above a whisper, in other social settings. Parents and teachers often think the child refuses to speak, or speak loud enough to be heard, but the child believes they are unable to speak. SM can cause severe distress and prevents her from participating in school and other age-appropriate activities. SM should not be confused with shyness or a reluctance to speak when learning or adapting to a new language.

Signs and Symptoms

A child with selective mutism may be chatty at home but unable to talk at school. Some children seem paralyzed with fear when they are unable to speak and have difficulty communicating even nonverbally. Others will use gestures, facial expressions, and nodding to get by. Some children will be quiet at home when someone other than a family member is present. Parents often notice signs of SM when a child is 3 or 4 years old, but she may not be diagnosed until she gets to school.

Diagnosis and Treatment

To be diagnosed with SM, a child must be able to speak in some settings but not in others. The condition must have lasted for a month (not the first month of school) and it must interfere with education and social activities.

Diagnosis should be made by a professional familiar with selective mutism who can rule out other conditions with similar symptoms. The clinician making the diagnosis relies on reports from parents and other adults in the child’s life.

Behavioral therapy is recommended for SM. The therapist works with the child and her parents to gradually and systematically approach settings where she cannot speak, building her confidence one situation at a time. The child is never pressured to speak and is always encouraged with positive reinforcement. The therapist teaches parents and the child how to use these techniques in real-life settings.

Medication is not always necessary to treat SM. Some children may be prescribed anti-anxiety medications if their condition is severe, they’ve had SM for a long time, if they have not done well with prior behavioral or other psychotherapy, or if they suffer from other impairing anxiety disorders in addition to selective mutism. Some children will be prescribed medication if the results of an initial behavioral intervention fall short of the desired gains, or the process is too onerous. The preferred medication for SM is one of the selective serotonin reuptake inhibitors (SSRIs) or antidepressants. SSRIs are effective for anxiety and are tolerated well by children, who should always be monitored for side effects.

What are the risk factors for children?

Because it overlaps with social anxiety disorder, there may be a genetic connection to SM. Other risk factors are temperamental (negative affectivity, behavioral inhibition) and environmental, including socially inhibited or overprotective parents.

Children with selective mutism tend to have been very socially inhibited and may be diagnosed with other anxiety disorders like social anxiety disorder, separation anxiety disorder, and phobias. Some appear oppositional when pressured to speak. Children with SM may also suffer from mood disorders and learning disorders.