What Is Selective Mutism?

Selective mutism is an anxiety disorder characterized by an inability to speak or communicate in certain social settings, such as at school, work, or in the community. The condition is usually first diagnosed in childhood.

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 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 of Selective Mutism 

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.

Selective Mutism in Children

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.

Selective Mutism in Adults

In some cases, selective mutism persists from childhood to adolescence, and even into adulthood.

In order to be diagnosed with selective mutism as an adult, the following criteria are usually present:

• Symptoms of selective mutism must have been present for at least one month.
• Symptoms must interfere with functioning at work or in social settings.

Adults with selective mutism often display behaviors similar to those related to social anxiety disorder, such as fearing public spaces (i.e., restaurants) and/or speaking to unfamiliar people. Selective mutism (and social anxiety) may cause an individual to avoiding social situations or withdraw completely, leading to social isolation.

A health professional will likely ask questions related to these or other behaviors when considering selective mutism as a diagnosis.

Causes of Selective Mutism

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
• Problems with self-regulation

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
• Autism spectrum disorder (ASD)
• Depression
• Developmental delays
• Language problems
• Obsessive-compulsive disorder (OCD)
• Panic disorder

Complications of Selective Mutism

Unfortunately, selective mutism may worsen anxiety. For instance, a child with selective mutism may dread going to school, where their condition makes it hard for them to be accepted among their peers.

Selective mutism can lead to communication problems. An adult who has selective mutism may be perceived as judgmental or passive aggressive if people around them don't understand their condition—an added layer that can make coping with the condition even more challenging.

If you or someone you know is experiencing the symptoms of depression, it's important to seek help. It may be beneficial to confide in trusted loved ones about your challenges; in addition, a mental health professional can help you navigate the frustrations you're experiencing.

Selective Mutism 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.

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

Therapy

A common treatment for selective mutism is the use of behavior management programs. Such programs often base the treatment around cognitive behavioral therapy (CBT).

In a study examining children with selective mutism who received CBT for five years, researchers found that the majority were able to speak outside of the home and symptoms lessened of comorbid anxiety disorders.

Techniques used in cognitive behavioral therapy for individuals with selective mutism may include:

• Desensitization: This is the process by which, over time, a person can overcome sensitivity to anxiety triggers by experiencing them directly. It's a slow and gradual process.
• Exposure therapy: During exposure therapy, a psychologist creates a safe space wherein an individual is exposed to the object of their fear (with selective mutism, this may be speaking in front of or directly to a stranger).
• Reinforcement: A therapist may teach someone with selective mutism how to use positive reinforcement to alleviate anxiety. For instance, together, you may come up with positive coping statements to use instead of negative self-talk when in situations that trigger selective mutism.
• Shaping: Shaping is a process by which desired behavior is rewarded with positive reinforcement (however, undesired behavior is not negatively reinforced). For instance, when a child with selective mutism makes any attempt to speak to a teacher or another child, a caregiver may reward them with extra television time or a later bedtime.
  

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 With Selective Mutism

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.