Selective Mutism (What It Is & What You Can Do)
If you are raising a child who talks freely at home, but teachers have reported that they are silent or unable to speak at school, you may have a child with selective mutism (SM). This behavior can be difficult for adults to understand. Many people wonder “how can a child who is so chatty in one setting fall completely silent in another setting?” or “my child speaks perfectly fine at home… why is he a completely different person at school?” When a child begins to show signs of SM, many parents feel worried, confused, and overwhelmed. These reactions are common and understandable. The good news is, thanks to growing research, our understanding of SM and our ability to effectively treat this disorder is stronger now than ever before. This article aims to demystify selective mutism - a diagnosis that is often misunderstood - and guide you toward the most effective means of treating SM.
WHAT SELECTIVE MUSTISM IS
Selective mutism (SM) is an anxiety disorder characterized by an inability to speak in certain settings, such as school or out in the community. Fewer than 1% of children have selective mutism, making it a relatively rare anxiety disorder. Most children develop SM before the age of 5, however, it is not uncommon for children to go undiagnosed until they enter school. As children with SM begin to have interactions with people outside of their immediate family, they demonstrate a failure to speak when speaking is expected. This is often first noted when a child enters nursery school or preschool.
Children with selective mutism are able to speak comfortably and communicate effectively in other areas of their life, such as at home or when with family members. However, when these children are in public or social settings, they appear nonverbal and are unable to communicate with their voices. This can be shocking for parents and caregivers who are accustomed to their child speaking freely at home. In addition to lack of speech, those with SM may demonstrate other anxious or avoidant behaviors such as avoiding eye contact, relying on nonverbal communication (e.g., pointing or nodding), or whispering their answers to a trusted friend or family member rather than answering questions directly to the person who asked.
A significant part of understanding selective mutism is actually understanding what selective mutism is not. There are many myths and misunderstandings attached to this diagnosis.
WHAT SELECTIVE MUSTISM IS NOT
Shyness. Many children are shy. SM goes beyond shyness and prevents children from successfully engaging in environments that require speaking.
Oppositional or manipulative. Children with SM are not deliberately choosing not to talk. Those with SM are experiencing high anxiety and distress and are not purposefully refusing to speak. Viewing children with SM as oppositional or manipulative can have harmful, adverse effects.
A speech and language delay. Although SM can co-occur with speech and language delays, one does not indicate another. Some children with SM experience speech and language concerns, but many do not. This requires thorough assessment from a professional.
Trauma. Selective Mutism is an anxiety disorder that is not caused by trauma. Rates of trauma in those with SM are consistent with the general population.
Autism. When in an anxiety-provoking environment, children with SM may demonstrate stereotyped behaviors such as difficulty maintaining eye contact or lack of verbal communication. However, autism spectrum disorder (ASD) and selective mutism (SM) are unique and separate diagnoses.
Outgrown. Early identification and treatment of SM is essential. The myth that SM will be outgrown with time or age is rarely true.
Many people find themselves wondering how selective mutism “happens”. Like many anxiety disorders, SM is understood to be caused by both genetics and environment. A genetic predisposition to anxiety combined with certain environmental or situational factors can lead to the development of SM.
SM & the environment
Take a moment to imagine the following scenario…
You are planning to attend a birthday party with your 5-year-old daughter. She has been looking forward to the party all morning and has talked with you at home about her excitement for the bounce house and birthday treats that await. When you arrive at the party, you knock on the front door and step into the entryway. You and your child are greeted by the parents of the birthday girl who say, “Hi, Emma! How are you doing today?” You look down at your child who appears frozen, staring at the floor and not responding to the friendly question from these other parents. An awkward silence falls on the group and you quickly state, “Oh, Emma has been having a great day, haven’t you, sweetheart? She is doing great!” The whole group takes a collective exhale - both Emma and the adults feel relief. The awkward silence has passed, Emma is no longer expected to answer a question, and you can all move on. You help Emma with her shoes, and she runs off to the birthday bounce house.
Parents of children with selective mutism find themselves in scenarios like this one all too often. When the child is asked a question or prompted to engage verbally, the child becomes highly anxious. This prompts avoidance - a common behavioral response to feelings of anxiety. In the case of SM, avoidance typically looks like not speaking at all. Sometimes, it can also look like pointing, whispering, or gesturing (an avoidance of verbalization). When a child is asked a question and does not respond verbally, this causes discomfort for everyone involved. Both the child and the adult(s) may feel awkward, embarrassed, anxious, or some other uncomfortable emotions. Cue the cycle of reinforcement...
When a child with SM is not producing speech when they are expected to speak, the typical response from adults is to “rescue” the child in the moment. This often means speaking for the child or somehow excusing the child from the question or request for verbalization. In the case of Emma at the birthday party, rescuing happened when her parent stated, “Oh, Emma has been having a great day, haven’t you sweetheart? She is doing great!”. By stepping in and speaking for Emma, her parent alleviated Emma’s anxiety and distress and helped the other adults in the scenario to feel more comfortable, too. The whole group was able to avoid discomfort as swiftly as possible. Everyone’s anxiety levels decreased and everyone (child and adults included) felt better. While this may seem like a natural or even helpful way to respond to a child who is not speaking when expected to speak, this way of responding to SM accidently reinforces SM in the long run. This is what we will call the cycle of reinforcement.
a word on self-compassion for parents
It is important for us to note that the cycle of reinforcement is something that occurs in nearly every household where a child has SM. When parents learn about their own role in the cycle of reinforcement, it is not uncommon for parents to feel emotions such as shame, regret, confusion, or anxiety (to name a few). We want to be clear that responding to your child in a way that inadvertently reinforces their SM is a natural thing to do. As their parent, you are hardwired to protect and care for your child. Witnessing them in distress is distressing for you, prompting an automatic response to alleviate that feeling as soon as possible. Parents who deeply love and care about their child may find themselves speaking for their child or even helping their child to avoid situations where speaking is expected. Other adults in your child’s life may find themselves accidentally reinforcing SM in the same way. Teachers, family members, and other adults are often engaging in the cycle of reinforcement as well.
As you learn more about the cycle of reinforcement and the role adults can play in the treatment of SM, we encourage you to practice self-compassion. Take a moment to notice what comes up for you as you think about your role in supporting your child with SM. What emotions are you noticing right now? Perhaps you are feeling overwhelmed by information, guilty for your role in accidentally reinforcing, or even feeling grateful to be taking the next step in getting help for your child and family. All of these feelings are valid and common for parents of a child with SM. There are many other parents in the world who have experienced some of the same feelings you are experiencing right now. We invite you to show yourself kindness in this moment and remind yourself that you have done the best you can and will continue to do the best you can for your child and your family. Taking these next steps to learn more about how to support your child with selective mutism is a wonderful and loving thing to do.
Since many adults’ well-intentioned behaviors ultimately reinforce SM, it is important for families to be able to receive evidence-based treatment. The most effective treatments for SM require the involvement of parent(s) and adult(s) in the child’s life in order to create effective and lasting change. This means parents and adults are essential members of the treatment team. When seeking the help of a trained professional for the treatment of SM, expect to be involved in the treatment. With the right evidence-based support, both parent(s) and child can disrupt the cycle of reinforcement and begin to move toward using a brave voice in settings where the child previously fell silent.
What to do about SM
At this time, the research supports behavioral and cognitive-behavioral (CBT) interventions for the treatment of selective mutism. Behavioral interventions tend to be most successful for younger children with SM and the addition of cognitive strategies is typically most effective for children who are at least 7 years of age. While behavioral and cognitive-behavioral interventions can vary, treatment often involves supporting the child through increasingly challenging speaking tasks and behaviors, in addition to positive reinforcement such as rewards or incentives for their successes.
Parent-Child Interaction Therapy for Selective Mutism (PCIT-SM) is one evidence-based behavioral intervention for SM that involves both the parent(s) and child in therapy. This intervention involves gradual exposure to social situations that involve speech, tailored to the individual child’s needs and experience with SM. PCIT-SM utilizes specific ways of interacting with your child to prompt verbalization, reinforce verbal responding, and increase your child’s likelihood of responding verbally when a situation requests or expects verbalization. PCIT-SM may involve the child, therapist, parent(s), and even other adults or school professionals in the treatment, depending on your child’s unique needs. Rather than reinforcing avoidance of speech, PCIT-SM works to decrease avoidance and increase the use of “brave voice”.
In addition to behavioral and cognitive-behavioral interventions, it is important to note that some individuals with SM may benefit from medication, speech therapy, or additional interventions. If you are wondering about the use of any additional interventions for the treatment of SM, consult your child’s provider(s) to learn more.
A path forward
Raising and supporting a child with selective mutism can be challenging, confusing, overwhelming, and also rewarding. The great news is that treatment of SM is possible, and the prognosis for children who receive evidence-based treatment is quite good. The research supports the notion that the sooner a child with SM receives intervention, the quicker they will respond to the treatment and the better the treatment outcomes. Your child can find their “brave voice”. If you are concerned that your child may be experiencing symptoms of selective mutism, it is not too soon to reach out for more information. You and your child deserve support in navigating the path forward.
Mind Chicago therapist Hannah Romain, LCSW offers evidence-based treatment for children with selective mutism and parents of children with selective mutism. To learn more, reach out to Mind Chicago today at hello@mindchicago.com.
This article was authored by Hannah Romain, LCSW.
