According to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), Selective Mutism is a childhood disorder typified by an inability to speak in certain circumstances. To put it plainly, it is a consistent failure to speak in certain social situations where there is a natural expectation of speaking. For instance, a child may be verbal at home but unable to speak at school, selective mutism can also be person-specific that is the child may be mute with some persons but not with others, thus symptoms are typically context specific. Children with selective mutism often find it easier to talk to other children compared to adults. Some will occasionally be able to whisper to a best friend at school.

Children with selective mutism differ widely in their ability to use nonverbal communication (e.g., eye contact, gestures, nodding and pointing). While some use nonverbal communication effectively, others are non-communicative and might not even laugh or cough in front of others. The latter are often unable to express their needs (like going to the toilet, hunger, thirst, or pain), highlighting the potential seriousness of this condition.

In spite of the considerable stress experienced at school, school refusal is rare. Selective mutism is often comorbid with other anxiety disorders, especially social anxiety disorder, and with neurodevelopmental disorders, especially language disorders.

Signs & Symptoms of Selective Mutism

•  A child who is talkative at home with his family, but changes his speaking to words with one syllable and utters or gestures in order to communicate in a different context like school.
•  Extremely attached (clingy) to parents or caregivers.
•  Excessive shyness.
•  The child avoids contact with other individuals (social isolation).
•  Emotional outbursts and temper tantrums.
•  Fear of embarrassment in front of a group
•  Oppositional behavior
•  Compulsive traits
•  Negativity towards a place(s) or individual(s).

Sometimes parents and educators are quick to label a child as having a certain disorder they actually do not have, so I will include signs that do not indicate selective mutism and these are:

A child has never talked in any situation or environment.

•  A child has just recently been introduced to the language in a particular environment. It is estimated that it takes up to half a year to become comfortable with a new language. When a child is learning a second language, he may go through a silent period until he becomes confident with speaking.
•  The mutism occurred abruptly in every environment after a traumatic event (note that it is mutism but it is no selective it is overall).
•  Sometimes other speech difficulties like stammering are present so a child avoids speech occasionally.

How is Selective Mutism Diagnosed?

The diagnosis of Selective Mutism may begin when parents or caregivers and educators recognize the out- of-the ordinary behavior and inconsistencies in speech between different environments like

home, school, church, public spaces or family gatherings. According to the DSM-5, prevalence is reported to be rare between 0.03% – 1% (in the American context), however what I have experienced in my work with children this side of the world is that, this disorder is not taken seriously, both parents and educators believe it is normal for some children and they will grow out of it. A comprehensive developmental screening is advised as well as a thorough speech and language evaluation.

The diagnostic criteria for selective mutism (DSM- 5) is as follows:

A. Consistent failure to speak in specific social situations in which there is an expectation

B. The disturbance interferes with educational or occupational achievement or with social communication.

C. The duration of the disturbance is at least 1 month (excluding the first month of starting school or moving to a new school). – [As many young children are silent when they face a new situation, such as starting school].

D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

The duration of the disturbance is at least 1 month (excluding the first month of starting school or moving to a new school). – [As many young children are silent when they face a new situation, such as starting school].
The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

E. The disturbance is not better explained by a communication disorder (e.g., childhood onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

The child’s lack of speech should interfere with daily functioning; the absence of speech hinders the child’s capacity to function at school or in social interactions. Children with selective mutism often present with symptoms of other anxiety disorders, particularly social anxiety disorder. Studies have found this comorbidity in about 90 % of cases.

There is no known physiological cause(s) of selective mutism and as such seeking the expertise of a professional who has experience in the diagnosis of selective mutism is paramount. And just like other disorders that do not have an organic cause, diagnosis becomes a painstaking and time consuming process.

Diagnosis may include but not limited to:

•  Parental interview – the therapist will compile a complete medical history of the child, development, social interactions, manifestation of anxiety, behavioral characteristics, and home life description.
•  Interview or interviews with the child and this can be a very long process because the therapist need to establish a warm and caring environment (rapport) to enable the child to communicate.
•  Observations of the child in the different environments to try and see the dynamics at play that might be contributing to the pathology.
•  Referral to other professionals if need be like a speech therapist for example.

What Causes Selective Mutism? / Risk Factors

No single cause for selective mutism has been found thus far. However, the understanding of this disorder has changed over the years and certain factors have emerged that has made professionals to piece together probable etiology and these are:

Genetic factors – Selective mutism and social anxiety run in families so there is a genetic predisposition.
Temperament – The behavioral inhibition trait (fearfulness and avoidance in unfamiliar situations) is generally associated with a greater risk for later anxiety disorders. Behavioral inhibition (BI) refers to a well-studied temperament style identified reliably in infancy and early childhood. Young children with BI display heightened sensitivity to novel auditory and visual stimuli, and avoid unfamiliar situations and people.
Neurodevelopmental factors – Children with selective mutism have higher rates of several neurodevelopmental conditions. The most prevalent are speech and language problems but elimination disorders and motor delay are also common. There is a small overlap with autism spectrum disorders.  
Environmental factors – issues such as bilingualism can contribute to the development of selective mutism in children. Transitions such as starting school or changing schools, moving houses, changing care givers are some of the things in the environment that can trigger selective mutism in children. In contrast to shy children who will warm up over time, children with selective mutism continue to be mute and withdrawn for longer periods of time which makes it pathological. Sustaining factors in the environment like the behavior of the people surrounding the child. There are two opposite risks; one is to accept the child’s avoidance, speaking for them and accepting their inability to improve their communication and the other is to expect communication, even forcing it by putting punitive measures. Although well intended, both attitudes are not helpful, they increase the child’s discomfort and can aggravate symptoms.

Trauma – after a traumatic event, a certain location or a person can trigger selective mutism in children.

As for most child psychiatric disorders, it should be hypothesized that etiology is most probably an interplay of the factors mentioned above not just one factor.

Functional consequences of selective mutism

Selective mutism can negatively impact children in a number of ways, as children with this disorder struggle to engage in reciprocal social interactions, participate in classroom discussions and activities, and fail to assert their needs.

Selective mutism can result in the following functional impairments:

Academic problems: Most children with selective mutism can fall behind academically because they fail to speak up about their struggles or lack of understanding in the classroom.
Social isolation: Children with selective mutism struggle to engage in reciprocal social interactions in some situations, and this makes it difficult to make and maintain friends. This can also lead to bullying by other children which further aggravates the situation.

Low self-esteem

Social anxiety.

 Low self-confidence – as a result they do not apply themselves fully to activities or not at all.

 Pathological attachment style – Most of the children that suffer any form of an anxiety disorder tend to get very clingy to one person and become very dependent on that person – most of the children I came across that had selective mutism in the school context had that one friend or adult who they would either whisper to or communicate with using gestures and that person was the ‘spokesperson’ that would then tell you what would have been communicated. In some cases they would self-isolate themselves altogether making it difficult to form relationships.

Social anxiety.

 Low self-confidence – as a result they do not apply themselves fully to activities or not at all.

Pathological attachment style – Most of the children that suffer any form of an anxiety disorder tend to get very clingy to one person and become very dependent on that person – most of the children I came across that had selective mutism in the school context had that one friend or adult who they would either whisper to or communicate with using gestures and that person was the ‘spokesperson’ that would then tell you what would have been communicated. In some cases they would self-isolate themselves altogether making it difficult to form relationships.

Treatment for Selective Mutism

After a diagnosis of Selective Mutism has been made the parents should seek the counsel and support of professional child therapists to ensure a coordinated treatment approach is designed and implemented.

Any of the following psychotherapeutic approaches may be used in treatment:

Behavioral Therapy strategies

Contingency management – When people are rewarded for positive behavior, they’re likely to repeat that behavior in the future. This is referred to as operant conditioning—a type of learning where behavior can be modified when reinforced in a positive and supportive manner.
Social skills training (SST) – The objective of social skills training is to equip the child with the necessary skills to negotiate their own social context in a health way that is beneficial to them and also acquire healthy social relationships. This also targets the improvement of other relevant social skills and also equip them with problem solving skills.
Stimulus fading and modeling – This is when a therapists introduces the feared stimuli gradually (e.g., an unfamiliar person) closer to the child, allowing time for habituation (or adjustment) to the stimulus until child gets used to it and are comfortable. Modelling is basically modeling what you are expecting the child to do and they imitate, mostly using peers for this is more effective.

These strategies have all been used successfully for treating Selective Mutism. Each is intended to help the child gradually adopt speaking-type behaviors, and includes positive reinforcement when the child is successful.

Cognitive Behavioral Therapy (CBT) is another form of therapy that has been used in treating selective mutism. This may help the child identify the thoughts that make them anxious as they relate to the behavior. The child will work with the therapist to replace the negative thoughts with positive ones.

Speech Therapy – If a language disorder is present, then speech therapy is also needed in connection with other therapies to deal with the anxiety that comes with the pathology.

Pharmacological Treatment There is no consensus regarding this approach but I am putting it out there for parents to be aware and also to know the reasoning behind it. Because selective mutism is connected to social anxiety disorder and social phobia, doctors may prescribe antidepressants and antianxiety medications. It is believed that these anxieties are because of an imbalance of chemicals in the brain, particularly the neurotransmitter called serotonin

Things parents can do to help at home:

• Children with selective mutism benefit from preparation, so plan ahead of events you have control over and help them to be mentally prepared
•  Allow more time to adjust to new situations or transition – do not hurry them to ‘get over it’ or ‘deal with it’ or ‘be like other children’.  A structured environment is very beneficial for them because they know what to expect so try to keep a routine.
•  Communicate about changes and assure them of your support.

Prognosis Just like other disorders, the earlier a child is diagnosed and engages in a treatment plan the faster they will be able to respond and the better the overall prognosis. It is evident that the longer a child remains mute the more conditioned the child becomes to this response. In short, prognosis for this disorder is excellent; many children overcome it completely with proper treatment. When the child with selective mutism is diagnosed early and has a treatment plan in place, the better the prognosis is for them to overcome the condition. If a child isn’t diagnosed until much later, the mutism may become a conditioned response.

Talent Adamson Behaviour Therapist

BA (Health and Social Services) Applied Psychology, BA Hon (HSS) Psychological Counselling – (UNISA)