Selective Mutism
What is Selective Mutism?
Selective mutism is not autism or a child being controlling or manipulative.
Selective mutism is an anxiety disorder that is diagnosed in children when they consistently do not speak in specific social situations when there is an expectation to speak.
It is very rare, occurring in only 1% of the population. It is more common in children than adolescents, girls are twice as likely as boys to develop selective mutism, and it is usually first noticed before the age of 5.
These children do have the ability to speak but refuse to speak when there is a demand to speak. This can interfere with educational and social performance.
Children with selective mutism do not initiate speech or respond to both other children and to adults. Most of these kids will talk while at home with their parents, and some may talk excessively in these situations.
Children may also refuse to speak to extended family such as grandparents and cousins.
Children diagnosed with selective mutism tend to have very high social anxiety and may even be diagnosed with Social Anxiety Disorder (Social Phobia).
What are some other symptoms of selective mutism?
Children with selective mutism may exhibit excessive shyness, fear of being embarrassed, isolative behavior, clinging, negative thoughts, temper tantrums, and oppositional behavior.
Freezing or appearing paralyzed, gesturing, nodding, and facial expressions may also take the place of speaking when a child is feeling nervous or anxious.
These children may also show signs of separation anxiety. Crying, screaming, pleading, and clinging are common symptoms of separation anxiety.
Parents often endure these upsetting behaviors when leaving their toddler with a baby sitter, dropping their child off at daycare, and in some cases leaving them at preschool.
What causes selective mutism?
Anxiety is the major cause of selective mutism. Anything that overwhelms a child and causes anxiety could trigger mutism.
It all starts from infancy. We are born with biological defense mechanisms. The startle reflex, for example, is a protective reflex that causes us to tense up and become more alert for possible danger when we hear a loud noise.
Other protective reflexes that can occur are eye blinking, coughing, gagging, vomiting, and diarrhea. These are biological defenses designed to eject and ward off anything that is harmful.
During times of stress or panic, the sympathetic nervous system activates another biological defense mechanism.
The stress response or the Fight, Flight, or Freeze response is activated by the sympathetic nervous system to protect us from danger.
For kids with selective mutism the danger is speaking and having everyone’s attention focused on them. The mutism then appears as a “Freeze” response.
Children are too small to fight off danger so the freeze response helps by not drawing attention to the self and not appearing as a threat.
Predators in the wild often need a chase or a fight to stimulate hunger. When possums “play dead” their predator becomes disinterested and will move on.
Children who are more shy or slow to warm up may refrain from speaking in new situations or around new people. This behavior could inadvertently be reinforced by parents.
Sensory processing issues such as sensitivity to sound or mild difficulty with receptive language skills may overwhelm a child and trigger a freeze response.
Children who speak another language and are not fluent with the native language might feel more insecure and anxious about their ability to speak, causing them to be more inhibited.
Over-protective parents can unknowingly foster anxiety in social situations and reinforce selective mutism by speaking for their child.
This child learns that it’s OK to be quiet because mom or dad will come to the rescue and speak for them. This avoidance only temporarily reduces the anxiety and actually prolongs the fear of speaking.
Avoidance becomes a viscous cycle:
The more your child avoids speaking in certain situations, the more fearful those situations become.
The more fearful those situations become, the worse your child’s fear of speaking becomes.
The worse your child’s fear of speaking is, the more your child will want to avoid those situations.
What is post-traumatic mutism?
Post-traumatic or trauma induced mutism occurs suddenly after a traumatic event. The child who once spoke easily in most or all situations, now does not speak in any situations. This child may not even speak to parents.
This is an acute stress reaction associated with the “Fight, Flight, or Freeze” response in which the child is stuck in a portion of the freeze response.
The traumatic event can occur directly through actual experience or through witnessing the traumatic event.
The trauma can also occur indirectly through learning about an event that affected family or friends.
The traumatic event can be anything that causes the child to have distressing intrusive thoughts, memories, and dreams.
How is selective mutism treated?
If you believe your child is showing symptoms of selective mutism it will be helpful and important to seek consultation with a mental health professional to first verify the diagnosis and then receive appropriate treatment.
Behavioral Therapy
Behavior therapy focuses on understanding how the child is being reinforced not to speak. Examples include parents and teachers who let the kid off the hook by either wanting to reduce the child’s anxiety or because of being impatient with the silence.
Parents and teachers are then instructed on how to respond differently to the child’s selective mutism. Emphasis is placed on understanding and acknowledging the anxiety.
Strategies are developed to reinforce the child’s gradual communications beginning with non-verbal communications and progressing to simple verbal communications within the social setting.
Stimulus fading: This involves your child being in a situation with one person that she can easily talk to. Then gradually introducing other people into this situation one at a time until she is comfortable with the new person.
Shaping: You begin by reinforcing all non-verbal efforts at communicating and continuing through one word verbal responses.
Self-modeling technique: This is when a child watches a video tape of herself talking comfortably with another person in hopes of developing confidence at the ease in which she speaks in that situation.
Play Therapy
Play therapy allows children to express their emotions without the pressure to speak. They are able to work out their fear in a non-threatening way.
Play therapy encourages a child to use toys, a sandbox, stuffed animals, dolls, games, sports equipment, art, music, and dance to communicate and explore thoughts, emotions, and unresolved trauma.
Cognitive Behavioral Therapy (CBT)
CBT helps the child understand the connection between anxiety, thinking, behavior, and the selective mutism. It teaches them how to identify the unhelpful thoughts and behavior that cause and maintain anxiety.
Children become more aware of the triggers for their anxiety and challenge inaccurate beliefs about themselves, other people, and the world.
CBT teaches children how to create more balanced thoughts to reduce anxiety and teaches behavioral coping skills to reduce the physical symptoms of anxiety.
CBT can teach basic social and communication skills to increase confidence and decrease anxiety.
Cognitive Restructuring is a component of CBT. Patients learn how to logically identify and challenging unhelpful thoughts that may be contributing to or perpetuating anxiety.
Examples:
Fortune telling: Predicting that bad things will happen in the future.
Mind reading: You assume that other people are thinking negatively of you.
Catastrophizing: “This is the most horrible thing ever and things will get worse.”
Patients are then encouraged to challenge their unhelpful thinking by answering these questions:
“What is the evidence for this belief? What facts suggest this belief is 100% true all the time?”
“What evidence does not support this Belief? What facts or experiences suggest that this belief is not true all the time? Are there contradictory experiences?”
“How does this belief help me?”
“What would I tell a friend who had this belief?”
Exposure to the feared situations is a key component of CBT. This involves the child gradually but repeatedly experiencing the feared situation while using the learned coping skills to reduce the associated anxiety.
Some research has indicated that exposure therapy may be more effective than behavioral reinforcement therapies (Vecchio/Kearney, Bergman et. al).
An example is in 2013 researchers conducted a study in which they randomly assigned 21 children ages four to eight years with selective mutism to 24 weeks of integrated behavior therapy for selective mutism or a 12-week waitlist control group. The exposure-based therapy group increased speaking behavior among the group by 75 percent compared with the control condition (Bergman et. al).
Medication
Research has indicated that fluoxetine (Prozac) has been found to be very effective at treating selective mutism and social anxiety disorder in children (Black, B, Udhe, T).
Fluoxetine is an antidepressant medication that affects the serotonin reuptake inhibitors (SSIR’s) in the brain.
Serotonin (5-HT) is a neurotransmitter (chemical messenger) in the brain that has an affect on emotions and mood.
Taking fluoxetine (Prozac) causes an increase in serotonin in the parts of the brain that are responsible for various psychological disorders, including anxiety disorders.
This increase in serotonin improves the functioning of these various areas of the brain that then reduce the symptoms of anxiety.
How can parents help their child with selective mutism?
1. Deal with your own anxiety effectively
As parents, we need to be mindful of not imposing our own anxieties and fear onto our kids by limiting their exploration and experiences, such as speaking for them and helping them to avoid scary situations.
Our kids will learn how to deal with anxiety by watching us and how we deal with our own anxiety.
2. Provide empathy and reassurance
Tell her that you know how scary things can feel. Sometimes it’s helpful to tell your child about a fear you had when you were her age and how you got over that fear.
Confidently tell her “It’s going to be OK, you will get through this, and I am going to help you.”
3. Teach your child about selective mutism and anxiety
“Sometimes it’s hard for a person to speak in certain situations where there is a demand to speak, like at school or other places where there are people you don’t know. In other situations, these same people might talk a lot because they feel safe and comfortable.”
Teach your child what anxiety is and how it can trigger selective mutism.
“The feelings you are having is your body’s way of helping you if there is danger. It’s called the fight, flight, or freeze response. So when someone is scared they might fight or run away from what is scaring them. Others might freeze when feeling scared and not speak.”
“But sometimes our body makes a mistake and prepares us when there is no danger. Kind of like a fire drill. There is no fire but the alarm stills goes off really loud.”
Teach your child how unhelpful worried thoughts can confuse the body to mistakenly think that there is danger when there is no actual danger. Teach them about fortune telling, mind reading, and catastrophizing.
Fortune telling: Predicting that bad things will happen in the future.
Mind reading: You assume that other people are thinking negatively of you.
Catastrophizing: “This is the most horrible thing ever and things will just get worse.”
Teach your child how avoiding fearful situations makes the anxiety worse.
Kids will normally want to avoid even talking about what they are afraid of. Avoiding only provides temporary relief.
Avoidance falsely confirms that the danger is real and should be feared when it is not real. Avoidance ultimately maintains the fear.
4. Teach your child how to manage physical symptoms of anxiety
Deep Breathing Exercise
Inhale through your nose slowly by expanding from your belly first then fill your upper lungs for a count of 5
Hold your breath for a count of 2
Exhale slowly and forcefully through pursed lips for a count of 10
Repeat this 5 to 10 times or do it for at least 1 minute
Progressive Muscle Relaxation
From a seated position begin by tensing your legs and buttocks for a count of 5, then relax
Tense your abdomen for a count of 5, then relax for a count of 5
Tense your arms for a count of 5, then relax for a count of
Shrug your shoulders to your ears and tense for a count of 5, then relax for a count of 5
Press your tongue to the roof of your mount for a count of 5, then relax for a count of 5
Tips: Let all of the tension release and flow out or your muscles. Exhale as you release the tension and relax. You should feel the muscles become loose and limp. Focus on the difference between the tension and relaxation as this is the most important part of the exercise.
5. Focus on “Communication” not on “Speaking”
Remove all demands and expectations for speaking and instead focus on your child’s ability to communicate.
There are more ways to communicate than by speaking. Start by playing fun games like Pictionary and then progress to charades. Give explicit directions that speaking is not allowed and anyone who speaks loses.
Reflect and reinforce appropriate non-verbal communication such as facial expressions, eye contact, and gesturing.
Expressions: “It looks like that makes you happy” or “You must be thinking of something funny.”
Eye contact: “You are doing a great job listening to me.”
Gesturing: “You seem confident or sure about that” or “Looks like you are unsure.”
6. Encourage one-word verbal responses
Play the One Word game to gradually warm up to speaking. An example of a one word question is “A part of a house and the noise a dog makes?” “Roof.”
Don’t ask yes or no questions because this will only get you a non-verbal head nod or shoulder shrug.
Ask open ended questions that begin with What, How, Who, Why. “What kind of treat do you want today?” “What’s your favorite flavor?”
Reflect and reinforce verbal responses. “You want ice cream for a treat today and strawberry is your favorite flavor. Awesome!” “Thank you for sharing that with me.”
Please give your child enough time to mentally process your question and to formulate a response. Don’t be too quick to fill up the silence. Kids with selective mutism often process things a bit slower.
7. Gradual exposure
Gradually expose your child to various levels of speech. Have your child start with whispering, then verbal yes or no responses, then regular voice one-word responses, then conversation.
Gradually expose your child to the social situations that trigger the selective mutism.
Start with having one person whom your child is comfortable speaking around and then gradually introduce other people with whom she is not comfortable speaking around.
Have them come to the home where your child is most comfortable. Then play Pictionary, charades, and the one word game with this person. Praise your child for any effort she makes toward communication.
Take your child to a public place to get a treat of her choice and encourage her to order it by name, “Ice cream.” Praise your child for her bravery.
Increase your child’s sense of control. Encourage your child to plan where the next exposure will be, who will be there, and what type of games to play, how she will show her bravery, and how she will reward herself afterwards.
Continue to increase the exposure with your child’s input in the planning process along the way.
Your child and her teacher can also plan classroom exposures together.
Your child will feel more in control the more that you involve her in the planning process. This will make it more likely that she will follow through with the exposure activity.
Provide opportunities for daily exposures in order to maintain the progress and not slip back into avoiding.
Setbacks
It’s normal for kids to have setbacks and want to avoid. Exposure can be scary.
Normalize setbacks and mistakes, “You fell down a lot when you were learning how to walk” or “I fell of my bicycle many times before I could finally ride it.”
Go back to or continue in the exposure situations that your child has the most success with and feels most confident before moving on to more challenging exposures.
Continue with exposure activities and praise your child’s efforts and not only when your child speaks.
For some children, too much praise can make them feel uncomfortable. If this is the case for your child, use a more business like tone of voice that is not overly emotional.
Make sure your child is identifying how she wants to reward herself and that she actually follows through with the reward.
