Selective mutism is part of a cluster of diagnoses called the anxiety disorders. Anxiety disorders are a group of psychiatric conditions that include:
These disorders are characterized primarily by the experience of excessive fear and anxiety. People with generalized anxiety disorder spend a lot of time worrying about a lot of different things. People with social anxiety disorder feel very anxious around other people because they are afraid of embarrassing themselves or being disliked. People with panic disorder have sudden rushes of intense fear or discomfort called panic attacks. They often worry about having another panic attack and might avoid certain situations that might trigger a panic attack. People with agoraphobia are afraid of going into certain situations because they are afraid it might be difficult to escape or because they might experience panic-like or other embarrassing symptoms. Commonly avoided situations are using public transportation, being in open spaces like parking lots, being in enclosed places like movie theaters, or being in a crowd. People with a specific phobia are afraid of a certain object or situation, such as flying, heights, animals, or seeing blood. People with separation anxiety disorder are afraid of being away from a certain person, usually because they are afraid that something bad might happen to them or the other person if they are separated.
The anxiety disorders are characterized by excessive fear and anxiety, along with behavioral disturbances, like avoiding certain places, people, or situations. The anxiety disorders differ from each other in the target or focus of the fear. In some anxiety disorders, like specific phobia, the person is only excessively fearful of a very specific object or situation. In other anxiety disorders, like GAD, the person may feel anxious a great deal of the time or about a lot of different things.
Selective mutism is a relatively rare psychological disorder that affects approximately .7% of children. The mean age of onset varies between 2 and 5 years of age, but may become most apparent when the child enters school for the first time. There is some evidence that selective mutism is slightly more common in girls than boys.
Selective mutism is diagnosed when the following conditions are met:
Children with selective mutism are persistently silent in some specific situations despite being able to speak freely at other times. Typically, children affected by the condition can speak at home with family members and but fail to speak in other places like in school settings and public places.
Selective mutism is thought to be closely related to social anxiety, as research indicates that the large majority of children with selective mutism also meet criteria for social phobia. Selective mutism is much more than normal shyness and does not reflect attention-seeking or defiant behavior. Children can appear completely unable to speak and may freeze up in some settings, as though they are afraid of others hearing their voice. Children with selective mutism often report that they want to speak but are afraid to do so.
Interference in functioning due to selective mutism can vary based on the extent to which the child fails to speak. In severe cases, selective mutism can greatly hinder a child's social and academic functioning, as verbal communication plays a key role in these areas of development. Selective mutism typically lasts several months, but may persist for several years if left untreated. There is some evidence that symptoms remit more quickly for children who establish speech in previously mute settings at earlier ages. Reports of older children and adolescents with selective mutism are scarce, but experts in the field have noted that based on their clinical experience, individuals who enter treatment later can nonetheless make treatment gains and overcome selective mutism so that it does not continue into adulthood. In addition to comorbid anxiety disorders, particularly social phobia, it is common for children with selective mutism to have speech and language difficulties. Some children have other comorbid conditions, such as depression, panic disorder, dissociative disorders, and obsessive-compulsive disorder.
Selective mutism is now understood to be an anxiety disorder related to inhibited temperament. There is some evidence that there is a genetic contribution to the disorder, as children with selective mutism are more likely to have family members who experienced social phobia and avoidant personality disorder and parents with a history of selective mutism. On a neurobiological level, behaviorally inhibited children may have a decreased threshold of excitability in the amygdala, which is an area of the brain that receives and processes signals of potential threat and sets off a series of reactions that help individuals protect themselves. In anxious individuals, the amygdala seems to overreact and set off these responses when no danger is present. Among children with selective mutism, anxiety responses are triggered by social interactions and settings in which speaking is expected, and these children experience feelings that occur when an actual threat or danger is present. Other factors may contribute to anxiety about speaking and the development of selective mutism, including expressive language disorders and a bilingual family environment. Research does not support the claim that a history of abuse and trauma causes selective mutism. However, a stressful environment may be a risk factor in the development and maintenance of selective mutism, as it may exacerbate the child's preexisting anxiety.
Selective mutism is treatable. The practice parameter for child and adolescent anxiety published by the American Academy of Child and Adolescent Psychiatry includes selective mutism. Additionally, the Selective Mutism Group has a position statement on evidence-based treatment strategies for selective mutism and the Aberdeenshire Council has practice guidelines for supporting children with selective mutism.
First Line Treatments
Cognitive strategies involve identifying anxious thoughts that contribute to avoidance of speaking. Cognitive strategies are most useful for children ages 7 and older, when they have developed better awareness of their thoughts. Techniques include recognizing physical symptoms of anxiety, identifying and challenging maladaptive thoughts, and developing a coping plan to deal with distress. A professionally trained CBT therapist is able to determine when it would be useful to add cognitive strategies to behavioral strategies for the treatment of selective mutism.
Second Line Treatments
For more information about drug prescribing for selective mutism in children and adolescents, click here.
Additional Treatments to Consider
The following strategies, while not a substitute for the more well-validated treatments listed above, might be beneficial for some children with selective mutism:
First Line Treatments
Cognitive strategies involve identifying anxious thoughts that contribute to avoidance of speaking. Cognitive strategies are most useful for children ages 7 and older, when they have developed better awareness of their thoughts. Techniques include recognizing physical symptoms of anxiety, identifying and challenging maladaptive thoughts, and developing a coping plan to deal with distress. A professionally trained CBT therapist is able to determine when it would be useful to add cognitive strategies to behavioral strategies for the treatment of selective mutism.
Second Line Treatments
For more information about drug prescribing for selective mutism in children and adolescents, click here.
Additional Treatments to Consider
The following strategies, while not a substitute for the more well-validated treatments listed above, might be beneficial for some children with selective mutism: