Selective Mutism: an Often Misunderstood Diagnosis
Kids with selective mutism often chat happily at home and with family members, but they don’t speak at all or talk very little in other settings like school.
WHEN WE THINK OF anxious children, we might think of kids clinging to their parents at drop-off time or terrified by clowns at birthday parties. But there’s another kind of anxiety that affects young children that is much less understood, even amongst pediatricians and mental health professionals, which delays diagnosis and intervention.
Selective mutism is an anxiety disorder in which a child who is talkative at home is unable to speak in other settings. Children with selective mutism often chat happily at home but don’t speak at all or to a very limited extent in places like school, with friends or even extended family. A child with SM may know all the words to a song at school but be completely frozen while everyone sings along. He might love playing with his friends, but never utter a word on a play date. Children with selective mutism frequently talk with family they see often but are silent or manage only a whisper when aunts and uncles visit. The child may nod, point or gesture, and even play along, but not verbalize when asked a question.
SM can often take a while to be detected because the child speaks freely at home and therefore the parent may have no idea she hasn’t uttered a word at preschool. Teachers may assume the child is just as quiet at home, so the parents must be aware of it. A very well-intended teacher may mislabel the child as “just shy,” and months can pass with the child silent in the classroom and on the playground. Children with SM may get hurt at school and be unable to tell the teacher, and they may wet themselves when they can’t ask to use the bathroom.
Oftentimes, teachers or other adults think that given time, the nonverbal child will warm up and “grow out of it.” Parents who suspect a problem might share their concerns with their pediatrician, only to be told that the child will talk eventually.
Children who have selective mutism can sometimes talk to peers but not adults, or vice versa, which is quite perplexing and can contribute to another damaging myth: that the child is defiant or controlling. Like other anxiety disorders, the fearful situation doesn’t always make sense to the layperson. Children with SM most often want to speak but feel they can’t. Many children I have worked with have shared later on that they felt their words were stuck. One little girl said she had felt her mouth was “super-glued.” A parent explained the disorder as “stage fright about talking.”
It’s not clear exactly how children with SM develop the disorder, but like other anxiety disorders, it’s often a combination of biology and environment. In other words, children with SM might have at least one parent who has a history of anxiety, so this can contribute to some biological predisposition toward anxiety. Additionally, the environment plays a role in shaping the disorder. In essence, when a child with SM is asked a question and doesn’t answer, a teacher or neighbor will back off because the child seems uncomfortable, or a parent or sibling will answer for the child. This ends up creating a cycle of avoidance, which can be hard to break.
The good news is that selective mutism is treatable, and the earlier it’s diagnosed the better. If a parent suspects selective mutism and the pediatrician tells the parent, “Don’t worry, she’s just shy,” it’s helpful to share some resources with the pediatrician about the disorder or offer some other details about the child (e.g. she hasn’t spoken all year at school). Caregivers should feel listened to and taken seriously, since they know their child best.
The most effective treatment for children with anxiety disorders is cognitive behavioral therapy. In the case of SM, the therapy uses techniques that prompt speech and then reinforce successful speaking experiences with lots of what’s called labeled praise, or specific praise for a desired behavior, such as saying, “Thanks for telling me” or “Great brave talking.” That’s in addition to small incentives or rewards, like a toy or prize for practicing talking with the parent in front of a new person or talking to a teacher. Children find their voices by being praised for “brave talking.” It may start with a whisper or a single word but, once unlocked, these children become enthusiastic and outgoing communicators.
Families become part of the treatment, as they help their kids emerge from silence by encouraging small acts of bravery. At the Child Mind Institute, we teach parents the skills kids are learning in therapy and help them look for opportunities to reinforce those skills at home. We use generalization, which means taking therapy “on the road” – we go to stores and other places in the community to help the child practice. Ordering their favorite flavor at the ice cream store is a thrilling victory for these kids. Working with the child’s teachers is important to help them continue progressing in the classroom. You can also check out resources online provided by the nonprofit Selective Mutism Association, part of the Childhood Anxiety Network, and learn more about the disorder at the selectivemutism.org.
Selective mutism may be a lesser-known disorder, but it’s real and very treatable. Once we recognize that these children are more than “just shy,” it’s remarkable to see them find their voices, and show the world who they are.