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

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.

Does Your Child Have an Anxiety Disorder or a Phobia?

Some children generally do well at home but struggle with anxiety in certain situations, like when they’re around peers at school.

FEAR CAN BE A HELPFUL emotion, particularly for children who are learning to navigate the world. Feeling afraid lets them know when they are in danger and helps them respond.

On the other hand, many children today struggle with anxiety that goes beyond what’s considered normal and healthy. The key is identifying when your child’s fear has changed from productive to harmful. The first step is to understand the different types of anxiety. These include:

  • Generalized anxiety.
  • Situational anxiety and phobias.
  • Social anxiety.

Generalized Anxiety

Generalized anxiety makes your child feel uneasy and nervous about the future. It can refer to worries about everyday issues, such as schoolwork, managing relationships and performing well in extracurricular activities.

Your child needs some anxiety to be motivated to get things done. This is called healthy or productive anxiety. For example, healthy anxiety is what prompts your child to stop watching YouTube videos and start preparing for an upcoming test.

But sometimes anxiety persists, even when it’s no longer helpful. It can get in the way of your child’s life and ability to function.

Situational Anxiety and Phobias

Some kids only struggle with anxiety in very specific circumstances. This is called situational anxiety. For example, your child may have anxiety only in dark rooms at night.

If your child keeps avoiding a situation due to fear of experiencing situational anxiety – or endures the situation and suffers intense distress – he or she may have developed a phobia. Although a child may think of the situation itself as dangerous, what the child is really afraid of are the feelings of fear and panic that he or she associates with that situation.

Phobias can make your child’s life difficult due to the extreme effort the child puts into avoiding triggering situations. The more places where your child has feelings of anxiety, the more situations the child avoids. Kids can get stuck in a cycle of fear and anxiety that reinforces phobias. By feeling a short-term sense of relief when they avoid the situation, they “train” their bodies that avoidance is the best strategy. The world becomes smaller and scarier.

Social Anxiety

Many people think phobias are only about fearing things like spiders (arachnophobia) or small spaces (claustrophobia). But for many children, it’s common to struggle with social phobia, also known as social anxiety.

Social anxiety involves experiencing anxiety, fear or panic in situations where other people are watching or paying attention. Kids with social anxiety dread having other people even notice if their voice is shaky or their hands are trembling. They are terrified of making a mistake or appearing weak in front of others. Studies have shown that some personality traits, such as shyness, introversion and perfectionism, put a child at higher risk for developing social anxiety.

Kids with social anxiety struggle with two main categories of situations: performance situations and interactive situations; and they often go together. Some children fear both types of situations. Children who fear performance situations find it difficult to do any kind of public speaking, even answering questions in class or giving a presentation. They may fear participating in a competition or sporting event. Those who fear interactive situations may experience heightened anxiety at social gatherings, such as birthday parties, meetings, lunch and recess. They may dread talking through a conflict with a peer, initiating conversations or even going out with a group of friends.

What Your Child May Be Experiencing

The way to help children manage excess fear and unhealthy anxiety is to teach them to understand what’s happening when they are caught in a cycle of fear and anxiety, and provide them with skills to cognitively reframe triggering situations as they work to calm down their bodies.

The cycle of fear and anxiety has three components:

  • Physical feelings.
  • Automatic thinking.
  • Behaviors.

The cycle can begin with any one of the three components and expand to the other two. For example, a child may first notice a racing heartbeat, and then start to think, “I can’t do this; I’m too scared.” Or, a child may be thinking, “I have to be perfect; I can’t mess up,” and then suddenly a bout of shaking and trembling begins. Or perhaps the child was unable to do something, like wear a usual “lucky shirt” on the day of a test, and this simple change in what the child does (or doesn’t do) – the behavior – leads to feelings of dread and thoughts of doom.

There are many common physical symptoms your child may experience in scary situations. They might have weak legs, shaky hands or a trembling voice. It may be hard to swallow or catch a satisfying breath. Some kids feel dizzy and numb, almost as if they were floating above their own body. Other physical symptoms include rapid heartbeat, chest discomfort, dry mouth, stomach pain or a choking sensation.

Too much anxiety can even lead to a panic attack, when the child experiences an intense rush of fear – even though there isn’t an actual life-threatening danger – along with multiple physical symptoms.

A child prone to anxiety has a brain that automatically fills with negative thoughts that reflect black and white thinking – or very rigid, inflexible ways of looking at the world. These negative thoughts distort reality and make your child feel far more anxious. It takes some practice to identify these negative thoughts. They often assume catastrophic outcomes – or that the worst will happen: “I will mess up and cry in front of everyone and lose all my friends.” These thoughts feed into the cycle of fear and anxiety.

What You Can Do

First, take a moment to recognize that you’re not alone in parenting a child with anxiety. It can feel overwhelming when your child screams, refuses to go to school or is unable to transition through their daily activities. The hopeful news is that anxiety is one of the most treatable psychological conditions. The first step is to get a referral to a psychologist or social worker who specializes in childhood anxiety. Your pediatrician or family doctor can help you with this.

In addition to seeking help from a therapist or social worker for the anxious child, parents can benefit from joining support groups or speaking with a licensed psychologist to work through their own mounting anxiety and frustration about the child’s situation.

Through practice in therapy and at home, one of the most important techniques your child can learn to master anxiety involves replacing automatic negative thoughts with positive coping thoughts. Some people refer to this dialogue as positive self-talk.

For example, if your child reports thinking, “I’m going to embarrass myself in front of everyone,” help the child identify this negative thought and replace it with, “These are just thoughts, not reality. Just because I fear something doesn’t make it true. Even when I make a mistake, people still care about me.”

The coping thoughts should be realistic and meaningful; if your child doesn’t believe them, the coping thoughts won’t be effective. Try to think of the most accurate outcome or explanation for the situation, not necessarily the most positive. For a child who struggles socially at recess, this self-talk might be, “Even if I’m not invited to be part of a game with the popular kids, I can find something to do, and I will get through recess. I’ve been successful at talking with a couple new friends, so maybe I’ll look for them today.”

Two excellent forms of therapy that can help your child change unhealthy thought patterns are cognitive behavioral therapy, and acceptance and commitment therapy. You can discuss these options with your child’s therapist and learn how to support your child at home. Relaxation training, such as abdominal breathing, meditation and progressive muscle relaxation, can also help ease your child’s physical symptoms of anxiety.

In addition, there are a variety of medicines that have proven effective in helping to manage the symptoms of pediatric anxiety disorders, especially when used in combination with talk therapy.

If you are concerned that your child is overly anxious, remember that there is help available, and it will eventually get better. Your child (and you) can get through this with support.

Diet Culture Dangers: Could your Child Be Heading for an Eating Disorder?

WHEN I TALK ABOUT “DIET culture” with clients in my office, I realize that initially most of my clients don’t really understand what I mean. It makes sense because dieting, body dissatisfaction and unrealistic eating patterns are commonplace in our society.

According to a 2015 research review in the Journal of Child Psychology and Psychiatry, the sociocultural idealization of thinness was the primary contributor in eating disorder development. Just as we educate our children about consent and the dangers of drugs, parents can help kids understand the perils and illusions of diet culture.

Diet culture isn’t a scary, dark alley you can avoid. Diet culture is everywhere, even in our safe spaces. Our kids are already getting dangerous messages. Cartoons villainize some foods and put hero capes on others. Children’s movies often perpetuate weight stigma and bias. Schools send home reading assignments with food and body shaming messages. The pediatrician recommends we “watch” our child’s weight when they’re on their biologically appropriate growth curve. The church youth group members start talking about weight loss and counting calories. Seeds of body distrust and food fears are planted quite early in diet culture.

The dangerous messages of diet culture can prompt our children to make seemingly benign changes in their behavior; yet some of the “I just want to be healthy” changes can negatively impact their growth, development and mental health.

These common yet dangerous changes can let us know when our kids need more support around trusting their own bodies and living in a disordered diet culture:

Specific Food Restriction, Avoidance or Fear

When a client tells me his or her child no longer wants a certain food or type of food, I immediately get concerned. It’s one thing for a child to recognize their stomach gets upset after an ice cream sandwich if the child has lactose intolerance. To skip a once-loved food because it’s been deemed “unhealthy” or has “too much sugar” is something very different. A sudden dietary change like avoiding rice, pasta or meat sauce (among many other restrictions) at dinner is a reason for me, as an eating disorder specialist, to start asking more questions. Did the child just complete a health class, watch a compelling documentary or witness others who influence the child start to abstain from certain foods as well?

Food restriction, without medical necessity (like a medically confirmed food allergy), in most cases stems from diet culture. When a child restricts or fears certain foods, it’s very possible that child heard the false beliefs that dieting, food avoidance or having a thin body leads to health. In fact, it’s quite the opposite and research has, for decades, supported that dieting behaviors increase the risk of eating disorders. According to a study published in the BMJ, adolescents who engaged in moderate dieting were five times more likely to develop an eating disorder, whereas those who engaged in extreme dieting and restriction were 18 times more likely to develop an eating disorder than those who did not engage in dieting at all.

Rigid Exercise or Tracking Behaviors

Many of the families I work with have active children. They may engage in dance, karate, gymnastics, baseball or a whole host of other activities the children enjoy. However, some kids are adding exercise that they don’t necessarily like but feel pressured to add to their daily routine to be healthy or change their bodies. When a client tells me about going to their sanctioned school sport practices but feels like it’s not enough and adds five days of running as well, I start to worry. What’s prompting this child to be rigid with additional exercise when just last year the joyful movement provided by their sport was enough?

It’s not just exercise that can become rigid and excessive. When adolescents report tracking miles completed and calories burned, that’s also a recipe for danger. Many have learned about tracking, whether for movement or caloric intake, from health classes or those most influential around them. Tracking, much like stepping on a scale, can trigger behaviors that increase the risk of disordered eating behaviors while undermining young people’s trust in their ability to fuel and care for their own bodies.

Too Much Time on Social Media

Calorie and fitness tracking apps aren’t the only dangerous tools our kids can find online. Social media is playing a role like never before. A 2017 study in the journal Body Image reported that engaging in appearance-related social networking sites use, particularly on Facebook and Instagram, was associated with body image issues. Of course, there are positive messages on social media, but with the diet industry and diet culture continuing to perpetuate the thin ideal, celebrity endorsements of diet products, and a narrow lens of health, we have to keep track of what our kids are visually consuming.

Heading for an Eating Disorder

Eating disorders aren’t a choice or a phase, they’re legitimate illnesses that require physiological and psychological treatments. And they can start very innocently with leaving out certain types of foods, under-portioning at meals and snacks, or not eating after a certain time. If these dieting behaviors go unnoticed, more restrictions or behaviors can ensue leading to chronic disordered eating patterns and clinical eating disorders.

Like adults, children may suffer from a number of life-altering and life-threatening eating disorders, including anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder and orthorexia. If you’re concerned that you or your child may be struggling with an eating disorder, there is hope and help, and you can find more information at the National Eating Disorders Association’s website.

As parents, we can help our kids build a strong foundation to trust their bodies, not fear food, and become resilient in our very normalized diet culture. When I talk with families about this in my office, I tell them that once you truly see diet culture for what it is, you can‘t un-see it. We can help point out these dangerous parts within our culture while teaching our kids that healthy bodies come in all shapes and sizes. In addition to offering a variety of foods and flavors around the family table, we can show our kids that our homes are the truly safe zones.

Bed-Wetting: What Is Normal and When to Worry

Once your child is ready for night training, to curb bed-wetting, make sure to have a good routine in place. This should include a consistent bedtime. After bath and stories, have your child get out of bed and go to the bathroom

MILLIONS OF CHILDREN struggle with bed-wetting. As a pediatrician, I understand the stress and frustration that bed-wetting can have on families. For some kids, wetting the bed can be embarrassing and upsetting; they get anxious about sleepovers and special events away from home. On the other hand, some kids don’t care they wet, but their parents don’t like the mess, the daily cleanup process or the continued expense of diapers. Either way, families often come to my office to find solutions.

The first thing I tell families is that it’s normal for a child to wet the bed well into elementary school. Trying to train a child to be dry at night when they are too young can cause more frustration, shame and anxiety. For some perspective, about 20 percent of a kindergarten class is still routinely wetting the bed, 7 percent of kids in elementary school wet the bed at least once per week, and 1 in every 100 teens still wets the bed. Letting your child know that there are lots of other kids who also wet the bed can diffuse worry and calm fears. For most kids, bed-wetting is cured with time.

Despite the common suggestions to limit fluids before bed or to drag your sleeping child to the bathroom before you go to bed, these “tricks” avoid dirty laundry without working on the real cause of night wetting. Wetting is caused by an immature brain-bladder connection, which is required to cue your body to wake up and pee. This immature connection is often complicated by the fact that kids’ bladders are physically too small to hold the amount of pee their body makes at night, setting them up to leak while sleeping. We also know that bed-wetting is genetic. Often a bed-wetting child has a parent, aunt, uncle or sibling who wet the bed. Bed-wetting can also be caused by stress or change. A new baby, a move or another transition in the family may be enough to see some night accidents.

Before I encourage my families to work on night training, I confirm that three things are true. First, your child should be at least 8 years old, even better if she has had a few dry nights in the past or if the volume of the wetting accidents is starting to decline. Second, your child needs to care about the wetting. If he doesn’t care that he wets at night, he will have no motivation for success. Finally, there shouldn’t be any signs of medical reasons for the night wetting. Specifically, the child has never had consecutive months of dryness, pain during or after peeing, snoring or increased hunger or thirst. Kids with these symptoms may need lab testing or a specialist referral before working on night dryness.

Once your child is ready to train, put a good nighttime routine in place. This should include a consistent bedtime. After bath and stories, have your child get out of bed and go to the bathroom. Make sure the path to the bathroom is free of clutter and well lit. Secondly, carefully monitor your child’s pooping habits. Constipation is sneaky and can sabotage success. A big poop can place pressure on the bladder, limiting the ability for it to fill adequately. This effectively makes the bladder smaller and more likely to overflow at night. Also, talk about the process. Having your child say, “I have to pee, I have to get up” may sound silly. Verbalizing the plan, however, is a significant first step in triggering the brain-bladder connection that you want to encourage.

The most effective means for training the brain-bladder connection involves using a bed-wetting alarm. These inexpensive devices, which rely on a moisture sensor, are placed in the bed or worn in the underwear to alert your child of wetness. As soon as your child leaks urine, the alarm will go off (vibration or sound). That is the trigger to get out of bed to go to the bathroom. For kids who are deep sleepers, this may take additional effort from a parent to assist them in waking when the alarm goes off. Use of this technique is often the quickest route to long-term success, achieving dry nights in the majority of kids over age 7 within 12 weeks.

The bottom line is that the most common cure for bed-wetting is time. As kids get older, the brain-bladder connection naturally matures. As each year passes, more and more kids will have dry nights without any interventions at all. If you have worries about your child’s health or your child is expressing concern about wet nights, please talk with your child’s doctor, who I’m sure would be happy to help.