Selective mutism (SM) is a childhood anxiety disorder characterized by an inability to speak or communicate in certain settings. The condition is usually first diagnosed in childhood. Children who are selectively mute fail to speak in specific social situations, such as at school or in the community.
Most children are diagnosed between 3 and 8 years old. In retrospect, it is often noted that these children were temperamentally inhibited and severely anxious in social settings as infants and toddlers, but adults thought they were just very shy.
Children and adults with selective mutism are fully capable of speech and understanding language but are physically unable to speak in certain situations, though speech is expected of them.The behaviour may be perceived as shyness or rudeness by others.
In a severe form known as “progressive mutism”, the disorder progresses until the person with this condition no longer speaks to anyone in any situation, even close family members.
Selective mutism is by definition characterized by the following:
• Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.
• The disturbance interferes with educational or occupational achievement or with social communication.
• The duration of the disturbance is at least 1 month (not limited to the first month of school).
• The failure to speak is not due to a lack of knowledge of the spoken language required in the social situation.
• The disturbance is not better accounted for by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively in people with autism spectrum disorders or psychotic disorders such as schizophrenia.
Selective mutism is strongly associated with other anxiety disorders, particularly social anxiety disorder.
Besides lack of speech, other common behaviors and characteristics displayed by selectively mute people, include:
• Shyness, social anxiety, fear of social embarrassment or social isolation and withdrawal
• Difficulty maintaining eye contact
• Blank expression and reluctance to smile or incessant smiling
• Difficulty expressing feelings, even to family members
• Tendency to worry more than most people of the same age
• Sensitivity to noise and crowds
It was once believed that selective mutism was the result of childhood abuse, trauma, or upheaval.
Research now suggests that the disorder is related to extreme social anxiety and that genetic predisposition is likely.
Kids who develop the condition:
• Tend to be very shy
• May have an anxiety disorder
• Fear embarrassing themselves in front of others
Other potential causes include temperament and the environment. Children who are behaviorally inhibited or who have language difficulties may be more prone to developing the condition. Parents who have social anxiety and model inhibited behaviors may also play a role.
Selective mutism also often co-occurs with other disorders including:
• Developmental delays
• Language problems
• Obsessive-compulsive disorder (OCD)
• Panic disorder
Diagnosing selective mutism involves a comprehensive assessment, which may involve:
• a speech and language evaluation
• interviews with parents, caregivers, or teachers
• collaboration with a variety of specialists, possibly including a pediatrician, child psychologist, behavior analyst, guidance counselor, or social worker
The speech and language evaluation can screen for any other conditions that might cause difficulty with speech, such as a speech delay or hearing impairment. Then, interviews with family members can help specialists get a sense of:
• when the symptoms began
• how the child currently communicates
• the home environment
• family medical history
Eventually, a speech-language pathologist (SLP) might wish to meet the child informally to observe their behavior. Minimizing stress is important at this stage, so the SLP will not put pressure on the child to talk.
The emphasis is on making the person with selective mutism feel safe but gradually more confident. Some examples of treatments for selective mutism include:
• Augmentative and alternative communication (AAL)
AAL involves temporarily giving people an alternative way of communicating that they find less stressful. For example, a child may learn to use gestures or point to symbols. In the short term, this can help a child communicate at school, but it is not a long-term solution.
• Exposure-based therapies
These approaches involve gradual exposure to a situation that a person may find anxiety-inducing, so that they can practice speaking. Over time, this shows the person that they can speak in front of people.
• Ritual sound approach (RSA)
This therapy involves an SLP helping a child learn to produce sounds from a mechanical perspective. They may start with nonspeech sounds, such as blowing or coughing, and work toward syllables and then words.
An SLP will tailor any therapy to the person’s symptoms, age, and other needs. People with selective mutism also require support for their emotional health. Selective mutism can make it difficult for people to talk about their feelings, state what they need or want, and socialize with others.
Psychotherapy can help children and adults learn to manage the fear they feel about speaking. It can also help with any coexisting mental health conditions, such as social anxiety.
In addition to seeking appropriate professional treatment, there are things that you can do to help your child manage their condition.
• Inform teachers and others who work with your child.
Teachers can sometimes become frustrated or angry with children who don’t speak. You can help by making sure that your child’s teacher knows that the behavior is not intentional. Together you need to encourage your child and offer praise and rewards for positive behaviors.
• Choose activities suited to their current skills.
Don’t force your child to engage in social situations or activities that demand spoken communication. Instead, choose activities that don’t involve speech such as reading, art, or doing puzzles.
• Reward progress but avoid punishment.
Where rewarding positive steps toward speaking is a good thing, punishing silence is not. If your child is afraid to speak, they will not overcome this fear through pressure or punishment.
• Don’t pressure your child.
Parental acceptance and family involvement are important in treatment, but you should avoid trying to force your child to speak. Putting pressure on your child will only increase their anxiety levels and make speaking all that more difficult. Focus on showing your child support and acceptance.
There is a good prognosis for selective mutism. Unless there is another problem contributing to the condition, children generally function well in other areas and do not need to be placed in special education classes.
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