Selective Mutism: Everything you need to know

Recall your school-aged years. Did you ever have to give a presentation? If so, you were probably nervous standing in front of the class. It would not be surprising if you also experienced sweating or trembling right before you froze speechless. Your words left you in your state of excessive nervousness. Children with the anxiety disorder selective mutism experience the same phenomena, but to greater severity and in all social situations outside of the home—in class, speaking one-on-one with a friend, or on the playground. Selective mutism exceeds “normal” shyness and greatly interferes with day-to-day life. Find out what is selective mutism, how is it diagnosed, does it relate to autism, how is it treated, etc.?

What is Selective Mutism?

For children and adults with selective mutism, social settings create an atmosphere of tension and anxiety. Selective mutism is an anxiety disorder characterized by ineffective communication in social settings due to an intense fear of social interactions. Those with selective mutism are rendered mute, unable to initiate verbal and non-verbal conversation, and might speak in soft whispers in settings where they feel uncomfortable.

Selective mutism is a debilitating disorder that interferes with social functioning and requires prompt treatment to adapt. It is important to note that selective mutism differs from regular shyness—the personality trait—which does not hinder daily functioning. The behaviors of selective mutism are from a legitimate fear of social interaction.

Selective Mutism at Home VS. School

The hallmark sign of selective mutism is that the behavior only presents when anxious in social settings. Symptoms are not noticeable in familiar environments. Children with the disorder are often nicknamed “chatty Cathy” by their families because they show little to no communication deficits at home. Variances in where behaviors are exhibited, combined with the periods of normal behavior, make selective mutism difficult to pinpoint.

Who suffers from selective mutism?

Less than 1% of children in the United States have this and females are more prone to the condition than males. The underlying cause is not entirely known. Genetic factors, in combination with environment, have been found to play a role. One’s chances of developing the condition are higher in families where mental health disorders are prevalent.

Behavioral Symptoms of Selective Mutism

The symptoms typically present in early childhood (2 to 4 years of age) and continue into adulthood if untreated. Behavioral manifestations range from mild to extreme.  For example, someone might speak to close friends without distress, but struggle to speak to other peers and authority figures. The basic symptoms impact social being, appearance, and mood.  

Social Being

Social skills are on par with age in many cases, as the condition’s manifestations are contingent on a particular setting. Despite this, social interactions are lacking outside of the home. Common social symptoms are:

• Failure to speak in social situations—This must occur longer than one month, but not while adjusting to a new daycare, school, or job.
• Social isolation—Peers start to retreat due to anti-social behavior (i.e. not responding to their social advances, etc.)
• Fear of embarrassment in groups—Situations such as raising a hand in class, responding to teachers, and talking in a group provoke extreme embarrassment.
• Separation anxiety— Excessive clinginess to caregivers is an outlet for social anxiety. The person is able to avoid uncomfortable social interactions with peers.
• Difficulty initiating needs—Children struggle to initiate play with other children and refrain from going up to authority figures to inform them of what they need. For example, asking the teacher to use the restroom.
• Avoids greeting others—They refuse to initiate contact.
• Freezing—Freezing and shutting down is prominent in younger population. As soon as communication is directed towards them, they become non-responsive. It is not as widespread in older children.
• Mumbling, whispering, or mouthing words—Responses to communication are commonly given in mumbling whispers or mouthing words like “thank you.”

Appearance

To an observer, those with selective mutism demonstrate traits that only fuel the isolation of the condition. They appear quiet and aloof, while also misusing non-verbal communication. Characteristics are:

• Consistent sad expression—Others describe them as appearing sullen.
• Expressionless face—If not appearing sad, having an expressionless, unreadable face is common.
• Stiff, motionless—Standing still without moving discourages social interactions.
• Lack of eye contact—Regardless of whether being spoken to or initiating a conversation, they rarely make eye contact.
• Difficulty waving hello or goodbye—Similar to how initiating hello or goodbye in speech is difficult, waving provokes the same distress.
• Cannot point or nod—Communicating via non-verbal gestures is hard, as the action draws uncomfortable attention.

Mood

When speaking children display drastic deviations in temperament. The mood swings are most evident in the home, as that is a comfortable environment where they are not mute out of fear of social interactions. Mood may also be effected by:

• Temper tantrums—Infants and toddlers have frequent temper tantrums prior to exhibiting social anxiety symptoms.
• Irritability—Levels of irritability fluctuate in selective mutism.
• Bossy/domineering—Interactions with family and peers come across as bossy, domineering, or controlling.
• “Acting out”—Children “act out,” which consists of not listening to a parent’s directions and acting “silly” in inappropriate situations.
• Avoidance and procrastination—Selective mutism makes one feel out of control and partaking in avoidance and procrastination conflict with tasks.
• Attention Deficit Hyperactivity Disorder (ADHD)—Periods of hyperactivity, impulsivity, and problems focusing are not uncommon.

Selective Mutism and Anxiety

The National Institute of Mental Health defines anxiety as persistent worry and/or fear that interferes with school, work, and relationships. There are multiple types of anxiety disorders classified by the circumstances in which the anxiety is triggered. Anxiety has the potential to worsen over time with a significant effect on mood. In general, someone with anxiety might seem irritable, restless, or having problems concentrating and sleeping.

Selective mutism alone is classified as an anxiety disorder. However, secondary anxiety disorders like separation anxiety, panic disorder, and obsessive-compulsive disorder (OCD) frequently result along with selective mutism. A secondary anxiety disorder is likely if feelings of unease stem beyond social settings.

Selective Mutism and Depression

Failing to control the anxiety of selective mutism can produce depression. Depression is a mood disorder that causes unrelenting sadness persisting more than two weeks. The disorder alters thinking and emotional processes and instigates feelings of sadness, outbursts, and a loss of interest in regular activities. Depression in selective mutism is easily confused with the condition’s usual symptoms—aloofness, sad expression—and should be monitored closely. A sudden shift in behavior at home is essential to differentiating depression occurring within selective mutism because the shared symptoms start to present outside of uncomfortable social settings.

Developmental Delays Associated with Selective Mutism

Autism, sensory processing disorder, learning disabilities—selective mutism is falsely assumed to be a variety of separate conditions because of overlap in its symptoms. For example, a lack of eye contact in social settings can be a sign of autism. While these false assumptions are myths, a subset of those diagnosed with S.M have comorbid developmental disorders.

Sensory Processing Disorder

Children with S.M are susceptible to sensory processing disorder. Sensory processing disorder involves the processes of sensory information. Lights and visuals, sounds, tastes or smells influence emotions as the body fails to process sensory stimulation.

Sensory processing disorder is an added component to anxiety and drives behaviors of selective mutism. As an environment increases in sensory stimulation, the ability to decipher social cues and interactions decreases, and the immediate reaction is to shut down or freeze. Experts agree the “freeze-mode” is mutism.

Learning Disabilities

This condiction is not a learning disability. Most with the condition are of average intelligence. From 20 to 30% of patients do have a form of developmental delay ranging from speech, language, and auditory abnormalities.

Studies show that this condition contributes to learning disabilities because school curriculum is based on verbal participation. The finding of learning disabilities in social settings was confirmed by Kolvin and Fundudis (1981) who found that–although the majority of their sample of children with SM fell within the normal range of intelligence—the average IQ was only 85. Like sensory processing disorder, aspects of learning disabilities exacerbate symptoms of selective mutism. Children and adults with selective mutism are less inclined to speak with the fear of their disability (i.e. speech impairments, not processing auditory information.).

Autistic Spectrum Disorder

Autism is a developmental disorder is a group of conditions that impact social functioning and communication. The difference between autism and selective mutism is that those with autism cannot pick up on social cues, while those with selective mutism can.

Despite the difference, the two conditions are related in specific cases. Mutism in certain settings can be a manifestation of autism. However, autism includes more extensive social symptoms than what is primarily noted in selective mutism.

Physical Symptoms of Selective Mutism

The psychological symptoms can cause physical ailments originating before or at the onset of school and social settings. Children with selective mutism often use the physical symptoms to get out of attending school because of their anxiety. While physical symptoms of selective mutism are typical, they should always be addressed by a physician to confirm their origin.

• Gastrointestinal pain
• Nausea
• Vomiting
• Diarrhea
• Headache
• Tachycardia
• Shortness of breath
• Trembling
• Fatigue
• Joint pain
• Dizziness
• Insomnia

How to Diagnose Selective Mutism

Due to its rarity and symptom variation, selective mutism is challenging to diagnose. Its symptoms tend to overlap with other mental disorders. So, the initial step in diagnosis is to rule out primary mental conditions when symptoms persist longer than one month.

Psychologists and psychiatrists well-versed in selective mutism begin the diagnostic process by taking a thorough evaluation of the child (or adult) in question. This entails behavioral characteristics, a developmental history to determine whether developmental milestones were reached, family history to investigate familial mental disorders, and if any stressors or trauma correlates with symptoms. Speech, language, and hearing evaluations are also conducted to exclude physical reasons for not speaking. Investigating the patient in numerous settings (i.e. home, school, etc.) is helpful in aiding in the diagnosis.

After the assessment, a selective mutism diagnosis is given by the DSM-IV-TR criteria. Persistent failure to speak in specific contexts should not be explained by:

1. An organic inability rooted in language ability (comprehension and comfort speaking the language)
2. Another communication disorder, such as stuttering
3. Concurrent diagnosis of pervasive development disorder, schizophrenia, or other psychotic disorder

Selective Mutism Treatment

While selective mutism is tricky to diagnose, a correct diagnosis leads to favorable treatment outcomes. The majority of professionals choose to begin treatment for selective mutism in the realm of therapy. If therapy is proven unsuccessful, pharmaceutical options are added by a physician.

Therapy for Selective Mutism

The first form of therapy used in selective mutism is behavioral therapy. Behavioral therapy seeks to change behavior in the context of the patient’s environment. Therapists assess environmental factors contributing to the undesired, anti-social behavior and focuses on locating negative reinforcements that encourage selective mutism behaviors. Experts agree that a prime instance of negative reinforcement is as follows: “Teachers who withdraw requests for children to speak exhibit one form of negative reinforcement that sustains behavior” (Wong, 2010). Techniques such as positive reinforcements, modeling appropriate behaviors, and talk-therapy elicit favorable behaviors.  

Medications for Selective Mutism

Medications are implemented in the treatment of selective mutism in cases where there are co-morbid mental disorders or if the selective mutism is apparent later in childhood development. The pharmaceutical options for treating selective mutism are still in the investigation process. Long-term repercussions are not yet known.

The main drug class in study is selective serotonin reuptake inhibitors (SSRIs). Serotonin is a neurotransmitter that sends electrical signals to the brain. An imbalance of serotonin is correlated with anxiety disorders. SSRIs improve the neurotransmitter balance to reduce symptoms of selective mutism. Common SSRIs are Prozac, Zoloft, and Celexa. Side effects are minimal, especially if the dose is increased gradually.

As science progresses, treatments for selective mutism will improve.

References

Blum-Shipon, E. (N.d.). What is Selective Mutism?. Retrieved from https://selectivemutismcenter.org/whatisselectivemutism/

Muris, P., & Ollendick, T. (2015). Children Who are Anxious in Silence: A Review on Selective Mutism, the New Anxiety Disorder in DSM-5. Clinical Child & Family Psychology Review, 18(2), 151–169. https://doi-org.ngu.idm.oclc.org/10.1007/s10567-015-0181-y

Wong P. (2010). Selective mutism: a review of etiology, comorbidities, and treatment. Psychiatry (Edgmont (Pa. : Township)), 7(3), 23-31.

Cheyanne Perry

Cheyanne is currently studying psychology at North Greenville University. As an avid patient advocate living with Ehlers Danlos Syndrome, she is interested in the biological processes that connect physical illness and mental health. In her spare time, she enjoys immersing herself in a good book, creating for her Etsy shop, or writing for her own blog.