What is Selective Mutism?

Selective mutism is a childhood anxiety disorder leading to the inability to speak or communicate in certain settings. The condition is usually diagnosed in childhood. Children who are selectively mute may not speak in certain social situations; this may be at school, nursery or other community settings.

If left untreated, selective mutism can lead to low self-esteem, social anxiety, social isolation and academic problems. It can also persist into adulthood if it is not treated during childhood. A child or adult does not make a decision or choose not to speak in certain situations; they are unable to speak. It can trigger a freeze response and feelings of panic, making talking impossible.

What causes selective mutism?

Experts view selective mutism as a type of phobia of talking in certain situations or to certain people. It is associated with anxiety, although the cause is not always clear. A child with selective mutism will usually have a tendency to be anxious and have anxiety in other aspects of their everyday life.

Some children become too distressed to speak when separated from their parents or caregivers. A speech and language delay or hearing problem may make speaking even more stressful. Some children cannot process sensory information, for example, in loud or busy environments, and this can make them unable to speak in this environment. There is no evidence to suggest that children who have experienced trauma, abuse or neglect are more likely to have selective mutism.

Mutism can occur as a result of post-traumatic stress, but the symptoms follow a different pattern and the child will usually suddenly stop speaking in situations where they had no trouble speaking before.

It is common for children at different ages and stages in their development to develop certain fears or anxieties around things they are unsure of. This could be that they have some separation anxiety from their parents or caregivers or they may have a fear of the dark or certain animals.

This is all completely normal and the child should grow out of this; however, anxiety becomes a problem for children when it starts to interfere in their everyday life. Severe anxiety can harm children’s mental and emotional wellbeing, affecting their self-esteem and confidence. They may become withdrawn and avoid things that make them anxious.

Is selective mutism considered a disability?

A disability is considered to be a physical or mental condition that limits a person’s movements, senses or activities. You are considered disabled under the Equality Act 2010 if you have a physical or mental impairment that has a substantial and long-term negative effect on your ability to do normal daily activities.

Can anyone develop selective mutism?

Selective mutism is quite rare and therefore the risk factors for the condition are not fully understood. Research suggests that selective mutism is related to extreme social anxiety and that a genetic predisposition is likely. There is unlikely to be one single cause.

Children who develop the condition usually are very shy, may have an anxiety disorder and have a fear of embarrassing themselves in front of others.

Children who have language difficulties may also be more prone to developing the condition. Selective mutism often co-occurs with anxiety, depression, speech and language delays, developmental delays, panic disorder and obsessive compulsive disorder (OCD). Selective mutism also appears to be more common in girls and more cases are reported from migrant or multilingual families.

What are the signs and symptoms of selective mutism?

If a child is suffering with selective mutism, the following symptoms may be present:

• A desire to speak but is being held back by fear, embarrassment or anxiety.
• Inability to speak in school or other specific social situations.
• Use of non-verbal communication to express needs.
• Speaking easily in certain situations, for example at home and with familiar people, but not in other situations or with unfamiliar people.
• Lack of movement or expression when in feared situations; this can include having frozen, stiff body language, lack of eye contact or fidgeting.
• Social anxiety symptoms may include being uncomfortable in a new situation, being afraid to make a mistake or afraid to eat in front of people. Over 90% of children with selective mutism have social anxiety.
• Temperamental inhibition which means they can present as being timid, cautious and restrained. This is usually evident from infancy onwards with separation anxiety as a young child. It should be noted that separation anxiety in young children is a normal developmental milestone and usually starts to decrease between ages 2-3.
• Physical symptoms can include mutism, tummy ache, nausea, vomiting, joint pain, headaches, chest pain, shortness of breath, nervous feelings and scared feelings.
• Some children with selective mutism have developmental delays. Delays can include, motor, communication and social development.
• For some children with selective mutism, sensory integration dysfunction or sensory processing difficulties can be the reason for the mutism. In busy environments such as the classroom where a sensory overload can exist for some children, this can cause anxiety and the freeze mode to take place, and the ultimate freeze mode is mutism. In the classroom children with selective mutism can present as being withdrawn, hesitant in responding, even non-verbally, having difficulty following instructions, and playing alone or not playing at all.
• Some children can have difficulty responding non-verbally to others, meaning they cannot point or nod their head or wave hello or goodbye.

Selective mutism in adults

Selective mutism in adults can be:

• The inability to speak in specific social situations; this may interfere with work.
• Appearing nervous, uneasy or tense.
• Exhibiting extreme shyness or acting socially withdrawn.

The inability to speak is not caused by a communication disorder, but adults, particularly, may face challenges when it comes to communication. It is thought that adults with selective mutism rarely seek help and therefore it is difficult to gauge the extent of the problem within the adult population.

Adult selective mutism occurs at different functioning levels. Low and moderate functioning people with selective mutism will usually not initiate treatment. Effective treatment usually involves teaching emotional agility and identifying emotions as well as thoughts.

Selective mutism in children

Selective mutism usually starts in childhood. It is thought to affect around 1 in 140 young children. The child will usually have a tendency to anxiety and have some difficulty with everyday events. A child with selective mutism may also have speech and language difficulties.

There is thought to be no relationship between selective mutism and autism, although a child may have both conditions. A child can successfully overcome the symptoms of selective mutism if it is diagnosed and managed appropriately.

For some useful resources and information on how to support children who are socially anxious you can visit Child Mind.

How to help children with selective mutism

It is important to seek appropriate professional treatment if you think your child has selective mutism, but there are also things that you can do to help manage your child’s symptoms:

• Do not pressure your child to speak.
• Reassure them that they will be able to speak when they are ready to.
• Reward any progress, even small progress, but always avoid punishment.
• Choose activities that they enjoy and which are suited to their skills.
• Encourage non-verbal interactions, including pointing, waving, nodding or shaking their head.
• Inform and involve teachers and anyone else that works with your child in a professional capacity.
• Try not to avoid social events but focus on making your child as comfortable as possible when attending these.
• Be patient with your child.
• Give them lots of love and support.
• Place an emphasis on activities that do not involve speaking.
• Encourage communication via other means such as via the computer.

Promoting positive mental wellbeing is important in general for children.

Some of the key ways to do this include:

• Having positive relationships with family, friends and professional people involved in a child’s life.
• Having opportunities to learn and develop.
• Having opportunities to take part in positive activities.
• Having a safe and appropriate home environment.
• Having a positive view of themselves and an identity that is valued and respected.

Young Minds offer useful information and resources about children and adolescence mental health and ways in which positive mental health can be promoted.

What treatments are available?

In order to receive a diagnosis of selective mutism your child must have displayed a consistent failure to speak in a specific social situation despite speaking in other situations.

In addition to this, children must also display the following:

• Symptoms for selective mutism must have been present for at least one month, or two months in a new environment.
• Your child must understand spoken language and have the ability to speak normally in some situations.
• A lack of speech must interfere with your child’s educational or social functioning.

Children are usually diagnosed between the ages of 3 and 8 years old. The quicker the response to treatment, the better the overall prognosis. With effective treatment, most children can overcome selective mutism. How long it takes will depend on the age at which they are diagnosed, as the older the child is, the longer the treatment will be needed.

The effectiveness of treatment may depend on whether or not they have additional learning and communication needs or anxieties and how long they have had selective mutism. Treatment will usually focus on reducing the anxiety associated with speaking rather than the speaking itself.

Other aims of any treatment plan will involve increasing self-esteem and increasing social confidence and communication. During treatment the focus will be taken off speaking, reducing the pressure on the person to speak.

It is important for it to be a gradual process, starting with them saying single words to one person before moving on to sentences, with the ultimate aim for them to be able to speak freely. Sometimes treatment can be avoided if the educational setting and family can work together to reduce the child’s anxiety enough for progress to be made.

The educational setting in which the child attends can be an important part of the process in overcoming selective mutism or children who have any kind of social anxiety. To learn more about promoting positive mental health in schools, please see our knowledge base.

The most effective types of treatment are:

• Cognitive behavioural therapy (CBT) – This type of treatment helps a person focus on how they think about themselves, the world around them, and other people, and how their perception of things affects their thoughts and feelings. This type of treatment is led by health professionals and is more appropriate for older children and adolescents. It is usually effective for those experiencing symptoms of social anxiety. CBT can also be an effective treatment for younger children in some cases. For more information about cognitive behaviour therapy please see our knowledge base.
• Behavioural therapy – This type of therapy works towards replacing bad habits with good ones. Behavioural therapy does not focus on someone’s past or thought processes, it focuses on current difficulties in order to help conquer their fears.
• Play therapy – This can be effective when all pressure of being verbal is removed and the emphasis is on helping the child relax and open up.
• Stimulus fading – The person with selective mutism talks at ease with someone, for example their parent, when they are alone. Another person is then introduced and will join the conversation; after some time the parent will begin to withdraw from the conversation.
• Shaping – This enables the person to gradually build up to the desired behaviour, which is speaking. This could begin with reading aloud and then talking activities, eventually resulting in a two-way conversation.
• Desensitisation – This is a technique that involves the person becoming less sensitive to other people hearing their voice. This might be done by sharing voice recordings initially and then moving on to telephone or Skype calls, for example.
• Positive and negative reinforcement – This involves responding positively to all types or attempts at communication.
• Medication – This would only be appropriate for older children and adults who have an extreme form of anxiety. Environmental changes and behavioural approaches should always be tried first, with medication being a last resort. Medication is sometimes used alongside another type of therapy.

It is important to remember that with a proper diagnosis and treatment, the prognosis for overcoming selective mutism is very good.