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What Is Selective Mutism?

Selective Mutism (SM) is an anxiety disorder in which a child or adolescent fails to speak in specific social situations or to specific people (e.g., school, birthday parties, or to familiar adults), despite being able to speak in other situations and to other people (e.g., home, parents, or to peers).

Whom Does It Affect?

SM affects approximately 1 out of 140 elementary-aged children and it is slightly more common in females than males. Parents or teachers often notice the signs of SM at a young age (around 3 or 4 years old). What Does Selective Mutism Look Like? Children with SM are physically and cognitively able to speak the primary language, and demonstrate an understanding of the spoken language in low-anxiety situations. Children with SM are typically described as “chatterboxes” at home. In other settings, children with SM can be completely mute and unable to speak, or less severely affected children may be able to speak to a select few, whisper, or rely on nonverbal gestures to communicate in these situations. Some children are described to look like a “deer in a headlight” while other children look relaxed and carefree when prompted to speak or engage. It may appear that the child is being willful or refusing to speak, but they are in fact experiencing high levels of anxiety that prevents them from speaking.

What Impact Can Selective Mutism Have?

Selective mutism causes significant impairment in daily functioning, academic performance, and/or social relationships. Due to the fear of speaking, children are unable to ask to use the bathroom or communicate when they are in pain, or fully participate in school or social activities. The duration of SM can last several months or persist for years, and, if left untreated, it can have many short-term and long-term negative consequences on a child’s life. These include depression, risk of developing other anxiety disorders, social isolation or withdrawal, poor academic performance or school refusal, and risk of substance abuse.

Are There Effective Treatments for Selective Mutism?

  • Behavioral and Cognitive Behavioral Therapy

    The most research-supported treatment for selective mutism is behavioral and cognitive behavioral therapy. Behavioral therapy approaches, including gradual exposures, contingency management, successive approximations/ shaping, and stimulus fading, are successful in the treatment of childhood anxiety.

These behavioral techniques start with exposures to situations that are less distressing for children (e.g., playing with the parent alone) and gradually work up to more anxiety-provoking situations (e.g., parent plays with child with therapist/teacher walking past the room, parent playing with child with therapist/teacher entering the room on the periphery, parent and teacher playing with child together, etc.). Contingency management involves the use of positive reinforcement or rewarding to increase the likelihood of verbal behavior.

Successive approximations/shaping refers to rewarding approximations of the desirable behavior until the desired behavior is achieved. An example would be to reward whispering until it is established, then move to one-word responses, and then later to normal speech.

Stimulus fading is gradually increasing the number of people and situations in which the child speaks by using shaping and contingency management.

Cognitive strategies can be useful for older children when they can reflect upon their thoughts. Techniques include recognizing bodily cues of anxiety, identifying and challenging negative thought patterns, and putting together a coping plan for anxiety so that it is less likely to interfere with speaking behavior.

Intensive behavior therapy has been found to enhance the impact of traditional weekly sessions. In this type of treatment, sessions may last several hours and take place daily for a number of days in a row.

  • Pharmacotherapy

    Medication has been useful in the treatment of children with SM. Medication is recommended for children with more severe difficulties, if the child has had SM for a long time, and/or if the child is not responding well to behavioral therapy. Medication should be used in combination with behavioral therapy to help children participate more actively in treatment. SSRIs (selective serotonin reuptake inhibitors) are recommended as first-line medications because they are effective for anxiety and relatively well tolerated by children.

What is Cognitive Behavior Therapy?