Ask The Expert Archives

I have a 5-yr-old girl that we suspect she has SM. She started pre-K (3 days a week) at three-and-half and that’s when we found out she did not talk, interact, or play with any one. She might, occasionally, give one-word answer in a very soft (whisper) voice. There are a couple of girls at her age that she knew since babyhood. She does not talk or play with them either, not even in our own home! When they come to visit, she just clings to me and let them take over her toys. She does not seek for help at school (she rather not drink her favorite drink than ask someone to open it) and does not speak up when she is being hit by other kids. She speaks to me and asks me a lot of questions at home. She argues and reasons with me quite often. Although she often does not answer my open-end questions (like “what did you do at school today?”). We tried play therapy for over 6 months to no avail. We had her evaluated by child psychologist and behavior specialist and they determined that her social skill is much behind her age but her academic level is ahead of her age. They suspect that she has “Pervasive Development Disorder” (PDD). We took her to see a psychiatrist and he wants to use Meds on her. He suggests either “Prozac” or “Paxil” since they both come in liquid form. I’m hesitate to try drugs mainly because of her young age. My questions are “do you think she indeed has SM?” “Does she has PDD?” “Do you recommend the Meds for her at this stage? or should we try something else?” “Which Meds may have better results – Prozac or Paxil?” “What’s the proper dose?” “Does she have to stay on drug for a long time? – that is, will she regress if we take her off the drug?” We want to do anything we can to help her but we like to make sure we are doing the right things. Thanks so much for your help.

Answer

Based on your letter it is virtually impossible to make a definitive diagnosis of your daughter. But, I have to say, the preliminary diagnosis of PDD, can have serious, long-lasting repercussions. You need to educate yourself completely on PDD and autism so you are confident in the diagnosis.

Unfortunately, many children with Selective Mutism are mistakenly diagnosed with autism (a form of PDD), and the diagnosis is carried through much, if not all, of their school life. You need to understand that children with Selective Mutism DO indeed have the ability to speak normally and to interact completely normally in certain situations; children with autistic disorders do not!!! Therefore, if your child can communicate normally with you, show true, appropriate emotions, make good eye contact with you, have the ability to laugh, talk, cry; hence show emotions; and to communicate…then autism or PDD sounds doubtful. The fact that your child was diagnosed as ‘socially behind’ can happen quite often with Selectively Mute children; simply because they do not interact appropriately with the examiners…due to their inability to speak (at the time).

My advice to you, is to continue to seek out advice from professionals, read and educate yourself completely. If Selective Mutism is diagnosed, and social phobia is the cause, then I do recommend considering a trial of medication. You asked about the types of medication. Paxil and Prozac are very similar, differences are subtle.. I would consult your physician as to which he/she is more comfortable prescribing. We usually start on very low doses. gradually increasing every week to two weeks until a safe therapeutic level is reached.

As far as response when a child is taken off the medication…it varies, some children continue to talk, and socialize normally, while others regress and need to continue on medication for an indeterminate amount of time. The use of these drugs in children is relatively new, so scientists are still studying the short term and long term affects. Preliminary studies are indicating that these drugs are very safe to use, and no long term detrimental effects have been found.

Our 3 y.o. daughter, who absolutely loves her preschool, stopped talking at school at the end of October. Her teacher informed me immediately and the only “incident” we can attribute this to was a group of 4th graders who were rambunctious on the bridge to recess. Our daughter will speak, sing, yell, etc. at home, at her grandparents’ home, at our close friends’ homes, in public, etc. and will actually speak to me in her classroom (where I spend a lot of time each week thanks to your Web site advice) and will even talk to other classmates if I am in there. We also have classmates over to the house (1-3 at a time) and she is verbal and enjoys being with them. She does, however, clam up with adults she is not very familiar with. A little girl in her class has never spoken and my daughter has asked three or four times: Why do S and I not talk at school? Except for the one time I asked if she would like my help learning to speak at school, we have not mentioned it.

Is she SM? If so, can I help her overcome this with the support of her school, her teachers and a “team” leader, such as a therapist? Which discipline is the best for this leadership position (I met with a counselor who has a great reputation in our area but seemed at a huge loss on SM)? Are you suspicious as to why our daughter has taken on personality traits such as those of the classmate who has been SM from the beginning? Lastly, our daughter is far and beyond smart – I do not know national standards but she is do much more progressed than her classmates. Is this a factor? We do not push her in that way but do follow her lead in what she needs for stimulation. If all of this is too in-depth, I would love the opportunity to discuss it in a phone conference. I do not want it to get to be an enormous issue rather than one that affects 10% of our lives. Thank you for your kind attention.

Answer

First off, without formally evaluating your child, I cannot state with certainty that she has Selective Mutism. I can tell you that if your child speaks quite normally in at least one setting but is MUTE in at least one setting, she seems to fit the criteria. You mentioned the other child whom your child is identifying. I believe that your daughter identifies with this other child because she is also demonstrating similar anxieties. If your daughter was mimicking this other child, there would be episodes where your daughter would not be consistent with her anxiety. So, what I believe you are witnessing is two children who are similar!

In regards to who should lead the treatment process. What is important is finding someone who UNDERSTANDS. Whether this be a psychologist, social worker, speech pathologist, physician, etc. In other words, as long the treatment professional understands the dynamics of Selective Mutism and is able to develop a treatment plan based on her unique situation, then you should be in excellent hands! The team approach is a must. In other words, coordinating home and school is KEY. i.e., working on ways to build social comfort begins with forming friendships with other children. While you are having playdates with specific children, the school is arranging specific social situations involving that child and your child. Your treating professional will be guiding the process along.

You mentioned not wanting your child’s SM to take up more than 10% of your lives. I can tell you that avoiding or belittling the issue will only backfire. In other words, your child needs to be aware of the process and work with someone that can help her acknowledge and assess her anxious feelings. You cannot put this on the ‘back burner’ or she will not learn to cope and will avoid her anxious feelings. I suggest making this a top priority but see it in a positive manner.

Thank you for your compassion and dedication to children with Selective Mutism. Please allow me to briefly ask my questions again. My daughter C…….. is four years old. She is in her first year of preschool, which she enjoys very much. She participates in all activities and interacts well with her peers. She has never spoken to her friends or teachers at school. (My five year old son did exactly the same thing in preschool. His SM resolved almost spontaneously the first couple of weeks after he started kindergarten.) As of February 1, 2000, C…….. has stopped talking to everyone, including myself, my husband and my two sons. We know of no trauma. We are blessed with a happy home and extended family. C……….will very quietly whisper in play, to herself and to her toys. She will not whisper to people. She imitates animal and baby sounds in a normal voice. Recently she has been saying “uh huh” and “uh uh” for “yes” and “no” (Normal volume. I suspect that she does not view this as talking.) She acts shy in appropriate situations, like new settings or strangers etc, but otherwise appears to be cheerful and happy most of the time. She interacts well with everyone she is comfortable with, though she doesn’t speak. She only occasionally appears mildly “anxious”. She has been seen by our pediatrician for a general and neuralgic exam. I have read a lot etc and understand that SM is considered to be a social anxiety. My husband and I see a psychologist to guide us in activities to help lower C………’s anxiety thus encouraging her to speak. (She evaluated C……… at school, in a normal course of a preschool day). I have four questions:

1. Is it typical for a child with SM to outwardly appear happy and interactive most all the time?
2. Does the fact that she has now stopped talking to everyone indicate this is a more severe or intractable case of SM?
3. How do you feel about Prozac in this situation? After consulting a psychiatrist, my pediatrician has prescribed it, at my request. She started on 2 mg two weeks ago, and just increased to 4mg. The plan is to increase every two weeks as needed, up to 10 mg at most. C……… weighs 39 lbs.

Answer

J…., I have read through your question very thoroughly; I appreciate all of the pertinent information that you conveyed to me. Who formerly diagnosed your daughter with SM? I am a bit concerned as to why she all of a sudden stopped talking to everyone…including your immediate family. It is possible for SM children to abruptly stop talking to immediate family members, but it is not typical. Any new changes in your family life? Did anyone she love leave? Like a caretaker or grandparent? Did her talking stop abruptly soon after she started school? Basically, is anything new occur in your daughter’s life. Some SM children stop talking when they feel ‘out of control’ with a situation. It is their way of ‘controlling’ a situation. This is just their way of dealing with an ‘out of control’ situation….it is not done in a manipulative manner.

I would advise you to see a developmental pediatrician. Your pediatrician should be able to recommend one. I would like a more definitive diagnosis. There are other conditions that can cause a child to ‘withdraw’; I would like those possibilities to be ruled out.

1. Is it typical for a child with SM to outwardly appear happy and interactive most all the time?
   Absolutely, many children play along next to the other children laughing and smiling…just not talking. SM children become ‘experts’ in nonverbal communication and can really get their needs and wants across to their teachers and classmates. What usually happens with younger children is that their peers become their ‘verbal interpreters’ and tell others exactly what the SM child is trying to communicate.
2. Does the fact that she has now stopped talking to everyone indicate this is a more severe or intractable case of SM? Before I can accurately answer this question, I would need to be 100% sure other reasons for total muteness were ruled out. If they were, then YES… this child has a more severe case of SM. Whether or not it is intractable is indeterminate at this time.
3. How do you feel about Prozac in this situation?
   If your child truly has SM, then YES, Prozac is an excellent choice. 10 mg is a reasonable dose for your child.

Our 4 yr. old daughter has not actually been diagnosed with SM at this point but shows all the signs. We just found that there is a name for this condition after contacting a school councilor and explaining her situation. Which led us to this site; we are so thankful to have this information! We have learned that we have unknowingly done many things right for her over the years (ie: playdates, social situations, gymnastics, not pressuring but encouraging) and have seen significant improvement. She will be going to Kindergarten next year and she is already beginning to develop a positive relationship with her soon-to-be teacher (she is working on speaking more to her preschool teachers this year). My question is: should be seek professional help as well? I have a list of children psychiatrist/psychologists; should we interview them? What criteria would you recommend? We have seen continual improvement; I would hate to see her regress because she is scared of this new situation. Thanks!

Answer

By the sound of your letter it seems that your daughter is making progress with her ‘speaking’. Has your child been officially diagnosed with Selective Mutism by a professional? The facts that she IS speaking to her preschool teachers, and becoming comfortable with her Kindergarten teacher are excellent, positive signs. How is her social development going? Is she talking and interacting with the other children? It can never really hurt to get a psychologist’s or psychiatrist’s opinion on the matter. I would try and make sure that her preschool teacher speaks to the psychologist to let him/her know exactly what is going on in school.

It also sounds like you have been doing the right things to help your child conquer this. Continue what you are doing. Some other recommendations that work well with young children are the ‘reward’ methods. Set up a sticker chart at home, and send one to school. Speak with your child’s teacher ahead of time about the chart. The teacher should put a sticker on the card for every time she verbalizes, even if it is just one word answers. After your child gets a certain amount of stickers (say 5), she should get some sort of reward. With the chart for at home, encourage verbalization at home to visitors, out in public, etc. You would be surprised how well this method can work with some children. Honestly, by the sound of your letter, it seems as if your child is making progress. Another suggestion is to try and send your daughter to a small, nurturing Kindergarten where she can get sufficient one on one attention, and does not feel overwhelmed with a lot of children in a class. I hope this information helps. Continue checking out the site for updated info!

Dear Doctor, I am a new member of the Selective Mutism Association. Upon finding your website, I was thrilled. Without a doubt, I am convinced my daughter suffers sm. She has just turned 4 this month, and with the passage of time her speaking in most social settings is worsening. She began a preschool program (2 mornings per week) this past fall. Both the teacher and the school administration informed me that they have never encountered a child such as my daughter. S….not only does not speak, but also does not engage in any play with other children, nor does she complete any projects independently. When entering the classroom, she basically stiffens, making even her entry to the classroom very difficult. However, she does not fuss about going to school; she tells me about the activities quite extensively when she returns home.

By recommendation of a friend, I have contacted an early childhood specialist, who specializes with children exhibiting social behavioral delays. She has met with my daughter at our home. S…. loves her playtime with the teacher, but has never spoken to her. The “special instructor” has also visited the classroom, and has written up her observations and several recommendations for the teachers. The teachers implemented some of her ideas after the Christmas holidays and had limited success. My daughter began walking on her own to the playground instead of being carried; sat at the snack table; and, on occasion worked on a craft (with a lot of assistance from the teacher). But there has been no speaking at all to her classroom teachers. Since the start of school, S…. has extended her non-speaking to other family members and friends to whom she had previously spoken. On one occasion, she spent an entire day not speaking to her favorite cousin (age 12); then suddenly told me “I’ve decided to talk to Amy” and then talked and played all evening with her. I have given you probably more background than necessary. My question is: Where do we start in helping her through this? Our pediatrician does not feel this is a problem. Whatever guidance you can provide us would be greatly appreciated.

Sincerely, H D

Answer

Without fully evaluating your child it seems to me that she clearly has SM characteristics. Obviously a professional evaluation is warranted to be certain this is SM.

I do have to mention that I strongly disagree with your doctor! We hear this often. Your doctor is mistaking your child’s SM with shyness, and assuming she will grow out of this. Unfortunately many of the teens I am treating were told this too when they were daughter’s age. We do not know that she will outgrow it, and most do not.

My recommendation would be to find a Doctor or therapist who understands SM and can help diagnose and develop a proper treatment plan for your child. When diagnosed early, and treated from an anxiety perspective the prognosis is excellent for overcoming SM. Fortunately your child is very young, and attacking this early prevents in-grained, learned behavior from developing. And remember, your instincts with your child are usually correct.

Answer

First off, you should speak to the therapist!! This therapist does not view SM as an anxiety disorder. If she did then she would not use the word ‘manipulation’ in describing your child’s muteness. Your child will make no progress and chances are will worsen with that type of attitude. In addition, punishing, withholding privileges, bribing, tricking, are all inappropriate ways to handle SM.

The main aspect of treating SM is to remove pressure and not to dwell on the talking issue. Desensitizing your child to her school environment, especially over the summer, frequent playdates, etc. are all ways to help your child. You need to educate yourself as much as possible to SM. Read our site, go on our forums, converse with other parents, and get yourself a therapist or physician that understands SM so your child can make progress.

I have a girl that is turning 5 in two weeks and has been SM for about 2 years now, but has always shown signs since birth. We have not tried meds yet. I’m getting to the point that I’m starting to push in that direction. But, sometimes I feel it is more of a power struggle with her anxiety. Have you found this to be the case with some SM children. If yes that is why I wonder if meds are the way to go. I should add she was diagnosed by two different therapists one feels it is all anxiety, the other feels she has some anxiety but for some reason she needs to control others. What is your input? I understand that you will not be able to analyze my daughter but I hope with your expertise you can give me something to go on. Also, do you know of any programs on California in LA or Orange County?

Answer

What you have described with your child; the ‘control’ issue is VERY common among SM children….so join the club! Stubbornness is a predominant characteristic of most SM kids! Regarding ‘control’, my theory is this; most SM children, that truly have anxiety, try and ‘control’ various aspects of their life as a means of handling their own inner anxiety. Perhaps this is how some SM children started out ..trying to control their environment by not speaking! I do not mean in a willful, defiant way, but in a subconscious way. But, I truly believe that the majority, although most have many control issues, are truly UNABLE to speak. As children get older, say 5, 6 or 7 years old, and are still SM, most will tell you that they just can NOT speak, that the words just do not come out. I would stick with the therapist that stated your daughter’s SM is an anxiety!!

My son has not spoken in school this year. We invited a classmate from school to our house. He still did not talk with him. He talks with us and relatives. He does not talk to us when he knows people are listening to him. He said that he is embarrassed. He is a very happy boy yet… We now have him being assessed. How can we build up his self esteem, confidence and lessen his anxiety?

Answer

You have asked the million dollar question! Every child is different and there are many different ways to build self-esteem, increase confidence and lessen anxiety. There are multiple tactics to try and use and needs to be based on your child and their current anxiety level and individuality. The way to build self-esteem is to help promote your child’s positive attributes. One example is to promote your child’s interest in sports, art, music, etc., whatever it might be. Help your child be the best he can be in as many areas as possible!

With increasing confidence comes lowered anxiety! Building social confidence takes time and trying a variety of different tactics, such as starting with small groups and introducing one child at a time and allowing your child to GUIDE the way, not anyone else. Helping your child do this will take some strategic planning and patience on our part.

Lowering anxiety is accomplished by either behavioral therapy alone or in combination with medication. However, never use medication without adjunctive therapy.

A trained professional who UNDERSTANDS SM should develop an individualized plan for your child that can be used at home, in social situations and within the school environment.

My six year old male student has not said a word in school for the last three years. He speaks on going at home and at relatives. He has told his mom he will not speak at school. Could this really be SM? He plays, runs around, smiles and does everything else the other students do except for talk. He gets along real good with everyone and seems to like his teacher. Could he possibly just be spoiled? I heard an audio tape of him, and it sounds like he pretty much rules the house hold. He does say and do what he wants at home, you can tell by listening to the tape. He is in school a whole day and also never uses the bathroom. He has never had an accident. As a teacher it is very frustrating and I really can’t test him very well. He is far behind the other students. Should he stay back for another year? Any information you can give us would greatly be appreciated.

Answer

I sense your frustration, but honestly, many of the questions you asked are too ‘vague’ for me to answer with certainty. Could this child have SM? Absolutely. Many of the characteristics you mentioned are similar among SM kids… They are often assertive, boisterous, extremely verbal at home….as far as ‘rules the roost’, that can be with any strong willed child. Many SM children hold in their urine throughout an entire day at school. This stems from not being able to ASK to go to the bathroom and the fear of bringing attention to themselves. Many SM kids do not eat in school as well…again, they do not want to bring attention to themselves.

As far as spoiled?? I am not sure what that means?? Spoiled to me is a vague term for a child that is ‘given’ whatever they want. In most cases, it is the observer that misinterprets ‘spoiled’ from something entirely different.

Should the child be held back?

I cannot answer that. Testing a SM child is indeed difficult, but the majority of the children are bright and are on grade level or above. At his age, if you feel that his skills are not up to par…then a nonverbal assessment may be warranted. Be careful though. With many SM children, anxiety holds them back from succeeding and performing well on many tests.

A good developmental test that can be done with minimal verbalization and is very user friendly and children seem to enjoy the test is the Bracken developmental test. The score correlates with school readiness and skills can be assessed. I recommend someone administer the test who the child already has a relationship with.

Our daughter is 6 and we have recently been in touch with our local Speech Pathologist (who specializes in SM)-she came to our home to observe K….. and told me K……appears to have SM from what she can tell, and she seems to be emerging. My concern is that she uses words and phrases such as,” these kids know exactly what they are doing.” They want to control everything. This may be hard to hear but they are very manipulative. She doesn’t say this in a mean way, and says it is from the anxiety. She seems to know something that I don’t understand and don’t see myself. She brought me a copy of the Personal DSM IV, so I believe she has recent info about SM. I am not understanding this (am I being defensive?) I try to be open to positive AND negative aspects of SM, but when I look at K….. in her most difficult situations I see fear, apprehension and anxiety, not manipulation or control. I want to be open to learning, but my instincts are telling me that K….. is not doing this on purpose. Is there anything you can tell me to help me understand? Why am I not getting this aspect of SM. Please help?

Answer

You are absolutely 100% correct! You are not missing anything, the speech pathologist is! These children are not controlling, defiant and manipulative…not in the least bit! The reason people feel this is because of this: Anxious children do not always LOOK anxious…especially after being in an environment for a period of time…the blank, expressionless, glazed over look is not present ALL THE TIME. So people see these kids running, playing and not talking…and when they are spoken to many of these kids just briefly look at the person who asked the question.and then turn away… SO, it looks just like defiance.

Your speech therapist is way off base, and it is attitudes like this that are the reasons we are so PASSIONATE and DEDICATED to our cause. We need so badly to educate all professionals out there… When children do overcome SM they will clearly tell you that they wanted sooooo badly to speak, I have heard such things as, “the words were stuck in my throat”, “my tongue was playing tricks on me,” “my lips wouldn’t open to let the words out.”

Kim, You are obviously right on top of things, and know your child, do not continue with a professional that sees your child as manipulative and stubborn. Children are so perceptive, especially our bright SM kids. Your child will pick right up on the feeling this therapist has and this is not in your child’s best interest.

My daughter M…… who is almost six has been mute in school and with adults since the age of three. She has been on 10mg of Prozac since May of this year and began treatment the end of March. She has been making good progress with eye contact and talking to her immediate family in front of others but she still refuses to talk in school, even to the children (one is her neighbor who she always talks with at home). She started Kindergarten last week and she said she will not talk because she is shy. I don’t know what to do. I know her psychiatrist will want to increase her dose but I have heard that 10mg is usually the magic number. Also, is medication going to make her talk? I am trying so hard to be patient but I know this is a critical year for her.

Thank you.

Answer

A few things, first off, she is not REFUSING to speak, she CANNOT speak.

You mentioned that she is on 10 mg of Prozac. What are you doing in terms of behavioral treatment? Is she working with someone to help her build coping skills? Using medication alone will not MAKE her overcome her SM. It will, however, lower anxiety ( when monitored correctly) enough to DO the behavioral treatment necessary to TRULY overcome SM

In addition, you sound a bit ANGRY and frustrated. I suggest that you, too, work with someone, or get some support in helping YOU cope with your child’s anxiety. Believe me, I UNDERSTAND your feelings, and I know it can be very hard when your child does not speak and you feel as if you ‘have done everything’ and you are simply frustrated as to what else to do.

I recommend this: Speak to your psychiatrist about a treating professional who can work with your daughter on an ongoing basis. Also, this treating professional should be able to offer you parental support, guide you and help you COPE and understand how to really help your child with the day to day issues that arise.

Your daughter is telling you she “won’t speak because she is shy,” simply because she is trying to make sense of her inability to speak. She is rationalizing it by saying she is shy, so she can feel OKAY about her mutism.

I can tell you, from working with hundreds of SM children, she needs to be working with someone to help her truly confront and gain control over her mutism, until she can do this, progress will be limited.

My daughter is 8 years old. She was diagnosed with Selective Mutism when she was 6. She has not spoken to any adult besides my husband and myself. She has been in Therapy for 2 years. She never spoke to therapist. We have stopped therapy. Could you tell us where to go from here?

Answer

You most definitely sound frustrated and unsure of your next step. I can reassure you that when approached correctly your daughter SHOULD make significant progress and ultimately overcome SM. You did not mention the TYPE of therapy your daughter received. There are so many variations in therapy. You stated, ‘She never spoke to her therapist.’ I can tell you that the therapist’ goal should not be to hear your daughter to speak to HER, but to help her in the REAL WORLD.

In other words, MUTISM is a reflection of severe anxiety. When we lower anxiety, verbalization will follow. SO, tactics need to be to help your child feel comfortable, remove all pressure to speak and to help her gain comfort in school and other social situations. ie, DESENSITIZATION is a wonderful tactic we recommend to ALL SM children. This involves slowly helping her to build a comfort level, by frequent, non-threatening exposure to anxiety-inducing situations, such as school.

Please search out a therapist who UNDERSTANDS SOCIAL ANXIETY. You can contact your local children’s hospital for a referral or perhaps your own doctor knows of someone in your area.

GOOD LUCK, and please know that the prognosis for overcoming SM is excellent when approached from the right perspective!

I have been aware of my daughter’s selective mutism since 09/01. She is 4 and has been under the treatment of a psychiatrist w/experience w/SM since 02/02.(these dr.s are hard to find.) Office visits are every other week alternating 45 minutes to 1 1/2 hr. Longer visits started recently -my idea. We meet at restaurants or the park-my idea. The dr.is 1 hr away so we travel there. After a warm up of about 5-10 min. C will speak with the Dr in a whisper unless she forgets herself and will speak normal tone. Our concentration has been to build her self esteem-(dance lessons) & to have her feel comfortable @her daycare. I spend 1 afternoon there per week and she will whisper to me in front of others. She doesn’t like crowds-too many kids she just walks away. What’s next? I felt that after 7-8 months of Dr visits it would be more than playtime-them getting comfortable together. What should the Dr be doing w/ my daughter? The Dr & I email as I do not discuss in front of C who believes the Dr is my old friend. We’ve discussed meds for the future-she likes Paxil. How do I know when it’s time for that? We have not set any goals but I feel we are at a standstill. I need directions-am I doing enough?

Answer

I have some questions for you:

1. You mentioned that it is your idea to GO places with the DR. What is the DR doing to help your child ‘lower anxiety’ and build coping skills’ when in the social settings that you go to.
2. You mentioned that for 7-8 months the goal has been to build comfort with the DR. That is great, however, what is being done to help YOU and your child in school, other social situations, etc. In other words, other then ‘playing’ and having fun, what recommendations are being suggested to help your child in school, other social settings, etc? You need to work with your child to help with methods to gain comfort in social situations. HOW TO FUNCTION…etc.
3. You mentioned that you and the Dr e-mail so that your child does not HEAR what you are talking about. That is fine in some situations. But does your child ACKNOWLEDGE and understand her anxiety? Until your child understands her feelings in various situations, she will have limited progress. ADMITTING and understanding that she ‘cannot get the words out’ is KEY and the first step in helping the CHILD overcome her anxiety.

I cannot possibly tell you ‘what should be done now’ simply because I do not know your child, but I can say that the goals of overcoming SM start with the child ACKNOWLEDGING and gaining control of her feelings of being ‘uncomfortable’, ‘scared’, etc. in social situations. Then, with the help of a treating professional and involving the child in the treatment goals, various tactics are used to help lower anxiety, build self-esteem and increase confidence in social situations. Hope this helps 🙂

My daughter is 4 years old and has selective mutism. At the age of 2 1/2, I enrolled her into preschool three half days a week, which I thought would help her with her socialization skills, because I thought she seemed to be shy. During her first year of preschool, I noticed and was informed that she hadn’t spoken to anyone, and basically that pattern has continued. She speaks only to the immediate family, and to the immediate family around other people, but not to other people. Last November I had her see a therapist at our HMO for approximately 6 months. I believe only play therapy was used, and no improvements were attained. However, the therapist was able to get my daughter to speak with her by having the two of them begin with animal noises, which lead to laughing, and then to speaking. The reason why we quit going, was that her visits were reduced from once a week to once a month, and I believe it was because the therapist had too many patients that she needed fit into her schedule. So, based on that I’ve decided to go outside of my HMO, and see a private therapist. Unfortunately, I’m finding, that out of the twenty therapist I’ve called so far, only two have had some experience with it. Certainly, I have not found someone who specializes. So, I was wondering do you know of anyone in the San Diego, CA area that could help my daughter? If not, should I go to the therapist who have had some experience, but seem to be resistant to Prozac i.e. meds? I’d appreciate any help/suggestions you could give me. Thanks

p.s. In your opinion, if behavioral therapy alone was tried and there were no results, keeping in mind that my daughter is of good health, weighs 45lbs, and is 42 inches tall, what dosage of Prozac would you start my daughter at, and how long would you keep her at that dosage before upping it if no results were found at the previous dosage? Also, what would be the highest dosage you would prescribe to her? The reason why I’m asking is if I have to go to someone that doesn’t know that much about selective mutism, at least I’ll have a reference of what the prescription they issue should be close to.

Answer

First of all, check our professional advisory board, Murray Stein is in the San Diego area and may be able to see your child. He is at the Univ. of Calif. San Diego (UCSD). If he cannot see your child, perhaps he will recommend someone in your area.

Secondly, before you consider medication, I am not sure you have EXHAUSTED all of the behavioral tactics that can be instituted. You mentioned that your therapist did play therapy. What did she do to help your child in the outside world? In other words, she got her to speak to her in the office, but did she work with you on ways to help her with increasing comfort in school? public places, how to desensitize her to her environment to lower anxiety etc?

From what you wrote it does not seem that way.

We work with many four year olds, and MOST do very well with behavioral alone. IF after three- 6 months of ‘correct’ behavioral tactics medication may be considered. Tactics should be geared towards LOWERING ANXIETY, BUILDING HER SELF-ESTEEM and INCREASING CONFIDENCE IN SOCIAL SITUATIONS using a combination of various approaches that are individualized to your child’s needs. i.e., desensitization. How often have you worked one on one with another child? Have your spent time in her school before and after school and SPOKE to her and asked her questions to begin the verbalization process in school. There is no way she will begin speaking to ANYONE until she is comfortable speaking to you.

Thirdly, You asked about medication. The drugs of choice are the SSRI’s such as Paxil, Prozac, etc. Dosages should start as LOW a possible and increase is based on RESPONSE, not just weight. GOALS are to move slow and stay low. MORE IS NOT BETTER when it comes to using these medications. A physician needs to use your daughters reaction as his GUIDE as to how to DOSE Her. There is no hard and fast rule. Wish there was. Hope this helps.

Our daughter is 6 years old and has Selective Mutism. She’s been in therapy since November of 2001. Her therapist is using ‘play therapy’ without drugs. Our daughter has progressed from no talking at all during sessions to talking openly with the therapist, but she still won’t talk to teachers, etc. Over the past couple of months it seems as though she has plateaued. Are there any other forms of therapy or treatments (short of drugs) that could help her progress through this disorder to a normal childhood quicker? The therapist seems to only want to use the play therapy, should we pursue a different therapist?

Answer

The answer is YES! There are other methods of treatment.

First and foremost, What is the therapist doing to help your child on the OUTSIDE, in social situations? If your therapist is NOT helping your child build coping skills and to accomplish various tasks OUTSIDE the office, then you need to educate her to SM and speak to her about ways to help your daughter deal with school, meeting people, etc. It is all fine and well that she is speaking to your therapist, but what about how to handle stressful situations in school?

You need direction and advice on how to help your child feel more comfortable at school (usually the toughest place for our kids!). Desensitization, Fading techniques, Modeling techniques, positive reinforcement, etc are wonderful ways to help your child. HOWEVER, understanding where your child is in terms of her anxiety dictates the specifics on the above techniques. I.E., if your child is so anxious that just walking into school with you produces ‘terror,’ then by offering her a sticker to say hello to her teacher will only petrify her more! Whereas, a child who can speak to many different kids, and who has whispered occasionally to her teacher, may be ready for that reinforcement to ‘say a word’ to her teacher. Every child is different and responds to tactics and techniques differently. You need a therapist who can READ your child and treat the WHOLE child, not just there MUTISM. You also need someone who can help your child COPE in various social situations—> REAL LIFE! Please speak to your therapist about this ASAP.

Answer

Interestingly enough, many SM children say this very same thing… that they do not like the sound of their voice. A suggestion would be to try speech therapy. With SM children that truly do not like their voice, speech therapy has helped them reach a certain comfort level and to realize their voice is not so bad. Along with the speech therapy, doing typical anxiety lowering techniques such as practicing verbalization in the school with you before and after school, having frequent playdates with children from the class, bringing those kids into class before and after school etc.

My five year old daughter was recently diagnosed with SM. Since she was 2 1/2 she has only spoken to her immediate family, 2 of her aunts, and 3 young cousins. After many months and many, many phone calls we finally found a psychiatrist to work with her. She put her on 10mg of prozac and she seems to be slightly more comfortable around people she knows well. She is nowhere near ready to talk. Unfortunately, the doctor it took me so long to find is suggesting we try to force her to talk now. She has only seen her twice and is recommending we deny her privileges if she won’t ask for them. I know she needs behavioral therapy, but I honestly don’t know where to turn for help.

Answer

Well, your instincts are correct. You may have found yourself a prescribing doctor, but you certainly did not find one whom understands SM or the debilitating effects of anxiety. FORCING your child to talk is like adding salt to an open wound. You will cause more distress, heightened anxiety and more avoidance in your child.

The main form of treatment is to help your daughter progress communicatively by moving from nonverbal to verbal…and understanding that her anxiety level will change from setting to setting and person to person. I suggest reading the handout: Understanding SM as a Communication Anxiety Disorder. This is on our member website.

Perhaps you can consider attending the summer retreat. We will have THREE full days of learning about SM and anxiety in our children. Good luck and keep us informed.

My daughter who is 3 1/2 years old has been diagnosed with selective mutism. She does not talk in her classroom nor to most people. Only a select few. At home she is very animated and loud but in school has a flat affect, is mute and seems stressed out most of the time. She does not cry when we drop her off and she says she likes school. I believe her SM may be related to some type of high anxiety (possibly from being ill and hospitalized when she was 1 years old). If we are able to shape her behavior in school by a reward-type chart what then happens to the anxiety? Where does it go? Will it manifest into something else?

Thank you for your time.

Answer

Very interesting question you have here. I would not just do stickers….especially if you are not doing any other therapeutic measures to help decrease anxiety. Because, in my experience, sticker systems need to be incorporated with other ‘therapies’, whether it be other methods of behavioral modification, medication, etc. Because you are correct. Just using stickers as rewards will probably not get you very far simply because you are not doing anything to lesson anxiety. Our main goal of treatment for Selective Mutism is lowering anxiety (by various tactics) and raising self-esteem (emphasizing positives).

We live in Canberra, Australia, and our daughter is seven and has recently been diagnosed with Selective Mutism. Very few people in our part of the world know about this condition, so we are trying to find out as much as we can in order to educate others. Our question is this: what is the best way to handle situations where our daughter is with us and she is expected to speak e.g. we see a friend down the shops and they ask our daughter a question. As our daughter won’t answer, should we: 1) answer for her; 2) tell them she’s a selective mute in front of her; 3) leave an embarrassing silence (which is usually filled by the other person saying “she’s so shy!!!”). What should we do??

Answer

You have asked an excellent but very difficult question. Many aspects need to be considered. First off, how comfortable are you and your child with KNOWING and TALKING about Selective Mutism? Secondly, How anxious is your child? Is she able to respond nonverbally and smile, is she able to whisper words to strangers or is she completely shut down and stands motionless and expressionless. My point here is that depending on your child’s degree of anxiety determines what you can expect from your child.

When involved in treatment, your clinician should be guiding you via goals to help your child MOVE FORWARD and progress. Assessing your child’s anxiety by having her express her fears (rating between 1-5 etc) will enable you and your treating professional to KNOW how your child feels. Here is an example.

Ask your child how she feels when someone asks her a question or says hello to her when in public. Ask her to rate her feelings (there are many methods to do this!). Then discuss with her ways that she can RESPOND without causing her too much anxiety. If she is mute in situations like you are describing to expect her to SAY ‘HI’ will only exacerbate her anxiety. However, perhaps she can HAND A NOTE to a stranger or WAVE without FEELING too anxious. Use her FEELINGS of anxiety as a gauge. As she waves or hands a note, reward her then ask her how she FELT about this. In a short time, she will feel less and less anxious and be able to do more and more! Your treating professional should be able to help you progress throughout various stages of communication.

Regarding what to say to others? Again, this depends on your comfort with saying your child is anxious and has SM. Depending on how ANXIOUS your child is determines what you say, but if your child is the typical SM child who is MUTE and often just ‘stares’ or looks away, you can say something like: ‘ My child sometimes has a tough time responding (or speaking to) people he just meets or does not know that well.’ Or you can say, ‘ My child has a tough time answering, but he certainly can wave well!…etc etc…bottom line, is you need to answer and respond as you feel comfortable.

The SMA~CAN also has wallet cards available that can be given to people to help them understand.

Dr. Elisa Shipon-Blum

My 5 year old daughter appears to have selective mutism. What should be done when other children state ‘so and so can’t talk or doesn’t talk?? should they be scolded? When my daughter does not answer a question addressed to her, should I intervene and answer it for her?

I witnessed an incident a few months ago where several children were sort of holding my daughter down and saying “she can’t talk, she can’t talk”, and laughing and so forth. They were obviously making fun of her, and I did not know whether I should have told them they should not do that, or it it rude, or something. There have been other incidents where children will make remarks about my daughter’s lack of speaking, and I am not sure how to handle it. Sometimes when I pick her up from school, her classmates will come up to me and say, “Oh, your her mom. She doesn’t talk.” This is said in front of her which I don’t think helps the situation. I am not sure generally how to handle comments from other children or even adults. I don’t think it is helpful to her to hear these things, but don’t know what I can or should do about it.

Answer

J……, your question is a very common concern among SM parents…I hear stuff like this all of the time. Unfortunately, children and adults are going to make comments. Most of the time, children are innocent and are just saying it the way they see it…. I have had more parents tell me that peers of their Selective Mute child are always coming up to them asking them (the parents) why their child does not speak. It is hard to answer this. My recommendation would be to smile, act like it is no big deal and say, “well, ‘so and so’ can be quiet, but she talks nonstop at home!” If the other child then says,” then why doesn’t she talk at school.?” Your comment can be….”she will, when she is ready”. Just down play the situation. Other children are just curious and often this answer suffices.. Regarding other adults…You can answer similarly…..I don’t recommend telling others that ‘she is just shy’… I hate LABELS! and your child is not just shy……..

Regarding your child….my advice is to spend some one on one time with her and gently bring up what happened in school. You can tell her that you know it must have been hard for her and that you understand. Tell your child that kids do not mean to hurt you but are curious…and you can bring up an example of something that may intrigue your child.

I have found that in the majority of cases, peers are actually very protective of their SM classmate…They often help them out in tough situations by telling others that do not know they are mute that ‘so and so does not talk’. This is tough for the SM child, but as far as they know, the child does not talk. Hopefully over time, with treatment your child will overcome SM….and ‘talking’ will not be as much of an issue.

Dr. Elisa Shipon-Blum

My 5 year old daughter has sm. we have just recently sought the help of a psychologist in our area (St. Louis, MO). my question deals with the “symptoms” of sm. my daughter fits all the criteria–not speaking in any social situations, lasting more than 1 month, etc. after reading postings on the support group for about 3-4 weeks now, I’ve noticed a pattern with many of the children mentioned. many of these have other anxieties besides sm. is this normal? I haven’t noticed anything with my daughter except her lack of speech. she has never had separation anxiety and seems to be an overall happy child. do other anxieties develop along with sm that I’ve just not noticed? I know that sm is a social anxiety and just wondered if there were other signs that I may be missing. also, can you give me advice in dealing with a psychologist who does not have a lot of experience with sm. should I be feeding her my knowledge (from sm website) or would this be insulting? we have just started with her and I don’t want to do anything that might offend her.

Answer

Some children have other anxiety disorder symptoms along with SM ….while others have only the characteristics of SM.. HOWEVER:, if you look over the other characteristics that SM children have, many have behavioral issues at home, such as inflexibility, procrastination, perfectionism, stubbornness, etc…these behavioral symptoms are all a direct reflection of the inner anxiety they are feeling. As children get older, some of the behavioral symptoms start to dissipate, and more outward signs of anxiety start to emerge; such as frequent worries and concerns….. I find that when children are older than 6 years, the ‘worries’ start to become more evident. Also, as anxiety worsens, other anxiety disorder symptoms may emerge in some children while more pronounced SM symptoms emerge in others. What I am trying to say is, every child is different.

Regarding your psychologist that is uninformed about SM: If he/she is willing to learn about SM and the various therapies that work with SM children, and you are pleased with them, then there is no reason why you should not stay with this therapist. The relationship she/he has with your child is important as well, so if your child has connected to this professional, is making improvement and your therapist is learning about SM and instituting the therapies that work with SM children, then my recommendation is to stick with what is working!

Dr. Elisa Shipon-Blum

My 7 yr old son has Spinal Muscular Atrophy and is in a wheelchair. He attends a regular school and has a shadow in the classroom to help him with books etc. He has not spoken in school since he started 3 years ago. Up until 3 months ago he spoke with a normal voice at home. Now he only whispers at home. (One morning he woke up and just starting whispering). At school he started the year not speaking at all. Now he whispers to everyone except the teacher. So what remains is getting him to speak in a normal voice in all settings. However, we are not seeing any progress and the school told us he cannot come back next year unless he can speak to the teacher. We started him on Prosaic first 1 mg now he is at 5 mg. Can you comment on the change at home, how to get out of the whisper mode to a normal voice, and any advice on dealing with the school?

Answer

Thank you for your question. Your child has heightened anxiety. I will apply your son’ s disability with communication to his physical disability. Your son is unable to walk and use his muscles effectively. You have therefore provided him with a wheel chair to be mobile. The same needs to be done with his communication and anxiety disorder. He needs a wheelchair for communication and anxiety to be able to communicate. A wheel chair for communication is in the form of educational accommodations in school and accommodations at home to help him. Just as you would not expect him to get up and walk.. You can’t expect him to ‘just speak.’ I hope this analogy helps you understand that his mutism is not something that he is choosing.

His whispering at home now is a direct reflection of heightened anxiety. I assume since the school is pressuring him to speak there is a lot of pressure at home as well. What needs to be done is the following;

1. You need to read as much as you can about SM from the SMA~CAN website. You will clearly see that helping a child overcome SM involves REMOVING pressure to speak and then planning, with the help of school, parents, child and treating professional specific tactics/techniques and therapy to progress form nonverbal–verbal communication. The approach being taken now is only making anxiety worse. He is feeling this at home since ‘whispering’ is occurring.
2. Your child needs educational accommodations whether be Individual Education Plan or 504 Plan. Please read the following link to help you understand these accommodations:
   By law, accommodations need to be made to help your son. Under the heading of “Child with a Disability,” it states that this term for a child aged 3 through 9 may include a child experiencing developmental delays in one or more of the following areas: physical development, cognitive development, communication development, social or emotional development, or adaptive development. Your school will need to do testing and a full evaluation to determine the degree of his communication impairment.
3. Work with a treating professional who understands SM so that they can guide you appropriately with treatment and school recommendations. The SMACAN has various resources for you to help you with knowing the laws and educational accommodations for your child.

A child cannot go from mutism to speaking in one step. I know your son is whispering but I also believe when he is doing so his anxiety is tremendously high only stifling him more. Is he able to initiate his needs nonverbally (go up to…) peers, teachers? Can he speak one on one with select children, in a larger group setting? There are many questions that need to be answered and determined so that your treating professional can guide you appropriately.

Dr. Elisa Shipon-Blum

Our daughter, will be 5 in September. she has been selectively mute for 2 1/2 years and has never been able to endure preschool due to anxiety. How do we ease the transition to school? Should we proceed slowly, as is our inclination or confront her fears as the school psychologist suggests? Also, do many sm’s have sensory issues or Asperger’s? we are finding cognitive and sensory delays in our daughter who is otherwise very bright. thank you!

Answer

Honestly, you will traumatize your child if you try to get her to CONFRONT HER FEARS head on into the new school year! I wholeheartedly disagree with this psychologist and I suggest you educate her to SM. Your child is a little girl that is severely anxious, the best approach is a gradual weaning into the situation. Start off slow, take her to the school before the school year begins, etc…I recommend you purchase EASING SCHOOL JITTERS to help with ideas on how to help your child feel more comfortable with school.

Also, I see sensory issues often with sm children. I recommend an evaluation by a pediatric occupational therapist to check for sensory issues. If your child does indeed have concurrent sensory integration disorder this can actually make her anxiety worse. Shutting down from sensory overload can be debilitating, and needs to be addressed.

Aspergers should not be too hard to differentiate from sm. Please pursue the correct diagnosis, this is of utmost importance in overall treatment.

Dr. Elisa Shipon-Blum

I am a Therapeutic Riding Instructor. We have several children diagnosed with Selective Mutism that ride at our barn. We have noticed that each of these children have low muscle tone. Is this typical in children with selective mutism, or just a coincidence?

Answer

From all of the research I have done, I have never heard of ‘decreased muscle tone’ being associated with SM. It is probably just a coincidence. BUT, it could be that many of these children were unable to participate in outside sports etc., due to their profound social phobia, and therefore are physically behind other same age children.

Dr. Elisa Shipon-Blum

Dear doctor, I have a 5-year-old girl who never talks in school except giving one or two-word answer. She does not play with others, never makes friends. At home, she talks just fine. She pays attentions to what we said, asks a lot of questions, plays with us, laughs… We took her to see two psychiatrists and both diagnosed her to have social phobia caused by high level of anxiety. Although they never mention she has SM but we think she does based on the information we get here. The only thing I’m not sure is that as very much relaxes as she is with us at home, she never answers our open-end questions. She only answer yes/no or multiple choices questions. She can speak full sentences very well or even argues with us. But she never tells us what she does at school when asked. We found out recently quite by accident that a boy has been picking up on her. She never reports it to her teacher or talks to us about it. She just became anxious about going to school. She seems defenseless when someone gives her trouble. Is this a common behavior for SM children to hold such information even from her own family? Is it common that they don’t answer open-end questions even to her parents? Also do you know any doctor or psychologist in Austin, Texas area who is specialized in SM? Her current psychiatrist wants to use med on her (Pexil or Prozac starting at 10mg) but we are not sure if this is a right dosage to start with. We really appreciate any help you can give us. It just makes us extremely worried that our little girl can not even protect herself due to her inability to speak. Thank you very much!

Answer

From the information that you provided about your daughter if she truly does speak in school…even one or two word answers she does not meet the definition of Selectively Mute.. But, it does sound as if she is socially phobic…so, basically, the treatment is the same in the majority of cases.

This Website will help you tremendously with your child. I am a bit concerned about her expressive language development. You mentioned that she does not ‘elaborate’ on answers and prefers answering multiple choice questions and will answer in one or two words…The reasons for this can vary. First of all, it is possible she has a speech and language problem. I am going to have our speech and language specialist answer this question regarding the specifics….but, just so you know, approximately 20-30% of SM’s have a speech and language problem…. Another reason for her ‘lack of elaboration’ could be that she is a perfectionist in many senses and does not want to say the wrong thing. Many of our SM kids have that characteristic. They are (subconsciously) concerned about what they say and how they say things. If this is the case, treating her Social phobia/Selective Mutism and building her confidence with her speech and language will cure this. One of the members of our advisory board lives in Texas, I will ask her about specialists in your area…then we will get back to you.

Addendum to Q 9

You mentioned Medication, The dosages you suggested of Paxil and Prozac are appropriate dosages, but I NEVER EVER start a child on this level. I start with a much lower dose than 10 mg and slowly build up this dose and then slowly over a few weeks-months move up (if need be). By starting low I am accomplishing three things. First, I am minimizing side effects. Secondly, I am starting low and my kids will eventually end up on a much lower dose than the average. Third, starting low enables me to use behavior modification and other psychological therapies to work hand-in-hand with medication.

Dr. Elisa Shipon-Blum

R…. (now 7) has had sm since recognized in kindergarten two years ago. Her first grade year she received counseling, but this year we do not have insurance and we cannot go. The teachers are very understanding and we do not focus this as a problematic pattern, however I feel there is something else underlying here…she is now pulling out her eyelashes and eyebrows (there is NOTHING left). she claims she “can’t help it”. Are you familiar with this situation…Self mutilation does not seem SM to me, Do you think it is an imbalance of some sort. Help please.

Answer

What you are describing is called Trichotillomania. Like SM this is a form of anxiety. Hair loss is caused by compulsive pulling and twisting of the hair until it breaks. The hair may be lost in round patches or diffusely across the scalp. The effect is a moth-eaten appearance. Children with this disorder often pull out their eyelashes, eyebrows and other facial hair. This is another manifestation of anxiety. Just as children with SM do not speak in select social settings, children with trichotillomania pull out their hair. This disorder is actually a manifestation of OCD, and is treated very similarly. I recommend finding a physician or therapist that specializes in anxiety to help you determine the etiology for your child’s severe anxiety, and to help develop a treatment plan for your child.

Dr. Elisa Shipon-Blum

My 5 yr old daughter has been diagnosed w/ sm. She was held back in pre-k to give her more time to adjust to a school environment. She not only does not talk in social settings; but also gets overwhelmed by loud noises & large groups. We have thus far only tried reward therapy & currently are trying audio therapy (which has been somewhat successful). I have read that the reason meds are used is for seratonin replacement. I have been taking a drug called Sarafem (fluoxetine hydrochloride) for that exact same thing due to a “hormone deficiency”. I only recently started this medication; but I already can say that my anxiety level has decreased. I have always had anxiety problems; but have never had any problems talking. My question is…is this seratonin deficiency inherited? Honestly, my husband & I have always said that we would never give our daughter drugs to help her; but after my experience on Sarafem, I may have changed my mind.

Answer

Please, take one step at a time with your child. You should not jump right to medication without fully exhausting other possible treatment modalities. From what you asked me in your question you really need to take time to educate yourself to SM and anxiety disorders. Please go through our site and especially read the other “Ask the Doc” questions and answers. Many of the questions will clearly help you understand the relationship between serotonin and anxiety.

As you probably know SM is indeed an anxiety disorder and anxiety disorders are correlated with LOW serotonin levels. So by replacing serotonin levels will usually help alleviate anxiety symptoms such as SM symptoms.

In addition, although this is not too prevalent in the literature, I have seen a strong correlation with SM (anxiety!) and sensory integration issues such as what you described when you said your child is sensitive to loud noises and large groups. In fact; I plan on doing an upcoming study on just this topic! My ‘professional’ theory is that low levels of serotonin correlate with sensory problems in some children. I believe that many of our SM children are not able to adequately ‘block out’ sensory input due to their low serotonin levels. By replacing serotonin we can often treat their SM and sensory issues. I see this happen often! I recommend having your child evaluated by an occupational therapist to further access whether your child does indeed have a sensory integration disorder.

You will need to have your child fully evaluated by a trained professional to give you the best treatment plan to help your child with SM and other symptoms she may be having.

Dr. Elisa Shipon-Blum

My daughter S…., who is now 10 is diagnosed with SM/Social anxiety, Expressive and Receptive Language Disorder. Just recently we found out that her left ear is 50% below normal when she had a central auditory processing test performed. My question is which problem should we tackle first? I have been visiting her school twice a week, during lunch recess, to play communication games with her and her friends. She speaks in a normal voice during my visits. The speech pathologist has given me books and games on language and communication skills, in which S….. willing does with me.

Answer

Approximately 30-40% of SM children have speech and language disorders, so I am not too surprised that your daughter has a disorder. But, because our SM children are slow to respond and cannot initiate when they are anxious, we often see many of our children falsely diagnosed with disorders that they do not have. Please be sure that your daughter has been evaluated by a specialist who understands SM and understands these anxious characteristics.

If your daughter does have a S&L problem you should be working on both SM and the speech disorder. Many times as speech and language skills are improving, SM also improves. Again, please be sure to work with someone who truly understands SM.

Dr. Elisa Shipon-Blum

My daughter Molly is 5 3/4 years old. She is Selectively Mute, she also suffers from ‘sensory overload’, i.e she does not cope well with crowded places, loud noises etc. She also seems to lack empathy, i.e she lacks socio-emotional reciprocity. She does not have restricted patterns of interest, nor any particular rituals, nor any self stimulating behaviour. She was diagnosed with Aspergers Syndrome in Dec 2003. Please would you confirm when it is autism and when it is not. I believe, (albeit perhaps incorrectly), that there is some overlap, particularly with the sensory issues. Please could you clarify this. We are carrying out numerous desensitization strategies at school with the help of a fabulous teacher, and we have increased Molly’s Prozac from 7.5 mg to 10 mg after 3 months.

She is happy to communicate non-verbally at school but will not speak thus far and never has in the school environment. Is there anything else we should be doing ? Also, can serotonin really fix the sensory problems? Thank you for being there to give your professional opinion. Here in Sydney, Australia, there is little in the way of understanding or expertise about SM, unless you can recommend anyone. Thanks again. I look forward very much to your reply.

Answer 1

You can HAVE an autism spectrum disorder and SM…but SM is not the primary diagnosis…the autism spectrum disorder is the primary diagnosis.

Clinicial experience dictates that Sensory Integration Dysfunction (DSI) is a precipitating factor into the development of SM…as are speech/language, social/communication impairments. It is often impossible to determine exactly WHY a child developed SM…other than to say it is a combination of many factors.

Communication Anxiety Therapy often words well with children with Aspergers…as long as the child is involved in other types of therapy for Aspergers. Ie, social skill groups, OT for DSI, etc.

All therapies must work together….Helping build social comfort is KEY…although we know it is often difficult for children with Aspergers to relate to others…and understand social cues. This is hallmark for Aspergers…As a result, anxiety is created or exacerbated just from the discomfort of social interaction and awkwardness. Many with Aspergers KNOW they cannot relate well and it is frustrating.

SSRI’s often do help alleviate some sensory overload symptoms. This is usually evident at very low dosages of SSRI treatment. NO NEED for higher dosages…which only leads to side effects.

So, recommendations are to work with a clinician who can help progress your child communicatively from nonverbal to verbal and at the same time coordinate Communication Anxiety Therapy with additional supportive services to help your child with issues related to Aspergers Syndrome.

Dr. Elisa Shipon-Blum

My daughter is talking in kindergarten! She spoke from the very first day and I count my blessings everyday. The reason I am writing to you is because although she talks at school, she still is very anxious. She worries a lot. Anything new or different is so very hard with her. Having a substitute in school is a major problem. I get her there, but she cries and is very upset. I know that SM is an anxiety disorder and although she is speaking to just about everyone, the anxiety still remains. She won’t participate in any type of play or show in school, which I can understand. I guess I’m trying to find out if this is normal for her type of personality, considering she had SM. Besides just getting her to school everyday, is there something else I should be doing. There have been a few times that something has happened at school. Once, an unknowing teacher asked that when she called on each student, they should all say a word about Halloween, and all the words should be different. Well by the time they got to my daughter, her idea had already been taken and so she just fell apart. The teacher had to call me to pick my daughter up because she was so hysterical and could not be comforted. My daughter does not take the bus anymore, she just couldn’t handle it. Am I worrying too much? Will these things resolve themselves slowly as she gets older and will she become desensitized as time goes on? As I’m writing this, I almost feel like it is unfair of me to ask all this when I know so many parent’s children are not even speaking. Thank you for whatever suggestions or comments you may have. Should medication be considered even though she is going to school, speaking and for the most part, participating in class? The teacher said she raises her hand all the time and that she is extremely bright.

Answer 10

Yes, it does indeed sound as if your child has anxiety. In fact, fears, tantrums, crying, inflexibility, and constant worrying are absolute signs of Generalized Anxiety Disorder. I recommend an evaluation by a professional.

There are techniques…such as Cognitive Behavioral Therapy (CBT) that can be used in children. CBT is known to help wonderfully with childhood anxiety. I would not consider medication unless you have tried alternative means of treatment or your child’s symptoms are so severe that her anxiety is negatively affecting her life.

Dr. Elisa Shipon-Blum

My 8 year old son has both SM and OCD and has been treated fairly successfully over the last 2 years with Prozac eventually getting up to 40mg/day by one of the Columbia researchers who did the clinical trials on Prozac. He talks to most children he is familiar with, few adults and the OCD has improved except for his eating. He will only eat a few foods, no meat vegetables, fruit or milk. He is hypersensitive to food textures, smells, etc. I have been told that this is common in these children. He is small for his age and will often not eat lunch in school nor even drink all day and says he can’t stomach watching other children eat with their mouths open. I think it is also having others watch him eat. We have tried desensitization, rewards, etc. with no success. I have been told that the only appetite stimulant will counteract the effects of Prozac. Can you suggest anything? Would Paxil be more effective?

Answer

This is a difficult question for me to answer. Because I do not know your child and whether or not there are any nutritional issues to be concerned about. If your child is at his ideal weight, and eats well, then I do not think any additional calories are needed. We really do not recommend ‘appetite stimulants’ to children unless there is a nutrition issue at hand. If weight loss is a concern you can always supplement with the various liquid nutrition that are available in your local pharmacy. For example, Pediasure by Abbot Labs provides complete nutrition for children 1-10 years of age. We will often recommend a well balanced diet and supplement with 1-3 cans a day for children with nutritional deficits or poor weight gain. My advice to you would be to speak with your pediatrician about his or her recommendations.

Dr. Elisa Shipon-Blum

My daughter turned 5 8/2/00. She has been introduced to many new situations in the past 6 months, but still fails to talk. She goes to Sunday school, part-time day care, and swimming lessons. She has never gone to preschool. She is indeed very bright and learns easily. I am teaching her to read and it is going well. Our thinking on holding her back from Kindergarten was in hope that we could save her the bombardment of questions that seem to follow her. Once children know her very well, they accept her and don’t mention her nonverbalization. But in new situations, kids her age are always pointing and asking why she doesn’t talk. It makes her talk even less and it also makes her shy away…and she isn’t a shy child. What do you think of an occupational therapist who uses sensory integration for SM. She told me that we would know within 5 days if it would work or not. No meds are used. I would like to try it if it has possibilities. Thanks again!

Answer

If your child has a sensory integration disorder than an occupational therapist can help from that standpoint. But, from all that you describe, I doubt highly that her SM will be cured that way. Some occupational therapists actually have ‘social group’ therapy. This is where a small group of similar age children get together with the therapist, and she helps the children interact with other children. This actually teaches children ‘how to socialize’ with others. I do recommend this, but again, I doubt it will cure your daughter, it may just help her with interacting skills.

By the sound of your letter, and the fact that your child is already five, my personal opinion would be to try a trial of medication. Since her birthday just passed, holding her back until next year may not be so bad from an age standpoint. I just hope from an academic standpoint you keep up with her needs, especially if she is as bright as you say.

Also, if you treat your child with medication and you ‘home school’ her this year, you could possible enroll her in first grade next fall. Some schools will provide a test for her to take, and if she meets the academic qualifications she can start in first grade. Look into this.

So, my advice would be to find a good physician that is comfortable with the drugs used for social anxiety; such as Paxil and Prozac. As you have probably read throughout our sight, these drugs have helped so many children. Especially when they are treated at young age.

Good luck, and please let us know how things are going.

Dr. Elisa Shipon-Blum

She is not very confident in new places and is afraid to say “NO” to others. My questions are: 1. Since she is bilingual (Bulgarian and English) and constantly switching between 2 cultures (Bulgarian grandparents live in the house and watch her and her brother when we work, my husband is American born) is it better to have a native English speaker watching her?

Answer

Does your daughter feel more confident in Bulgarian? If so, and she is in an English speaking preschool, I suggest helping her build her English skills. Perhaps she can teach her teacher Bulgarian??!! Our kids tend to like to be the big shots and knowing something that someone else might not know is a tremendous self esteem booster. Starting with basic colors and numbers is a great way to start. Alone time, one on one with her teacher where focus in on the activity she is working on, rather than looking at her teach directly.

My daughter is 4 1/2 years old. She was diagnosed with social phobia (and SM), and began treatment this past summer with both a psychologist and psychiatrist. Her doctor prescribed Prozac, and we have seen wonderful results in alleviating her anxiety. However, there has been no progress in her speaking. She currently speaks to only my husband and myself, and her grandmother. (She stopped speaking to her grandfather about six weeks ago, while he was hospitalized.) To give you some background to her treatment: she was initially started at 4 mg of Prozac, and remained at this level for approximately 9 weeks. It was during this period, we saw her anxiety dramatically decrease. She was increased to 10 mg of Prozac over a three week period, and has remained there for the last month. We have seen some changes in her behavior (but not as noticeable) since this increased level of medication. We have visited both her psychiatrist and psychologist in the past week. There has been no change in her medication; we will “wait and see” how she does over the next 6-8 weeks. Additionally, the psychologist feels that there is really not a whole lot else we can do at this point in order to prompt her speaking. While we are thrilled with her general progress, we cannot help feel frustration with the “non speaking”. We appreciate the conservative approach to medication, but also feel that the sm is a habit, and this behavior is becoming more engrained with time. Our professionals view the lack of speaking as simply part of the overall anxiety issue. While we know this is true, we need help with encouraging her to speak. The “play therapy” is a 50 minute session, now every 3-4 weeks. The therapist talks to myself &/or my husband for approx. 20 minutes, then plays with my daughter for the remaining time. We are questioning the value of these sessions, as they usually play with a dollhouse, sometimes my daughter draws pictures, and occasionally a puppet show. The cost for these sessions is high; our medical coverage does not include these services. My question is: in your professional opinion, do you feel we are doing all we can do for our child? Is there any other intervention we can try? I feel we are definitely on the right track with the treatment thus far, but I have doubts that our daughter will just one day talk on her own. Please advise. I am a member of the SM Group, and read everything on your site I possibly can. This site has been my lifeline for the past several months!! Thank you for your time

Answer

You are right, I see minimal value in the play therapy she is receiving as far as helping her with her social anxiety. You are not getting tools or tactics to help your child outside of the therapist office, something that needs to be done or your child will not make progress. What is the therapist doing to attend to her needs within the school? at home? and in other social situations. If she is helping you with this, that is great.

Your daughter needs to have an individualized plan drawn up to help her develop the skills needed to begin to talk. You are correct, her mutism is a result of anxiety. But a behavioral approach needs to be in place. I see way too many children who are JUST placed on medication and no behavioral plan at all. These are the children who make minimal progress overall. Then when meds are discontinued, children often resort back to severe anxiety because they never developed the skills necessary to combat their anxiety. Medication is used as a jump start to therapy, not a cure-all. Please speak to your therapist and prescribing physician about this.

Also, I do not recommend raising her medication dosage at all. MUTISM will not improve until BEHAVIORAL tactics are set into place. The only thing that will occur with raising medication dosages are tendencies for side effects.

Dr. Elisa Shipon-Blum

My 4-year-old daughter began displaying SM behavior at 2 when she refused to talk in preschool. She is now 4 years old and still has yet to speak. Once her SM was recognized and diagnosed, we began working with a licensed social worker, and have had great success with the help of a trained pet therapy dog named Boomer. However, I am unclear how the success we’ve seen in the counselor’s office with K…. opening up and speaking freely to a relative stranger, can be transferred to the classroom. How does this work with children that you deal with??

Answer

Excellent Question! I agree wholeheartedly with your suspicion. Your treating professional needs to devise a treatment plan that will incorporate tactics for you to use with your child OUTSIDE of her office. I have so many parents who contact us because of this very issue. Their child has been involved in treatment, sometimes for years, is perhaps doing well in the ‘office’ but has not made progress at home or in social settings, such as school. A program to help lower anxiety at school (where most SM cases are the most severe) and other social settings, build self-esteem and to devise tactics to help increase confidence in social settings. You need tactics to use in school and at home, or I agree, you will see little overall progress.

Dr. Elisa Shipon-Blum

Our daughter is 4 years old and goes to her 2nd year-Kindergarden. She has selective mutism. She speaks very well with us as parents, as brother (2 years) and to close relatives. In addition, she speaks reasonably well within communities of different environment (ordering food in restaurants, supermarkets, Shopping Centers). We would highly appreciate your help in how to get her to reduce her anxiety and speak at kindergarten with her teachers and peers. Awaiting your kind response and thanking you we remain.

Answer

Wow, you are truly asking a million dollar question! I could give you a book about three inches thick on ways to help lower anxiety. And, what works for one child does not necessarily work for another. However, the ultimate goal is to help your child acknowledge and be able to understand her anxiety by helping her to figure out her feelings in various anxious settings. What needs to be done is to try to encourage one on one get togethers, one child at a time, with her school friends. Playdates away from school are key!! Spending alone time with her teacher and encouraging small groups in school with the kids she is the most comfortable with is recommended as well.

I recommend working with a treating professional who can help progress your child from one step to the next. Please understand that your child needs a lot of understanding and acceptance as well. She needs to know that you support her 100%. It is amazing that when parents convey that they UNDERSTAND and remove all pressure to speak how much the child improves!

Dr. Elisa Shipon-Blum

Our six year old daughter was diagnosed with SM two years ago after a year of not talking at kindergarten. We did a year of family therapy (with a good therapist, but she had no personal experience with SM) and although A…….. still does not talk, she is socially much more relaxed – better eye contact, holds hands with friends, etc. It is now a year since we finished therapy and we felt it was time to get A……. on medication. Our physician is being very helpful and yesterday we started her on 5mg fluoxetine. Our physician has no experience with SM – how often and by how much do we increase the dose to get her up to 10mg? Also, you mention behavioral therapy a lot. We have not, in the past two years, found anybody who specializes in SM. Can you not build a page on the web site to guide those of us who must instigate behavioral therapy for our SM child on our own? I don’t want her progress on fluoxetine to be hampered be lack of behavioral therapy. Thank you for all your marvelous help and advice to all of us struggling with SM in the family.

Answer

Sounds like your child is moving right along. You are right, you need an individualized behavioral plan for her to be in school and at home. Medication without the use of a behavioral plan is inappropriate. Coping skills need to be implemented. Behavioral plans include various forms of desensitizing your child to their social environments, positive reinforcement (rewards for progress) and quite a few other techniques. What techniques work with one child may or may not work with another simply because every child is unique. A professional needs to GUIDE you and monitor your child’s progress. He/she has gone through years of training to know when and how to use these tactics. So there is NO one-plan-fits-all behavioral approach. This is the same for medication usage. Starting at 5 mg is higher than I usually start, but that is just my approach. As far as how to dose, again, each child is different. Some children can be progressed more rapidly than others. Timing of progression is based on the child’s positive and negative response to medication. My experience is to start very, very low, move very, very slow and to try to maintain the child on as low a dose as possible. Your prescribing doctor needs to monitor your child and should be able to make judgments as to the progression rate of the meds.

Dr. Elisa Shipon-Blum

She is very scared and likes to watch scary movies (witches, etc). Should I let her watch some as to “collectively (along with someone else) live through her fear and talk about it”?

Answer

I can’t really answer this. I normally don’t ‘expose’ young kids to scary movies/stories for the primary reason that our anxious kids have worries and fears…Normally…So adding more to worry about and think about only adds to the anxiety. There is nothing wrong with drawing pictures or talking with you about fears/worries, but to exposer her, at such a young age, is not something I would do. However, please consult with your treating doc about his/her thoughts on this.

She refuses to stay alone or appears claustrophobic when the door of the room, car is closed. I also have to sleep with her or at least let her fall asleep with me. Should I continue to do that?

Answer

Again, fears/worries are common with children with anxiety. This is another worry and fear. Nightime is a classic time for our kids to manifest their worries. Afterall it is dark and Mommy and Daddy are in another room sleeping. And she is all alone. Spending one on one time with her at night is nice and recommended, however, be sure to put a time limit on this and prepare her for you leaving…Having her sleep with something of yours is a nice soothing way to help her feel close to you. I suggest speaking to your pediatrician about his/her recommendations on this area as well.

2nd He comes home everyday telling that he spoke to his teacher. I know the teacher would tell us if he did talk to her, in order to believe him I ask the teacher when he’s not around. He’s very adamant about saying he talked to even though he didn’t. I want to believe and he wants me to believe him.

Answer

This is more common than one would think. For our kids, who want to speak so badly, even a mild ‘deep breath’ or shallow ‘Hi’ where no one else can hear is interpreted by some children as ‘talking to’ another person. Also, for many, they do reply so quietly with minimal lip movement that no one see this! Please do not argue or contradict your child. Just smile and allow him to tell you this, do not make a big deal of it and as time goes on, and he is progressing communicatively, he will be speaking more audibly.

I noticed that most people have their pediatricians working with them. I love our pediatrician and he’s the best in the area but he doesn’t seem to have any interest in SM and helping me with my son. I called and spoke to him but he just referred me the local hospital to have him evaluated. Should he be working with us? Should I have the CST send their findings to him?

Answer

Actually, pediatricians rarely work with the child on an ongoing basis. We are working hard to educate pediatricians into recognizing SM and to then direct families to the appropriate mental health professional, but most pediatricians do not actively treat SM. However, some pediatricians, considered developmental pediatricians, may work with families and children more regularly for SM, but regular docs rarely do.

Dr. Elisa Shipon-Blum

Should she be aware of the goal of the therapy with the psychologist: to reduce anxiety and to help her talk; or is it better to be unaware?

Thank you so much. You are a great hope for me.

Answer

Absolutely. Your daughter cannot overcome something she is not aware of. However, the term SM is not what is important here but rather how she feels and interprets her inability to speak and communicate.

Thank you so much. You are a great hope for me.

You’re welcome and good luck.

Dr. Elisa Shipon-Blum

I was at the conference and you said to e-mail you about getting some advice. My child is the one that quit talking to us after my husband came home on for break from Iraq. Now he is home for good. Still not talking but is writing more than she was doing. They put her on zoloft and now I need some help on goals on how to help her. If you need more info let me know.

Thanks

Answer

There is NO way to create goals to ‘get her to talk’ without knowing WHY she has become mute after her dad returned home. Her anxiety heightened, but why? This needs to be determined by a thorough evaluation. Goals cannot be set before a comprehensive evaluation is done. Then, based on your child’s unique needs/characteristics a treatment plan can be developed. Random goals cannot just be created. NO clinician can determine what KINDS of goals without a thorough evaluation simply because I nor anyone else, understands the nature of your child’s mutism…There are countless tactics as you learned about at the conference…and the choosing of tactics/goals are put together in an organized way…based on the individual. It would be wonderful if there was a one size fits all treatment plan, but there is not.

Your first step: Speak to your treating professional as to the need to determine WHY your child became mute with everyone once Dad came back. Until this is determined, progress will be very limited.

Dr. Elisa Shipon-Blum

Answer

Obviously since I do not know your child I am not able to give an accurate opinion here. However, for children with SM, without additional learning problems or severe social delays (What is your child like one on one with another child, ie, at home? Is he age appropriate? Is he able to communicate?) children with SM should not be held back. What needs to be done are accomodations within the school setting, not retaining him. If he is academically ready for the next grade level, mature and ready, then holding him back is not the correct decision. This may hurt his self esteem as well as stifle his growth. You need to talk with your school study team about this and have a professional who knows your child read over the reports and help you with this decision.

Answer

You truly need to do this ASAP. You need to be working with someone who can help you with your son, to help you understand his needs and to help put together a treatment plan approach for both home/school.

Answer

Does this teacher seem too eager for her to speak, constantly looking over and checking out what she is doing or possibly saying? From what you write, you daughter is self conscious about her teacher and her teacher’s expectations. Please educate your teacher. However, since teachers do have more of an expectation than peers and perhaps extended school personnel, teachers are often the hardest people for our children to talk to.

Dear Doctor: Thank you so much for giving me the opportunity to talk about my daughter’s condition. My daughter is 4 and a half now. She has always been extremely shy just like me at her age. I myself didn’t talk to any of my teachers for the first several years in my early education in China. Due to my own experience, I’m quite concerned about my daughter’s shyness. She started preschool two years ago and it took her 6 months to start to talk to her friends in school occasionally and just after this summer, she started to talk a little bit to her teachers when alone. She still can’t answer questions when asked in front of the class and she can’t participate in group activities. But one good thing is I think she is improving, though very very slowly. My question is, since you have seen probably a lot of kids her type, do you think at this stage she will keep improving slowly, or I need to seek some professional help? Next year will be public school, if she still won’t talk to the teachers in the classroom, how is she going to be scored? I’m pretty sure in the first 6 months she won’t be able to say a word in the classroom due to her shyness, which was what happened in her in both of her preschools. She started talking at very early age (about 10 months) and has always been very talkative at home. Thank you very much for listening and I’ll appreciate any advice from you. Thank you

Answer

A 4 yr old child with the degree of SM you are describing most definitely should receive help or, in my opinion, she will continue to be SM in most situations. Most children make considerable improvement as the school year progresses. In fact, by the end of the year, many children may be speaking to teacher(s), some children ,etc…but then, once the environment is changed…going to camp, starting a new school year, etc. MUTISM and anxiety resumes. Also, understand that treating a 4 yr old is so much easier than treating an older child. The treating professional will help your child learn the coping skills to FUNCTION in school and other social situations.

Regarding ‘scoring’ or ‘grading’ your child:

If your child is still SM when she starts public school, I recommend an IEP (Individual Educational Plan) or 504 Plan that will enable for the school to provide special accommodations to help your child feel less anxious. However, if you start with effective treatment now, your child should improve greatly by the time the next year roles around.

Also, the fact that you were Mute and ‘very shy’ is further proof that SM is indeed a genetic disorder.

Dr. Elisa Shipon-Blum

Thank you for all the helpful information your books and the web site offer, they truely have been the primary source of information we have used to help our son. In the last year my 1st grade son has made great progress. In k he spent most of the year not talking to anyone. This year he talks to 4 friends and his teacher. He has made the most progress since starting 10 mg prozac in Nov. 03. Prior to that he took Zoloft for 9 mths with little progress. I’m wondering if he would benefit from increasing the dosage? Any suggestions? He is receiving therapy with a therapist that is experienced (20+ yr) with SM, but she focuses on his talking mostly (she is our 4th one in 1 1/2 yrs.).

We have worked with him for the last 2 years to decrease his anxiety and he uses techniques he’s learned 2x daily. He says he is comfortable with not talking and has stated people like him just how he is. He’s very social and has many friends and rarely feels nervous at school. In Jan. a new student joined his class and within a day my son talked to him. My son stated that this boy didn’t know he didn’t talk and he felt comfortable with talking to him. He worries what the kids will say when he talks, he thinks they won’t think he’s the same person. I know my son is in a comfortable zone at school (his teacher agrees) and I feel all the key elements are in place to help him to successfully transition to moving to the next level, I just don’t know what to do to help him. We need to develop a detailed plan on how to progress at his comfort level. Do you think it would be beneficial to bring him to your center in PA. to get assistance? His behavior is engrained in who he feels he is and I need help helping him unlearn this.

Any information you could provide would be appreciated!

Answer

Increasing medication is not the answer. There is nothing in the information that you wrote that mentions HOW you are helping him to progress. Lowering anxiety is just one facet to treatment…for the very reason you described. Your son is comfortable but he also does not know how to PROGRESS without help. The therapist you are working with should help you to transition him from nonverbal to verbal communication via various tactics/techniques…so that he can UNLEARN mute behavior to become a verbal communicator, i.e, your son said that he does not feel the need to TALK…that others know him this way. What he is saying is that TALKING will change the dynamics between his friends, draw attention to himself, and most of all, he really has no idea how to do this.

Please speak to your therapist about methods to help your son progress communicatively. Your son is literally in the ‘verbal transition’ phase. In other words, nonverbal responding is easy and effortless with most individuals he knows. I am sure with NEW, unfamiliar people he may have trouble responding at first and probably cannot initiate comfortably, but in school, he can respond with ease and is most likely and expert in nonverbal communication…that if we were to peek into the window of the classroom (without hearing anything), he looks and acts like every other child! So, now is the time to transition him or he will remain this way…for in indeterminate amount of time.

Answer

I too am pleased that your daughter has been adequately diagnosed. The sooner, the better.

Your question regarding medication in your 2 3/4 year old is a difficult one to answer. Yes, children have been treated as young as your daughter, I personally have never treated a child this young. Let me explain a few things to you.The medications physicians tend to use for SM are the seratonin-reuptake inhibitors; mainly Prozac. Other similar medications, Paxil, Zoloft, and Luvox are also being used in more frequency now. Unfortunately, none of these drugs have been adequately tested in young children, and we do not know the long term affects of these medications, simply because these medications have only been on the market for about 12 years. But based on preliminary studies, physicians are assuming these medications are safe to use in children. But again, we are just assuming!

I do use these medications in practice, and have had excellent results. I must say though, I am a bit hesitant with your young child.She really is so very young, she is only 2 3/4 years old.I understand your concerns and need for urgency in her treatment, but I would use medication as a last resort in this case; simply because she is so young.There are many children that do not talk at her age, and then slowly over the next year, begin to talk and come out of their SM. I am hoping this happens with your daughter

My advice, at this time, is to try the play therapy, it has been proven to work, especially in young children.Also, engage your child in as many social events as possible, have playdates with school mates, and please,and I repeat, PLEASE, try not to talk about her mutism in front of her. You would be surprised how many children hear their parents, teachers and friends talk about them as ‘unable to talk’, and truly begin to see themselves as non-talkers! Try and just encourage her to verbalize in public, ask her questions in front of others, even just one word answers at first. Try and be patient, and give her some time, if in a year, by almost 4 if she truly has made no improvements, then yes, I would encourage medication. You would be surprised how many young children do ‘come out of it’ by four, and the ones that do not, we take a more aggressive approach.

Dr. Elisa Shipon-Blum

We had e-mailed you a couple of weeks ago regarding some concerns we had about our 4 year old daughter and the starting dosages of her Zoloft. Thank you for your quick response. Her Dr. had started her on .5ml (10mg). Within a couple of days, we started seeing the negative side effects (insomnia, nervous agitation, etc.) and cut her dose to half of that .25ml. We completely agree with your philosophy of starting slow and low and discussed our concerns with her doctor. He’s been very agreeable to working with us and what we’re comfortable with. We attended the San Diego conference in January and I unfortunately did nottake enough notes during your medication lecture. I know you have discussed it in previous posts, but I was wondering if you could give us some specific guidelines as to what doses we should be aiming at. For example, at what increments do you increase the doses, after how many days do you increase and what factors do you base your final treating dose on? Her doctor has spoken of using 25-50 mg as a treating dose which I know you think is quite high. I know as parents, we are ultimately in charge of our daughters health care, but when dealing with a treating professional, what is the best way to maintain control without showing any disrespect to them and their professional advice. Thank you so much for your time and dedication to this cause.

Answer

Glad things are working out with the medication and you were able to apply the knowledge you gained from the California Conference! Although I would love to be able to help you dose your child by the use of tables and ‘procedure’ I simply cannot. Experience dictates my treatment.

For Zoloft, Dosages range from 2.5 mg to 25 mg. Starting at 1.25 or 2.5 depending upon weight are usual starting doses that I use and then guided by side effect profile. I do not use a time frame as much as side effect profile and response to Communication Anxiety Therapy. Meaning if a child is on only 5 mg but making wonderful progress with the tactics/techniques I do not go up in dosage. If the child is making minimal progress, but having side effects I do not go up in dosage.

I believe you are beginning to understand that although a dosage schedule would be a great way to go and would certainly make life easier, I just don’t use one and my determination is based on experience.

However, I never go up more then 2.5 mg at a time. NEVER…why? Simply because that is a small enough dosage that if side effects are seen, I can back up or remain. If you jump more then 2.5 mg I find that if side effects due occur they are more severe and harder to manage.

Re: Dosage adjustments – spans range from 1 week to months depending upon tolerance and progress. I take the route of caution 100% when using SSRI’s in children. And I have never had a need nor desire to use another type of medication.

Also understand that although meds can help tremendously, I find that the KEY to working with children is Communication Anxiety Therapy and viewing SM as a Communication Anxiety where treatment is geared towards the WHOLE Child and helping him/her in the REAL WORLD. With meds alone, progress comes to a standstill unless a child can learn how to COPE and progress communicatively. Parents and teachers to help the child progress communicatively. PLEASE be sure you are working with someone to help you progress communicatively so that your child can get the most out of treatment and when meds are finally weaned, she has built the necessary coping skills.

Dr. Elisa Shipon-Blum

My 6 year old daughter has been in therapy for about a year. She has made some progress, but recently seems to be getting more anxious. For example, there are about 4 children whom she used to speak to, but has now stopped. We are considering beginning medication on her. Do you think this is wise and what medication do you recommend?

Answer

You mention your child has been in therapy for about a year. I wonder what type of therapy has been done. Has she been involved in treatment that focuses on her SM and helps her develop the communication skills and lowered anxiety as well as the necessary coping skills (accommodate UP/DOWN in terms of communication…nonverbal/transition into verbal/verbal depending upon her anxiety level)?

Also, what is causing her sudden anxiety? Are there expectations that she is feeling from school personnel or peers? Something has caused her to feel more anxious…since she was doing well.

In terms of medication. I am an advocate of this when needed…and perhaps now is the time (I am unable to make this determination) but focus needs to be on 1) Helping to determine what has caused your child SUDDEN anxiety that is causing a regression AND 2) Treatment focusing on helping her build the coping skills via developing communication skills…so that when anxiety is higher, she will not resort back to SM.

Using meds without doing the above will only mask the situation.

Dr. Elisa Shipon-Blum

My son was diagnosed with SM about 4 years ago and he is now almost 8 years old. We are doing best we can to help him. We are living in London and few doctors suggested medication. I am not comfortable to the idea of medicine. Can you please give me some information about the medicine and also whether you recommend medication also. Thank you.

Answer

Regarding your 8 year old son, if you have truly tried everything you can with the help of a doctor and/or therapist and your son is truly Selectively Mute, then YES, I do recommend a 9-12 month ‘jump start’ with medication. We have had tremendous results with medication. Read over the many questions previous to yours where other individuals ask about medication. You can learn a lot about the various meds out there. Medication has been a true lifesaver for so many SM kids. Within a week we can even see changes in some kids! This is proof that these children truly have a biochemical imbalance.

I am an advocate of medication when you truly do not know what else to do. You mentioned being against medication, why??? Because there are no long studies??? Well, nothing is guaranteed, but preliminary information states these drugs are safe. Also, let me ask you this, What are the longterm implications or side effects from a child that is so anxious they are mute in most, if not all public settings? How does this affect a child’s self-esteem, social development, and overall well-being? I have seen completely dysfunctional sm kids treated with medication and have been completely cured of their SM allowing them to develop and start a new!

Dr. Elisa Shipon-Blum

My 6 year old daughter has selective mutism. The therapist said she is “not ready” for therapy. We are working on a behavior modification program at school with the teacher but it is very slow. We have finally gotten our daughter to use the bathroom at least once a day at school when she is told. She will only go if another student is standing at the door so no one will walk in. My husband is very reluctant to use medication. Do you think that medication is a beneficial part of the treatment program for SM? Thank you for your help.

Answer

Depending on the degree of mutism, often dictates the route of therapy. i.e., for a child who is totally mute at school (not talking, whispering with other children or teachers), who is not verbalizing with friends at school or other adults outside the home is a severe Selective Mute. I tend to recommend a combination of medication and behavioral therapy. For the child who is talking or whispering to children in school and at home and is not completely MUTE outside the home, I will speak with the parents and together, based on many circumstances, we will come up with a game plane. Perhaps the child has never been under therapy before, or perhaps the child has been seeing different professionals for two years…In other words, there are many determining factors to weigh when determining whether medication is warranted. I can say quite confidently, that YOUNG SM children (your daughter’s age) USUALLY respond incredibly well to medication. Knowing that I use VERY low dosages of medication for only 9-12 months, I believe that using medication with behavioral therapy is the route to go in the majority of cases. In other words, it can take an indeterminant amount of time with using just behavioral therapy. Using medication SPEEDS the process exponentially in most cases…especially younger children where there are not years of LEARNED behavior ingrained. Please consider this: What are the long term consequences of a child that becomes socially isolated and withdrawn?

Hope this helps.

Dr. Elisa Shipon-Blum

My 6 years old has SM and has been on Prozac since November last year. We started her at 4mg then gradually increased it to 8mg then 10mg. She has been 10mg since 12/18/2000. Prozac seems to help her to relax more.

Although she still doesn’t talk to her classmates or teachers, she does respond in a small group (3-4 people). Two weeks ago, she even initiated a question to one of her teachers (again, in a small group). The only side effect of Prozac that I could tell is that she seems to be more hyper than before. She has tendency to climb everything she can, make loud noise at home. Her dad and both my in-laws have excessive compulsiveness. We suspect she does too. We went to see a different psychiatrist a few days ago and told him this history. He wanted to switch here to Paxil right away. He said he could not increase her Prozac dosage because it will make her more hyper. Also, he said that Paxil is more effective in treating excessive compulsiveness. He wanted to start her at 5mg of Paxil and increase the dosage by 5mg every week – so it’s like 5mg lst week, 10mg 2ndweek, 15mg 3rd week,…until it reaches 60mg at the end of 12th week. I think this is a lot of med for a 6 year old, but he insisted we either take his way or we see someone else. I don’t have problems switching to Paxil. But I’m concerned about the dosage she will end up taking. Will you please give us your opinion on this? Do you think it’s too much med for my little girl? Do you think it’s unusual to increase the dose by 5mg every week? We desperately need your advice. Thanks so much for your help.

Answer

First, you mentioned your daughter was on Prozac. Are you doing any behavioral modification with your daughter?? If you are not, then she will certainly not respond optimally. In addition, the hyperactivity to Prozac can happen. I recommend you give it a bit more time. Most side effects, such as hyperactivity do subside over a period of weeks to a few months. And, you just started 10 mg a little over 2 months ago. So, I do not agree with your doctor about changing her medication for multiple reasons.

Have you ever heard of the use of Zyprexa in children with anxiety or SM?

Answer

No, I have not used this is children. This drug is used more for Bipolar depression and has recently been approved for the use with schizophrenia. The SSRI medications (such as Prozac, Paxil, Zoloft, Luvox, Celexa) are used most often in children with anxiety disorders

Dr. Elisa Shipon-Blum

We have a 7 year old son who has SM, and has never spoken at school. After attending your wonderful seminar in Florida, we returned and got him in to play therapy and started him on 2.5mg of prozac. He is on his second month of prozac now 5mg. We have seen no progress yet. The doctor suggested that we give him a small dose (2.5mg) of Xanax twice a day, as well as the prozac. She told us we would keep him on the Xanax anywhere from 3-6 months. Have you ever used this in treating SM, and what would your expert advise be? It was obvious after attending you seminar that you have great knowledge regarding this disorder and we truly respect your opinion. Thank you.

Answer

Hello! Nice to hear from you 🙂

NO, I have never ever used Xanax or any other benzos to treat children. It is not necessary. Side effects of tiredeness is too common, no matter what the dose, with Xanax. Plus, it is an addicting drug and long term effects such as short term memory loss have been known to occur. To me, there is no reason at all to use Xanax.

What is going to help your child progress is the communication anxiety therapy…..strategies via games to help progress him communicatively. Without this, progress on any med will be limited.

Dr. Elisa Shipon-Blum

My 5-and 3/4 year old daughter, L… , has been put on 5 milligrams of Prozac and is doing great. I encourage all parents of SM children who have reached the end of hope, to try medication. My question is how long does the usual run of medication last? months? years? forever?

Answer

I recommend the use of medication for 9-12 months (after a child begins speaking and feeling comfortable in social situations). The younger the child, the less amount of time medication is usually needed. i.e., your child is 5 yrs old. If your child is doing BEHAVIORAL THERAPY and medication, and is making tremendous progress, I would say that 9 months is an adequate amount of time for your child to be on the medication.

I would also like to add that if you are using meds without behavioral therapy to help lower anxiety and build coping skills, it is possible that when she comes off the meds, anxiety may come back. She needs to have behavioral tactics now to allow for COPING SKILLS to conquer anxious situations as life progresses on. SMA~CAN research clearly indicates that children who have been given various forms of behavioral therapy and have used medication do much better when off meds than children who are only on meds.

Dr. Elisa Shipon-Blum

Our 5 yo daughter was diagnosed with SM in May/oo. She showed signs for about 2 years prior-we thought her to be shy. She usually would only whisper VERY quietly when others were present, but when people stopped trying to make her talk, she started talking to us out loud in front of others. She now will sometimes say uh-huh to people she wouldn’t talk to before, but she won’t use words. How long should we let this progress before trying meds? She does see a psychologist, but I don’t think she has progressed from the visits. We are holding her back from K this year because we stand the thought of kids constantly asking why she won’t talk-we worry about a slip back. Thanks in advance for any advice.

Answer

Thanks for writing in. Your question brings up a lot of very pertinent thoughts.

1. when to consider medication and
2. whether to hold your child back in school

Regarding Medication. If you see your child progressing, I would hold off for a little while. Sounds like she is verbalizing. I usually recommend medication when you have ‘exhausted all other options’ and/or ‘a child’s mutism is impinging on their well-being’. For example, many children, especially as they approach 5, 6 and 7 years old become more and more aware of the mutism and ‘inability’ to speak. Many kids actually become depressed and anxious over this, which in turns causes increasing stress. If your child is making strides, and showing improvement, hold off until after school starts and see how she does. Is she going back to the same school? The reason I ask is because she ‘see’s herself as a non-talker’ there. IF she were to go to a new school, where no one knows she ‘doesn’t speak’, it can sometimes be just the cure for some children’s mutism!

I am not quite sure why you are holding your child back from Kindergarten. Is it because she is not academically ready? Her birthday falls right on the cut-off? She is emotionally immature? If your decision is based on her mutism, I am not sure you are making the decision for the right reasons. Many extremely bright and mature children are mute due to their profound social phobia. I do not believe the extra year will help that much. In fact, it can hinder them in many respects.

From research I have read, holding back can often cause more stress….and academically-ready children are not stimulated enough with another year of pre-k. Please write in and let me know your reasons. Remember being Mute does not mean a child is immature! ……..just socially phobic…

Dr. Elisa Shipon-Blum

I am writing my question here because it may be one that other parents have. My daughter is doing GREAT on meds. Still she doesn’t contribute much in class discussions. This seems perfectly normal to me given what I believe is her natural temperament, without anxiety. Here’s my question though. Her psychiatrist says the meds act as a dis-inhibitor and when one comes off of them it is natural that they become somewhat more inhibited. So if she is too inhibited ON MEDS to speak in a group much doesn’t that mean that off the meds she will be even quiet in school and then it does become a problem? I hope this question makes sense. Best to you.

Answer

Yes, medication does disinhibit our children in many ways. However, you should be working on behavioral coping skills so that when she does come off the medication she will have the skills necessary to COPE in these group settings. If your daughter is not speaking in a group setting when called upon, I suggest working on ways to help her feel more comfortable in these settings. Start with one or two children, have the teacher meet with your daughter and a few kids…..To expect a child to speak in a group, having never built up from a few children at a time is like taking a person afraid of heights to the 30th floor and asking them to look over and feel comfortable. You need to start slowly.

Dr. Elisa Shipon-Blum

My daughter, who will be 5 years old in June, has SM. My question is about medication. We are currently seeing a psychologist 1x/week who is trying to help us by getting my daughter comfortable enough with her, so that eventually she will speak to the psychologist. The idea being that the psychologist will then be able to help her in school in September when she starts Kindergarten. But it is obvious she will need medication to help her along. Her suggestion is Paxil. My main concern is that we don’t know the long-term effects on children of this med. I worry that years down the line a study may find some dangerous side effects. When a child is still developing, how dangerous is a medication like Paxil?? Also, I have read that sometimes medication can “jump-start” the brain to start producing seratonin on its own. Is there any truth to this statement? Thank you for any information you can give me.

Answer

P .., your concern over medication is a very common concern among most parents. Try and read over the previous questions and answers, I think you will see that many other parents have asked similar questions. As I have mentioned in previous questions, there are NO long term studies to prove the overall safety of these types of medications. BUT, all of the preliminary studies indicate the medications are safe for children. The reason there are no long-term studies is simply because the medications have only been a round since 1988…..so there is no way to really know what will happen in 30 years from now. I have to say though, you must considera few things. What are the long-term effects of being SM or socially phobic? They could be horrendous, right? Well, this is one reason why many parents have chosen the medication route.

Many physicians are using Paxil more and more now; it is the only SSRI drug approved for social phobia, and since SM is primarily thought to be an anxiety disorder due to social phobia, Paxil is being used. Prozac, Paxil, Luvox, Celexa, and Zoloft are all similar acting drugs…the differences are subtle and can often be used for the same disorders. My concern about Paxil is the very short half life. Because of this, withdrawal reactions when you decide to discontinue the medication can be quite bothersome….If a dose is missed, you can start feeling ‘withdrawal’ as soon as 24 hours after a missed dose. Prozac, on the other hand, does not have much of a withdrawal reaction; it lasts for days, and if a dose is missed, no effects are usually seen. This is the main reason why I prefer Prozac. Plus, we have had a lot of success with this drug in children.

You asked about the drug helping the body to produce seratonin on its own…the mechanism isn’t known, but studies indicate that many people can successfully discontinue the medication after approximately 9 months.Good luck!

Dr. Elisa Shipon-Blum

I am a clinical child psychologist at Children’s Hospital Medical Center in C…………., and I discover that I am one of the few people in this area treating SM. I began getting referrals because I see many children with other anxiety disorders. I have become comfortable with the CBT, and use the conception of a SID involving social hypersensitivity. I find that parents are very resistant to the idea of medication, and I am less confident in recommending psychiatric consult, since I have little knowledge base regarding the use of medication with SM. I have reviewed some or the resources on the bib. on this web site, but wonder if you can provide me with a model to help parents see medication as a treatment option in addition to therapy?

Sincerely, R………… K…………, Ph.D. Clinical Psychologist

Answer

Dr. K…………

I am thrilled to hear you treat SM children! We are desperately trying to find professionals that truly understand this anxiety disorder. Your question is an excellent one and is important because in many of the children with SM behavioral approaches are not always completely effective. In fact, I am convinced that the majority of children have true biochemical imbalances and medication to restore the ‘lowered neurotransmitter(s)’ is often necessary.

My approach to parents is this: Depending on the severity of SM, I recommend a trial of behavioral modification. If after an agreed amount of time, I tell the parents that I believe combining behavioral techniques with medication will enable the child to progress more rapidly and more effectively. My logic to the parents is that the reason behavioral techniques are not working is the child’s anxiety level is too high to enable an adequate response. We use medication to lower the child’s internal anxiety level enough to enable the behavioral techniques to be instituted

I often use a ‘barometer’ as a means of explaining. I show them that children with anxiety, specifically SM in our case, have a certain level…and we need to lower their internal anxiety level in order to effectively treat SM. I hope this has helped you. Thank you for your efforts and willingness to learn and further your knowledge of SM.

Dr. Elisa Shipon-Blum

My daughter M. is seven yrs. old. She has a younger sister, almost 5, and a baby brother, 14 months. We speak English at home, but all of my children were born outside of the U.S. where we reside (I am in contact with SMA/CAN coordinator in our country). When M. was two and two months, she started a private daycare program for 2 yrs, although at that time her English was superior to her age, but she was not very fluent in the local language of our country. The staff tells us that she did speak there to them and to other children, although still a shy and timid child (she learned the second language). When she was just over 4 yrs. she entered pre-K in the public system in our city (it is pre-K and K together for 2yrs.). Her teacher there was the first one to notice and/or mention to us that possibly she has selective mutism. She did not speak to the teacher, her helper, or any of the children there. She ended up repeating kindergarten (three yrs. in that school) because it was suggested to us that one more year in kindergarten would help her to be mentally ready for first grade, considering her selective mutism problem. During that time, my husband and I sought the advice or help of over 10 different professionals, including a year and a half of art therapy (M. is an incredible artist, but now I realize that that method of therapy was only feeding her silence) and several sessions at a child psychiatrist who after seeing her just wrote a recommendation for therapy. This past summer, we finally found a child psychologist/behavioral therapist who has some past experience with SM patients and seems to be the most knowledgeable professional thus far (most of the sessions have been with my husband and I, which I prefer).

M. has never been on medication and is constantly making progress. Last April we were visiting my mother in Florida and my brother and sister were there with their kids. M. spoke and played with her cousins for the first time! She even jumped in the deep end of the pool and yelled “look at me!” She started first grade and made one new friend that she talks to. She doesn’t speak to the teacher or any of the other kids. She doesn’t have any problem to use the restroom at school, which was a big issue in the past. During the summer, she started to ask for and pay for her own ice cream at our pool. Last week we were at a park and she bought her own popsicle. A few weeks ago some of our friends that she has always known but never spoken to, came for dinner. They have a 10 yr. boy, 4 1/2 boy and a baby. For the first time, she spoke to the two older boys, played and laughed with them and just acted like a regular little girl. She even spoke to their mother when she asked her a question. About a month and a half ago the same thing with some other friends of ours, they asked her how is first grade and she answered them. She does have a few friends not in her school that she speaks to as well as some friends that she plays with that she doesn’t speak to.

Recently, at school she has had a problem because a group of girls that she wants to play with don’t really include her and even started to get a little nasty. I told her that because she doesn’t speak they don’t know that she wants to be their friend or play with them. She said she wants to talk but she just can’t. My husband even bought her healing stones and told her that they will help her not to be so shy. Our therapist saw her last week and is trying to push her to say one word to her teacher or to anyone else that she has difficulty with. She became so anxious that she began to sweat profusely. I do not feel that she is ready to make that step. All of her previous progress has been on her own initiative.

MY QUESTION: Although, I have read about other cases that seem much worse than M., I am wondering if medication would now push her to that point that she could more easily overcome her anxiousness and get over this thing. She is full of desire and motivation to speak and have friends and be like every other kid her age. She says she wants to talk, but it just doesn’t come out. I don’t want to pressure her too much, but I also feel that if other kids will be mean to her it could have long term damage (the kids that she does speak to love to play with her and think that she is funny). In the beginning ,I was adamantly against medication, but I see that she is so fed up with her SM and I want to help her. Do you have a suggestion about meds or a way that I can get her to make more progress on her own initiative? Thank you so much for your time!

Answer

From what you have written, it seems that you are just embarking on the behavioral therapy. I would not necessarily go to medication just yet. The therapist you are seeing seems to be expecting too much at this point. Your child is MUTE in school with children and the teachers. Why then expect her to say a word? What needs to be done is to help her assess her feelings of her anxiety, then use her feelings as a goal. Is she able to respond and initiate nonverbally? If not, then you need to help her do that first, prior to any verbalization.

Does she speak to her school friends when at your home, or even one at a time when home? If not, that needs to be done first. Has she spoken to YOU in the school? If not, then she needs to work on that. But understand that you need to know that by trying these goals she is OKAY with this and not feeling too anxious about these goals (which should be rewarded with positive reinforcement of some sort).

A child goes from mutism—> Nonverbal (response, initiation)—> verbal ( response, initiation) but the steps in-between are based on her degree of anxiety and what SHE CAN accomplish without too much anxiety. Spending time alone with the teacher is easier than in a large class setting, spending alone time with ONE child at a time or just a few is easier than a large group, etc. Understanding the steps that need to be taken is crucial to helping your child overcome her anxiety and mutism.

Dr. Elisa Shipon-Blum

We all realize that there are ways to help the SM child(ren), but no definite cause has been found. There seems to be various theories. But I was quite surprised while surfing the web that one source believes that there may be a connection to a brain deficiency. Have you heard this before? Our psychologist had not. Since SM is such an unknown, research continues without answers.

Answer

The deficiency you are referring to is a seratonin deficiency….since Selective Mutism is primarily an anxiety disorder, studies indicate that there are actual deficiencies noted in the brain….seratonin is the main neurotransmitter that is affected, although dopamine, and norepinephrine are also involved at times. The area of the brain that is affected is the prefrontal lobe clearly demonstrable on certain brain scan imaging. The medications used to treat anxiety disorders such as Selective Mutism actually work by boosting the available quantity of the deficient neurotransmitters.

Dr. Elisa Shipon-Blum

Our 6 year old son was put on Zoloft 12.5 mg. a day for his anxiety and hopefully to help his mutism at school. He has just been on it for 5 days and doesn’t seem to be doing to bad, just a little upset stomach the first hour or two after taking it. My question is this a strong enough dosage to do any good? What is an appropriate dosage to be helpful to a child this age with select mutism and anxiety? I’d like to know so I can talk to our doctor about it at our next appointment.

Answer

Every child is different. Honestly. I start children on very low dosages, and at the same time I start doing behavioral techniques. The low dose of medication is just used to JUMP START therapy. In other words, it is meant to lower anxiety just enough to do all the behavioral therapy necessary to build coping skills. I gauge how much medication is needed by how a child is doing with the behavioral therapy to help his anxiety. If he is making progress, I do not up the medication dosage at all. If after a certain amount of time (varies according to parents, child and situation) we may increase the dosage to help the child do the behavioral therapy. Some children are so anxious, that it is difficult to make progress with behavioral therapy alone, or on certain levels of medication, so we up the dose and change behavioral tactics.

If side effects occur, we lower medication dosage…Dealing with medication is so individualized. It is important to realize that what works for one child may or may not work for another. So monitoring closely is so key to progress.

I certainly hope your doctor has either put together a plan to help your son at school and other social situations or has referred you to someone that can help you with that. Using medication alone is not a good idea at all.

Dr. Elisa Shipon-Blum

Our daughter sees a psychiatrist who prescribed meds. We were not able to find anybody that had treated SM before. Our daughter is 37 lb. She was put on Zoloft because the doc thought it to be the “cleanest” of the choices. She started at 12.5 mg/day for 1 week, then 25mg/day for 3 wk. Now she has moved up to 50mg/day. I wonder what you think of this dosage given her weight and age (5). We really haven’t noticed much of a change yet, although I think she is talking louder in front of other people, but only to the people she normally talks to. If this dose is OK, how long would we keep her on it before we might see her talk to someone new? Thank you, we do so appreciate your input.

Answer

Personally, I do think this is a lot of medication for a small child. I do not prescribe as aggressively as this doctor did. You also need to do some behavior modification along with the medication. Since many of these kids have been mute for most of their lives, many are pretty set in their ‘mute’ ways. My recommendation would be to instigate positive reinforcement (such as stickers), encouraging verbalization with store clerks, waitresses, etc. You need a good behavior approach to complement the medication.

Dr. Elisa Shipon-Blum

We have a 4 1/2 year old daughter that was diagnosed with SM in Nov 2003. We have seen signs of the SM from a very young age. We have had very slow progress with behavioral therapy which was also started in November 2003. We started her on 10mg of Zoloft this week. Is this dose too high to start at? Our Dr. wants to increase this amount to 20mg by the end of the week? should we be going slower? What are the most common side effects you have seen with meds & how soon do you start seeing results?

Answer

Although I cannot make a judgment about another physicians practice of prescribing medication, I am certainly not comfortable with the dosages you are mentioning. However, this is MY style and my comfort measure. I am concerned that your young child is being dosed to high and too fast. I am concerned about disinhibition. When a child becomes too ‘free’ to do and say what she may be thinking (i.e, acting out, seemingly difficult, daring, unconventionally bold, etc.) Plus, side effects of hyperactivity, insomnia, tummy aches, bad dreams, bed wetting or sleep disturbances. Many parents claim seeing changes quite rapidly. My experience is the younger the child the more rapid the changes. However, I ask that you pay attention to her behaviors and side effects.

Dr. Elisa Shipon-Blum

I have a 5 year old daughter with SM who will be entering kindergarten in the fall. My question is this: I was supposed to start my daughter on Paxil in July so that she would be as prepared for Kindergarten as possible. She was in therapy for about 6 mos., but we eventually got to a point where we couldn’t make any more progress IN the therapy sessions, although OUTSIDE of the therapy room, I was starting to see improvement. Anyway, just when I resolved myself that I was going to medicate, I started seeing tremendous strides in my daughter’s behavior. She went to a 1 week camp at her former preschool, where she had never spoken a word, and spoke to the NEW teacher on the first day and continued to do so the whole week (not just one word answers). She even asked for a drink of water. My daughter even told me on the way home from camp that first day that she didn’t speak in preschool, but she did talk in camp. She also expressed to my husband one evening that it was easier to talk, than not to. Also, around the same time, she began to order her own food when we went out to eat. She’s never done that before. Overall, she seems to be more comfortable with new people, she’ll talk to more kids now than she ever did, but there are still a lot of adults and kids, sometimes, that she will not talk to. It almost seems like people she has a “history” with of not talking, she still won’t speak to, but she’s talking more easily to new people. So based on all this, we decided to hold off on the medication and see how she does in the fall.

I have a psychiatrist who is ready for my call, if we see she is mute that first week in school, I will jump right on it and start her on the medication so as not to let her non-verbal pattern become to ingrained in her, in this new situation. My problem is that I am starting to second guess my decision. As you know, SM does not just disappear over night. Should I be starting her on Paxil anyway, even though I am seeing all these positive steps? Just to guarantee that she will at least start the year off speaking in school? Am I taking too much of a risk by letting her start the year without any medication? Do you medicate a child who is showing progress, just to help take the edge off? If she doesn’t speak that first week and I jump right on it and start the Paxil, will it more difficult for the med. to help, than if we had started her on it before school started? If it were your daughter and you saw these positive signs, even if she still showed some signs of the mutism, would you still medicate her or would you give her the chance to see if it could be worked through without the medication?? I truly respect your personal and professional opinion and I look forward to your response. There are so few “experts” out there, thanks so much for all that you do!

Answer

Wow, you certainly have a lot of information in this question. IF this were my child I would HOLD OFF on medication at this point.It is not uncommon for SM kids to start talking in brand new situations…in fact this is very common! Another common trait is they will be mute with most of the people they were mute with in the past…in other words, if you were to take her back to her preschool, she would probably resort to her old, non-talking state; simply because that is how she saw her self there….mute.

In some circumstances, all it takes is a new situation and the ability to ‘realize’ that they CAN talk…to be able to come out of their SM! I hope this is the case with your child! If your child is mute in K, give her a few weeks before ‘jumping right’ to Paxil. K is a major adjustment for any child, and so much harder for children with an anxiety disorder. It sounds by your letter that you are indeed knowledgeable about SM, so I think you will ultimately make the right decisions with your child. Bottom line……wait, encourage your child to speak in public as much as possible…ask her questions with other children around and just take a wait and see attitude.I wish you and your child all the best. Sounds like you are right in-tune, so I have confidence this will all work out!

Dr. Elisa Shipon-Blum

My daughter is nine and had improved dramatically and then regressed after we moved last Jan. Paxil was tried and at 20mg she had double vision. We tried Zoloft up to 50mg and during the increased dosage she had aggressive behavior at school (a first for her). I took her off, not really knowing for sure if I should have. She’s currently homeschooled because the school won’t help her yet they are giving her detentions, but denying her services. Quite the dilemma. Prozac was her first med., but she did first talk without it. She seemed to get mean and mood swings after awhile of being on it. Now that we’ve tried others should I go back to the Prozac? or could the 20 of Paxil have just been too high for her? Thanking you in advance.

Answer

You mentioned that Paxil, Zoloft and Prozac were tried with your daughter. I am wondering how the doctor dosed her medication.I find that many doc’s tend to start these medications at TOO high of a dose for our young children; and they then move children up in dosage way too fast. As a result side effects as you mentioned are seen. The body needs to adjust to these types of medications and the lower the starting dose the better in MOST, if not all cases.

I am also disturbed by the school’s position with your child’s SM. The school is obligated to meet the needs of EVERY student! You need to be more aggressive with your school system! They have a legal obligation to help your daughter. Please direct them to our site, print out info and educate the school yourself! We need to be our children’s best advocate, so please be aggressive with this. We are here if you need us.

Dr. Elisa Shipon-Blum

I am desperately trying to find out what the normal rule of thumb is for how much time is adequate between increasing the doses of medication. My daughter (7 1/2) just began Zoloft a week ago at 25mg. Her doctor suggested increasing to 50mg after one week. I’m concerned this is too soon for an increase because all info. I’ve received about meds. stressed to proceed slowly for best results. We were hoping to be prescribed Prozac but our children’s doctor and a child psychiatrist chose Zoloft as they feel there are less possible side effects. Most of the info I’ve read on your site have described cases using Prozac with positive results. Could you tell me the differences between these two medications including the pros and cons and why Prozac seems to the first choice in the States. We live in Switzerland by the way. Most so called experts we’ve encountered here have little knowledge and/or hands on experience with SM children so this is also my reason for proceeding cautiously. I want to be sure every step of the way. I am hoping you will be able and willing to send me a reply. It will be graciously appreciated. Thank you.

Answer

I agree, the dosages of Zoloft that this Dr wants to use, in my experience, are WAY TOO HIGH. Starting on 6.25 of Zoloft is more like it…..and regulating depending on your child’s response. A dose like you are describing will not cause faster or better results but will actually just increase side effects. Zoloft and Prozac are very similar….I have had results with both, although, I use Prozac a more…just because of the positive side effect profile and favorable responses. The key is starting super LOW, and giving more is often more troublesome than giving less!

Dr. Elisa Shipon-Blum

My daughter just turned 8 and is in the second grade. She has been selectively mute since starting school. At home and in public, she is extremely talkative and high-spirited. At school, she is active and participates in all non-verbal activities. Thus far, play therapy and playdates have not resulted in any positive changes.

For about two years now, we have been very hesitant about trying drugs to help our daughter overcome SM. However, after reading many of your answers on this site, and after reading the Tribune article, we are becoming more receptive to trying some kind of drug therapy, and soon. You seem to believe that Prozac is very safe and effective, but I would like to ask: (1) what are typical short-term side effects (e.g., nausea?, headache?, hyperactivity?, etc.), (2) what are some potential or actual long-term effects? and (3) what are the prospects for discontining

Answer

From what you have written it sounds as if your daughter is a perfect candidate for a trial of medication.When therapy has not worked and parents have exhausted all avenues, it is time to try medication. As I have mentioned in previous questions, short-term studieson Prozac have been very favorable. No one really knows the long-term effects, but preliminary studies are suggesting the drugs are safe.

My recommendation would be to try medication, give it at least three to four weeks before you can expect to see some real positive changes. Although, it isn’t uncommon for some children to begin showing subtle signs of improvement by the end of the first week. Remember, the changes are subtle, and the progress your child makes will build on the accomplishments she starts to have. i.e., she may smile more, seem more relaxed in social settings that she was previously completely unemotional and uptight in.She may whisper more at first, the whispers may get louder, she may seem more interested in playing or just being with others she was previously uncomfortable with.As she starts to ‘come out’ you will need to ‘encourage’ her more and probe her to speak in previously mute settings. Also, make sure your prescribing physician is comfortable and competent in prescribing and dosing these types of drugs. One of the biggest reasons some children do not respond fully is because the prescribing physician is uncomfortable or unaware ofthe proper usage of the drugs.

Dr. Elisa Shipon-Blum

My stepson has Selective Mutism. He is 8 years old. I was wondering how you felt on giving him one capsule of St. John’s Wart a day. It seems to help keep mood levels on an even level. Both myself and M…’s dad take St. John’s Wart. We know how much it helps both of us so we were wondering about giving a capsule to M… each day. M…’s dad is 43 years old and he is sure that as a child he had selective mutism but was not aware of it at the time. He has since grown out of it. Because of this he is very protective of M…. He is very quick to answer for M… in unsettling situations. What we are wondering is if this is a good idea. Are we best to just answer for him etc. or should we be insisting that he try and answer more for himself. Thank you for all your help.

Sincerely, L…..

Answer

If you check back on some of the ASK THE DOC responses on our member site, the question about herbs has been brought up a few times. My opinion is this: Herbs are very, very nonspecific, and are not studied in children at all. St John’s Wort is more for depression than anxiety, and SM is an anxiety. You would need a relatively high amount, but we have no idea how much to give to children because, even with adults, the dosages are so variable. Extracts vary and amount of real herb is different from brand to brand. Honestly, I am not a fan of herbs, so I cannot recommend them to children. If you are seriously considering this route for an 8 yr. old, perhaps speak to an herb specialist who studies and works with herbs as a profession.

Regarding ‘answering for your child, this is tough because when a child is SM, it is natural to try and protect the child and answer for them to minimize embarrassment. What needs to be done is for you to work with your child and to let them know you understand it is difficult for them to answer sometimes…if they answer that is great, if not, it is okay too. Just this message alone takes off pressure.

You see, verbalization will occur once anxiety is lowered. So, until this happens through a variety of ways (behavioral therapy with or without medication) you cannot expect a young SM child to all of a sudden start to speak. Without therapy to help with coping skills, and to lower anxiety, ‘ASKING’ a child to answer or telling him to answer will only promote more anxiety.

Bottom line, once your child is under treatment to help with lowering anxiety, building self-esteem and increasing their confidence in social situations, verbalization will naturally occur…and you will soon know when and how to gently encourage so that anxiety is not heightened

Dr. Elisa Shipon-Blum

Our son J……, who is now 5 and will begin K this fall, has shown signs of SM for two years during preschool. He just began therapy sessions with a child psychologist who has had experience with SM children. He is recommending an SSRI along with behavioral therapy; which we are all for. I have two questions:

1. What has been your experience with Celexa. That is what I’ve been taking for the last 2 years to help with my life-long battle with social anxiety. I find it very helpful. Does it come in a liquid form? Have you tried other SSRIs besides Prozac with your patients?
2. What is your opinion on whether a parent should administer a medication with or without the child’s knowledge. Our thinking is that if the child takes the meds without knowing, they will view the transformation to talking as something they achieved themselves and it will build their confidence for future social interactions. On the other hand, if they are aware of the meds helping them, this might create a dependency on the drug, almost like a crutch, where, once it comes time to wean them off they may regress back to not talking. I read one posting where a child begged to be put back on medicine when the parents took him off.

Answer

1) Celexa has been used with much success for children with anxiety. However, I have not used Celexa since I have had tremendous results with other medications, such as Prozac and Paxil. A clinician often gets ‘comfortable’ with a medication and sticks with it when it works well with minimal problems. I have used Prozac the most and Paxil secondary. Since Prozac has gone generic I have been forced to use other medications for parent’s insurance companies to reimburse. I have therefore used Paxil.

2) This is a very ‘individualized’ question. Depends on the age of the child and the individualized child’s personality. i.e., Some children are afraid to take MEDICINE, cause they attribute medication to being sick. Plus some children are afraid that if they take a medication to help them TALK (which is what some people tell kids), some children will rebel thinking the medication is going to make them talk and they will therefore FEEL scared. Other children BEG for help and are open to trying anything that will END THEIR suffering. Some parents with similar age children as your child, tell their YOUNG child they are taking a VITAMIN that will help them feel more comfortable (I have used this technique often). I do not recommend telling the child it will make them TALK, simply because TALKING elicits feelings of being scared and if you tell them they are taking something that will help them SPEAK, in their young minds they are assuming they will feel SCARED OR ANXIOUS. It is hard for them to understand not feeling afraid or scared, when that is all they have ever felt. Inevitably, the majority FIGURE OUT quite soon that the ‘vitamin’ they are taking HELPS them feel NOT SO SCARED

Your concern about dependence is not something that has ever come up. You can get around that by saying that when you take this vitamin (or medication) is will help replace what your body needs. Keep in mind that for younger kids saying VITAMIN is appropriate cause some children will think something is WRONG with them if they are taking a MEDICINE. So I have used the vitamin approach for most of the younger kids (your child’s age).

You will be doing behavioral therapy, so hopefully, while your child is taking meds he is building the coping skills necessary. So that, when he comes off of the medication he will be innately less anxious. Also, understand that one of the keys to treating our children young is so that they SEE themselves as a speaker and less anxious person. They do not have the years of ingrained behavior so that is very positive for our kids.

Dr. Elisa Shipon-Blum

My daughter Molly is 8 yrs old, 100 lbs. Just started Paxil taking 1 teaspoon per @day. What is the highest dose you would recommend to see any change for her? (she started out 1 week at 1/2tsp then up to 1tsp) Paxil 10mg/5ml thanks

Answer

This is difficult to answer. Are you doing behavior therapy along with medication?? Behavioral modification techniques need to be done with MEDICATION. Using meds without behavior is doing your child a disservice. She needs to learn valuable coping skills and needs to become adjusted to social settings, such as school. I have seen way too many kids on meds alone with minimal progress, and then when behavioral techniques are instituted, the children make tremendous progress. The goals for medication are to use the LOWEST amount of medication necessary to do the behavioral techniques that will help lower anxiety in social settings, build self-esteem and build confidence in social settings, such as school. From this info, you can understand why it is difficult to answer your ‘dosage’ question.

Dr. Elisa Shipon-Blum

Hello, I have a 10 year old daughter who was diagnosed with SM when she was 3 1/2. She has NEVER talked at school and never spoke in therapy. I am having a very difficult time finding a doctor who knows anything about SM. There is a therapist at her school who worked with her for the last 6 months last year and will do so again this year, but she didn’t have any real progress. Every year my daughter says she will speak at school and every year she doesn’t. She is a straight A student except for her reading because the teachers can’t test her in that. I don’t know much about the different meds, but from reading some of your letters and some letters from other parents of SM children my daughter sounds like a good candidate for medication. Could you give me some advice on the different meds and some of the short term and long term side effects? My husband and I are getting frustrated, our daughter seems to be perfectly happy not speaking at school but I am worried. She has learned to cope with it and has a lot of friends who accept her for who she is.

Answer

From reading your letter, I believe your daughter is the perfect candidate for medication. At this point you have gone through many years of trying to help your child; therapy was not successful…you really have no other option at this time. SO, talk to your family Dr. or pediatrician and tell him or her you are ready to try medication. You have nothing to lose, and everything to gain! Honestly, the majority of children do respond to medication, so it is worth a try. If your Dr. tells you he is against medication, then pursue other DR’s in the area, call them first and ask them about their experience with SM AND prescribing Prozac to children. Many DR’s do not ‘recommend’ these drugs to children for the simple reason they are just not comfortable prescribing it!

So, if your Dr. is of no help, and either will not prescribe it himself/herself and is reluctant to recommend a psychiatrist, then call your area children’s hospital and ask for the various child psychiatrists that they recommend. Call them all up and speak to them before choosing one.

Please read over the many questions proceeding yours, I have talked about medication so many times……The types used in SM, the pros and cons…if you have any further questions, that I have not already answered I will be happy to answer them.

Prozac, Paxil and Zoloft are the most common medications used for SM children. They ‘replace the missing seratonin in their brains’ and help them to function in social situations. Preliminary studies indicate these drugs are safe in children, but because Prozac (the oldest of the bunch) has only been around since 1988, no one truly knows the long term effects.

You mentioned that your child will tell you that she ‘is gonna talk next year’…This is very, very common for SM kids. They really do WANT to talk…they just cannot. It is like they have stage fright, and the words will not come out, no matter how hard they try. By replacing seratonin, most children will improve, and their social phobia will lessen.

Dr. Elisa Shipon-Blum

I am a pediatrician involved with the care of a 6 year old with SM. She has been in therapy with a psychologist, her 1st grade teacher and her school guidance councelor. We are now at an impass and the opinion of the psychologist is to start meds. I wanted to ask your opinion on which one and if there are is any literature on this topic. I was also wondering if you have seen any of the ill effects described in the English study where children on SSRI’s had worsening of depressive symptoms.

Answer

Hello, Thank you for your dedication.

In terms of SSRI’s. I primarily use: Prozac, Paxil and Zoloft. My very favorite is Prozac. The slight stimulating effects are often a good choice for our timid SM children. However, I use Paxil and Zoloft with success as well.

NO, I have never had a problem with the ‘depressive symptoms.’ WHY? First off, the children I work with are usually not depressed. The literature was focusing on ‘depressed’ children/teens. Secondly, I am an advocate of LESS is MORE. What I find is that children who come to me on high dosages…may be disinhibited…and/or apathetic…seem disinterested, not motivated, have blunted or flat affects. I believe this can be misinterpreted as ‘depressed.’ When dosages are lowered, I see these children/teens emerge out of this ‘apathetic’ state.

From my experience …when dosages are too high…first comes disinhibition. Then, as time goes on (especially if dosages are increased) then I see apathy.

For most children, rarely do I use over 15 mg of Prozac…With preteens I may go as high as 20 mg..And with teens..as high as 25 mg.

BUT never higher…

So, less is more and unless the child is involved in therapy…meds will be of minimal value. The child may look more relaxed, but they will not learn the coping skills NOR…build communication skills.

My daughter has been on Prozac for 10 months and we’ve seen little progress. She seems a little more relaxed, but is not speaking at all in school or to adults other than close family members. We are not sure where to go from here;the psychiatrist recommended that we try her on a different medication. I’ve heard that Prozac works well for a lot of kids, but is it not effective for some?

Answer

This scenario happens far too often. The main reasons for this are:

• Depending on medication alone to “make the child speak”
• No treatment plan to enable the child to develop coping skills for overcoming anxiety

What needs to be understood is that mutism becomes ingrained behavior, and that unless specific tactics and techniques are introduced, this behavior can’t be easily unlearned. Therefore, if a child is taking medication but there are no tools to help them unlearn mutism, progress will often be limited and stifled.

Dr. Elisa Shipon-Blum

Answer

I wholeheartedly agree with you…continue to wean your son! He has been successfully weaned down to 15 mg with no setbacks, why not try and remove him completely. I have mentioned many times in previous letters that studies indicate that 9-12 months is enough time to ‘reset’ the body to successfully be able to produce the mood-altering hormone, seratonin. So, why not give it a try.

I would decrease by 2.5 mg every 2 weeks, and see how it goes….take it slow and I think you may be pleasantly surprised! Do not be surprised if your son takes a little bit of ‘a step back’…as far as some increased shyness, etc, but I doubt very highly if his mutism will return again. A big key to these children that are successfully treated is that they NOW ‘see themselves’ as TALKERS..therefore, it is rare for them to go back to being mute.

You mentioned a sensory integration disorder with food. Sensory issues are very very common with SM kids…or any child with anxiety issues; simply because seratonin. It is thought to be related to sensory integration. I recently read some studies on this exact subject, I will try and locate them and send them to you.

My advice, try and wean. Why keep a child on medication indefinitely. As you know, we truly do not know the long term consequences of these drugs. I treat Prozac, and the other similar medications as a ‘JUMP START’ for a SM child….I never plan on keeping a child on these medications longer than 1 year, before I try and wean them.

What does SM have to do with my 5 and a half year old not wanting to go to the bathroom in school. She holds it in all day and refuses to go. She use to only go in her own home then slowly the aunts and grandparents. Now she will go in a diner or Burger King but school no way. What is this all about? Also she talks to kids during play time in school just not the adults. She is in Special Ed because of this. Do u feel children with sm should be in special Ed so they get the attention that they need in the smaller classroom even though their academic level is good?

Answer

First off, I am completely against special Ed or labeling of ’emotionally disturbed’ for Selectively Mute children, unless there are other major issues going on with the child. Shuffling our kids into special classes and giving them ‘labels’ is a sure fire way to put them on the wrong course for success. I am adamant about this! Schools do this simply because they do not know how to properly manage the SM child…We are trying desperately to change this. The school personnel at your child’s school need to be informed that SM is an anxiety disorder that needs to be tackled from that perspective. Once it is seen and dealt with from an anxiety standpoint, our kids usually do quite well in the regular classroom.

Regarding ‘not going to the bathroom in school,’ this is actually quite common! SM kids have difficulty ‘initiating’ so going up to the teacher can be impossible for some SM kids… Some hints would be to have signs she can use with notes pre-written, direct access to the bathroom so she can ‘just go.’ There are some kids that no matter what tactics u use will still ‘not go.’ This usually changes as they get older and realize that ‘accidents’ are not looked at favorably by teachers and peers….and are incredibly embarrassing. There are also kids, that DO hold it all day, and no matter what you do, they will always do just that.

Dr. Elisa Shipon-Blum

Our son is just turning 5 and has SM (although not officially diagnosed yet). He does not speak with adults, for the most part. There are a few select adults that he will talk with, a few more that he will communicate with (pointing, pretending to be a puppy with barking and paws, or using pretend voices), and the rest are just not communicated with at all. The majority of adults fall into the latter category. He will become more comfortable in a social setting as time goes by, but never to the point of speaking. By becoming more comfortable, I mean that he will sit in his own chair at a table and eat his food (rather than hiding behind me or kneeling on the floor). But we are constantly told to tell other people not to look at him. Children, on the other hand, seem to not be a problem. He will usually play quite well, although there does seem to be control issues over how games are played or whether they are listening to him. His emotions are always very close to the surface.

We have been homeschooling him (for a number of reasons) and had planned on continuing this, prior to learning about “selective mutism”. Now we are a little on the fence over what to do. Personally, it seems to me that if we are in a position to homeschool, it makes sense. Given an anxiety disorder, why put them in a situation that makes them more anxious, as long as other socializing and educational opportunities are provided? On the downside, I can see where having the same people on a daily basis working with our son might show quicker results. Do you have any experience with parents homeschooling their SM children, and if so, what is your opinion on the benefits and/or risks therein? Would you have any specific advice to a homeschooling parent of a SM child? Thanks so much for all the help you provide
.

Our son is just turning 5 and has SM (although not officially diagnosed yet). He does not speak with adults, for the most part. There are a few select adults that he will talk with, a few more that he will communicate with (pointing, pretending to be a puppy with barking and paws, or using pretend voices), and the rest are just not communicated with at all. The majority of adults fall into the latter category. He will become more comfortable in a social setting as time goes by, but never to the point of speaking. By becoming more comfortable, I mean that he will sit in his own chair at a table and eat his food (rather than hiding behind me or kneeling on the floor). But we are constantly told to tell other people not to look at him. Children, on the other hand, seem to not be a problem. He will usually play quite well, although there does seem to be control issues over how games are played or whether they are listening to him. His emotions are always very close to the surface.

We have been homeschooling him (for a number of reasons) and had planned on continuing this, prior to learning about “selective mutism”. Now we are a little on the fence over what to do. Personally, it seems to me that if we are in a position to homeschool, it makes sense. Given an anxiety disorder, why put them in a situation that makes them more anxious, as long as other socializing and educational opportunities are provided? On the downside, I can see where having the same people on a daily basis working with our son might show quicker results. Do you have any experience with parents homeschooling their SM children, and if so, what is your opinion on the benefits and/or risks therein? Would you have any specific advice to a homeschooling parent of a SM child? Thanks so much for all the help you provide.

Answer

Honestly, where I live, in Philadelphia Pa, homeschooling is not common here. However, I am not an advocate of homeschooling for SM kids. I will tell you why. Understand this is just my professional opinion, not based on scientific studies, ok??

Since these children have anxiety, the majority with social anxiety, I believe these children need early and frequent socialization. If you can provide your child with this while homeschooling, great! But, in the majority of cases, parents will admit that most homeschooled children do not get the same amount of socialization as children who attend school away from the home. Think of it this way…if you were afraid or uncomfortable with speaking…and you had to give a speech, you would be nervous, right? Well, if you started young, giving speeches and getting up in front of people ….each time adding a few more people to the audience.,…..and did this for many years, chances are you would build a tolerance and learn how to cope with giving these speeches, right?

Imagine…all of a sudden, having to get up in front of many, many people to give a speech, when having not done it too many times in the past, and when you did give a speech it was to a few people at a time on an inconsistent basis…how do you think you would feel giving this big speech now??? My bet is you would be a wreck compared to having given lots of little speeches along the way and adding a few more people at a time to your audience. You would be desensitizing yourself to your ‘speaking’ environment. This is a lot like SM……if you start a child out young, like your child and desensitize him slowly and comfortably…learning to cope and be comfortable with children around, it will be easier than having him wait till he is in high school or college to have to learn to fend on his own in an academic setting.

I am talking about an SM child here…one that needs to socialize and combat social anxiety… I am just afraid that homeschooling, is in a way, sheltering and protecting your child from ‘socializing’ and learning how to cope at an early age with his social anxiety (if that is what he has). You may just be postponing the inevitable.

If you are going to homeschool, then please make sure you are socializing your child outside the home to other peers. Your child needs to learn and experiment with children his own age in order to build social confidence and social skills. If you are providing this, then all the more to you and good luck to you. You are your child’s mom and you have to do what you feel is best for your child….Even if it means not agreeing with others.

Dr. Elisa Shipon-Blum

My son N……..is six years old. He was promoted from kindergarten to the second grade this past August. Unfortunately, the school did not inform us before the first day of school. He has since refused to speak in the classroom of the second grade class. He speaks at school in aftercare and with his friends from his old class. He has been getting excellent grades in this new grade and actually now admits that he likes it. He has expressed a desire to me (the parent) to “want to” talk in the classroom but doesn’t know how to start. He has been getting some behavioral therapy but to no avail. I have an appointment scheduled in January with another psychologist.

Answer

I am assuming your child was not SM prior to the grade skipping. It seems quite obvious that your child is very anxious with his move to the second grade. He may have academically been ready for the second grade, but obviously socially and developmentally he was not. He feels insecure and uncomfortable with these older children and is so afraid and scared, he is now SM. SM is a result of anxiety, and your child is clearly so anxious, he is mute in this setting.

Please do not use the word REFUSES to speak. If he is truly SM, he CANNOT speak from severe anxiety. Recommendations would be that behavioral techniques to help lower his anxiety be instituted, especially because he tells you he likes school. If, by the end of the school year, he is still SM, despite a behavioral approach to treatment of anxiety, I would seriously consider whether or not to repeat this grade, with extra academic enrichment in place for next year. Social development is incredibly important and crucial to a child’s emotional growth.

Dr. Elisa Shipon-Blum

My 5 yr old daughter Olivia will be starting Kindergarten this fall. She is currently in a private pre k class and has 5 students in her class. My sister in law who she is very close to, can possibly be her teacher which we think would be great to calm her anxiety. She is going to be co-teaching this class with another teacher -there will be 36 students. Olivia also has social anxiety. Do you think this is a good idea? My sister in law and the other teacher are excellent and are willing to accommodate Olivia 100%. Olivia also has a good friend who will be in this class as well. Avg students in each class are 23, so we are only talking 13 more kids. I don’t know what to do. Thanks so much…

Answer

Since I do not know your daughter I cannot help you answer this question for you. However, if you have teachers (and since one is her aunt!) who are 100% dedicated and willing to help your child, this is an ideal situation..since they will UNDERSTAND your child and her needs… Although a smaller class is ideal…having teachers who are willing to go that extra mile to help socialize and build comfort for your child is crucial. Perhaps she would be in a class with only 5 children, but the teacher did not truly understand SM and completely misinterpreted mutism for defiance and control. Your child’s anxiety would heighten since your child will be misunderstood and undo pressure and expectation would be placed upon her.

So, work hard over the summer to meet as many kids as possible prior to the school year. Spend time in the new classroom and spend time with her aunt…so that when she is in school in the fall she has already built comfort with the classroom, some peers and her teacher!!

M…… shows many signs of SM and will be 3 in September. She will most likely qualify to attend preschool through our school district’s special ed program. (Preschool is 2 1/2 hours, 12 children, 1 teacher, 1 aide, specialists come in during week). Do you think it is a good idea for her to go to school at her age? If so, we would have a choice of number of days 1,2,3 or 4 per week. How many days/week would you recommend? Our special ed caseworker thinks 4 would be good considering M…….’s problems. Thank you for answering my questions!

Answer

Your child is not yet 3 and you are already labeling her as SM? and you are already thinking of putting her in a ‘special ed’ class? I think you are making a mistake at this point. First of all, most SM cases do not require ‘special ed’ especially at your child’s age. A wonderfully caring preschool teacher who educates herself about SM and spends time getting to know your child should be all that is needed right now. It sounds as if they do not know what to do with your ‘mute’ child and are taking the easy way out and placing her in a special ed class. What are they going to do with your child in this class that is different than what they would do with her in a regular classroom? You need to understand that. SO few teachers, psychologists and even physicians do not truly ‘understand’ SM, so they end up shuffling children through special ed. and labeling them as ‘special needs.’

Who diagnosed your child at 2 with SM??? My advice to you would be to socialize your child in a comfortable, non-threatening way..bring no attention to her muteness..make no comments about ‘not talking’ and place her in a regular classroom. The number of days is up to you. Since she is not even three, why not spend your time with her a few days a week. Take her places, get to know other young kids, have her involved in one on one playdates…and make no mention of talking. I suggest posting on the forum and asking others about their experience with SM with very young children. I would hate to falsely label a 2 1/2 yr old as having SM….It is way too premature.

Dr. Elisa Shipon-Blum

My son is 7 and in first grade. He is taking 7.5 mg of Lexapro and does play therapy 2x/week but has not yet spoken to his therapist. He only whispers to one boy in school and doesn’t participate in gym, recess, library, etc. He is extremely gifted and is reading at the sixth grade level and has been doing multiplication and division since he was 4. We are trying to determine the best teacher for him for second grade. Our school cluster groups the gifted children. There is a really sweet, caring, kind teacher who everyone says would be perfect for my son. However, the gifted cluster would be with a different teacher, one who pushes harder academically. My concern is that my son has always viewed himself as being quite different from his peers. In your opinion, is it better for a gifted SM child to be with a caring, nurturing teacher or with his intellectual peers? How much does it add to his anxiety to not be placed with intellectual peers? Also, the friend that he does speak to will not be placed with him next year as he needs a different type of teacher.

What do you think of Lexapro? We will probably increase the dose or switch meds at the next appt. since we haven’t seen much progress. I would really appreciate your opinion. Thank you.

Answer

I am glad you are actively seeking treatment. However, you mentioned your son is in play therapy. The question I ask is: What is the therapist doing to help your son progress communicatively? Play therapy is fine assuming your therapist is helping your son progress from nonverbal–> verbal communication and understanding your son’s anxiety in various settings. i.e, when he is in school, can he respond comfortably via pointing/nodding to his teacher one on one? In a group? With a few children? Can he initiate his needs nonverbally? i.e, Can he go up to his teacher and indicate his need without feeling anxious? How is he transferring speaking from one person to another? Can he give his order in a restaurant, can he make a phone call or answer a call? IF you are not sure of these answers of how your therapist is progressing your son, you need to talk with him/her. She should be informing the school with you as to how to help your son in school. Working in an office setting playing games to feel relaxed is fine assuming the goal is to progress outside, in the real world. Your therapist, teachers, and you need to work together to help your son. It can’t be done independently.

In other words, what is classic for SM is that a child’s anxiety changes from one setting to the next and from person to person. I your son is speaking or not speaking to your therapist is not a measure of progress. What is, is how he is improving communicatively out of the office.

The teacher can make or break a school year in terms of communication comfort. Having a teacher who understands SM and that there will be times of more and less anxiety, and how to help your son feel less anxious as well as to be able to read your son’s body language is important. Understanding that his inability to communicate one day is a reflection of anxiety and not defiance or control is important as well.

In terms of teacher selection and gifted placement is whether or not your son wants this. Many children feel confident and safe with their academics and stifling them academically does not help them…some need that stimulation and want it. Other children are not so interested and would rather be with their friends and are not that motivated. There are many ways between now and then to build comfort with peers who would be in his gifted class. This relates to what I was saying earlier. Work needs to be done via IEP or 504 Plan or without any plan, but with accommodations to help your son build social comfort and progress communicatively with other children. Again, this is crucial.

Also understanding that some SM children, despite giftedness, may still have difficulty finishing, completing assignments in class, may need extra time for testing..will hesitate and have trouble ‘thinking’ in class. If this is the case with your son, then pushing him ahead into a more challenging curriculum may not be in his best interest. If he has no trouble in class and flows through his work as he does at home, then you may have your answer to school placement next year assuming you can build rapport with other children who will be in his class.

Dr. Elisa Shipon-Blum

I wish to obtain some helpful advise from you regarding my daughter. P.. is now 7 years old and has been diagnosed with selective mutism by her current psychologist/therapist. She does not talk in school whether it be among peers or during class. Dealing with a large group overwhelms her. With this, she is often alone during class breaks although there is a group in her class who ‘sympathizes’ with her and have ‘adopted’ her as their groupmate. She of course finds it difficult to relate with her teachers. For example, she cannot even submit an excuse letter to her teacher face-to-face. She has to put it on the her teacher’s table before the latter arrives. Going to the toilet during class hours is also one of her problems. Rather than ask her teacher’s permission, she would just force herself to hold it. Several times, she has gone home wet and for a time was sick with Urinary Tract Infection. In general, she does not interact easily nor talk to strangers or new faces or to a large group. Her circle of comfort is our immediate family (she has 2 sisters), her grandparents and my sister, brother-in-law, brother and our household helpers. With us, she is a normal bubbly kid of her age. She is especially close to her younger sister (P.. is a middle child) who is 4.5 years old. My youngest daughter is outgoing and hence, P. most often uses her as a security blanket in unfamiliar social situations.

At the age of 2 we sent P. to a speech therapist since she still was not talking normally at that time. Her words were limited to Mommy and Daddy and very seldom would she want to express herself. She was very stubborn and when her wish was not granted, would lie on the floor which we thought was her way of attracting attention. After going to speech therapy for almost a year, her speech had greatly improved and her fits of anger also controlled. But she still was very shy and was not talking outside of the family circle. We then sent her to a psychologist and through therapy sessions starting with one-on-one and then to group settings, she was able to talk and be comfortable in that group. At this time, she was attending pre-school and was quite comfortable (although still shy) since she was in a class of maximum of 15 and the activities then were quite simple (mostly play). We stopped bringing her to therapy sessions when she was 5 years old since her therapist migrated to the U.S. and we could not find a good one at that time.

She is presently in Grade 1 and we feel she is not able to cope in her current school environment. She is in a class of 50 and every year the kids will be reshuffled among all the other kids of their level (total of 200). She has gone back (starting 5 months ago) to weekly play therapy sessions with a psychologist. I have talked to almost all her teachers to make them understand her behavior. The more difficult teachers still force her to recite which really traumatizes her. There was a whole week this school year where she was crying and did not want to go to school. She did not tell us why, but we later learned through her classmates that one of her teachers embarrassed her by telling all of them not to be like her who does not know how to talk. I have talked to the teacher since but the damage was done. My husband and I are seriously looking for a smaller school that will give her the opportunity for her to be happy and get out from her shell. We are eyeing a Montessori school that typically has a maximum of 25 students per class and whose teachers, hopefully will be more understanding. Her current therapist told us to defer the decision of transferring her to a new school until end of the school year since she might have been able to talk in class by then. Judging from my daughter’s behavior and from what I’ve read so far, I think this is not possible. Hence, we are almost sure of getting her a new school. We have involved our daughter in the decision making process and she has positively told us that she likes to be in the Montessori school than in her current school.

Are we doing the right thing? I also wish to obtain some more advice in dealing with our daughter. At home, she is a perfectly expressive, jolly and playful girl.

Answer

From the sound of your letter you certainly seem like you know what you are doing with your daughter. A bit of information, the wetting is common among many SM kids…this happens because our lil SM’s do not ask the use the bathroom and they literally get to the point where they can no longer hold it. The Urinary Tract Infections are most likely from your daughter holding in her urine for so long that the urine is literally backing up into the kidney, and causing REFLUX and possibly hydronephosis. You will need to make sure the teacher takes your daughter to the bathroom quite often.

I agree with you, a small Montessori school is a wonderful idea for your daughter. These children notoriously do much better in smaller, less structured classes. Reasons for this are obvious. My advice would be to pursue the private school and start taking your daughter there often, getting her used to the school. Take her when few people are around, and just let her get comfortable with the school environment. Engage her in conversation in the new school…and do this continuously until she starts school. Another bit of advice, try and speak to the principal about allowing your daughter to meet the other children before the new school year. Call the mom’s and arrange playdates with the new children. This way, your daughter will have gotten to know many of these kids before school, spoken to them already and will then carry this over into the new school!

Believe it or not, going to a whole new environment (such as school) may be enough enable your daughter to start speaking, I have seen this happen many times. The main reason for this, is that these NEW kids and teachers will not make a BIG DEAL when she talks…whereas in the school she is in now…everyone would probably bring a lot of attention to your daughter…a real ‘No, No’ to a SM kid!

My goddaughter is 5 1/2 and has been diagnosed with Selective Mutism. She has been in a Montessori school for preschool and now kindergarten. She hasn’t spoken in school yet but talks nonstop at home. The class structure is 26 4-6 year olds in one classroom. It stresses peaceful, quiet, individual and at your own pace work. We are confused about what do for first grade on. How do you feel about Montessori vs. public classroom setting?

Answer

The number of children in a class is important but what is crucial is the accommodations a school can make to help your child with her anxiety. Most children with SM feel overwhelmed and are usually stifled communicatively in group settings. Accommodations need to be set forth to help your goddaughter feel safe and comfortable. One on one help with another teacher/aid, small group work and understanding her level of communication comfort is important. Obviously working with a professional who can assess your child and develop an individualized treatment plan to help progress within the classroom setting is a must. You can’t do this alone. You need the help to know the steps that need to be taken to build social comfort, confidence and to enable for communication progression. Also know that in private schools they do not have to abide by the IDEA laws of education to provide help to a child, they can decide to ‘not deal with a situation’ and to recommend you seek another school that can provide more accommodations for your child if they do not have the staffing or ability to provide for the ‘ideal classroom setting’ for your child.

The only place that HAS to provide you accommodations is the public school system. However, since few understand SM, you will most likely need to be very, very active in the process to help them know what your child needs. Working with a professional who understands is a must since he/she can help direct the process for you. Most public schools will provide an evaluation via a school team, but the concern I have and see so often, is that misinterpretation of SM symptoms leads to inaccurate placement and inappropriate accommodations. i.e, mute child implies, lets get her to speak! etc., etc.

So, what needs to be done now is to talk with relevant personnel from both possible schools, spend time in the classrooms and meet possible teachers. Talk to other parents in the school system who have had accommodations set up for them. Was the process easy, hard? etc. If you have a nurturing school now, and they are doing everything possible to help your child and willing to go that extra mile, then I would opt for that situation a million times over. So whether public or private is not the answer, it is where is your is child accepted more for WHO she is and understands how to help your child is the school for you!

Dr. Elisa Shipon-Blum

I have a question about placement with my four-year old son. He is currently in a private preschool 3 days a week with 5 other children. It took him 6 months to warm up and start communicating within select school settings. We did start him on a low dose of Zoloft in March. Since then we’ve seen expected changes where he talks more and feels more comfortable in familiar settings. About two and a half weeks after he started the Zoloft, I watched him perform in a sing-a-long at school. He was singing and doing hand movements. I cried the entire time. I never thought this would happen. He didn’t ever sing in class prior to the Zoloft.

He still has issues with separation anxiety but he has a friend that makes the transition easier.

In August he may have an opportunity to attend the same school that he will attend for Kindergarten. His older 7-year old brother attends there currently. The preschool class at the public school is for ESL and low income children. My son would not qualify for either of these however the ARD committee could recommend placement there because of special issues – SM. My son currently goes to this public school twice a week to see the counselor one on one and to work with the speech teacher. We’ve had very limited success, maybe because there are no other children involved.

I spoke with both of the public school preschool teachers and I sat in one of the classes. Both teachers told me because of the ESL there are several “shy” children in the classes. They said there are also outgoing kids which makes for a good socialization mix. The kids at this age level are not pushed. In fact a teacher may notice that the child knows his ABC’s because they quietly say the ABC’s while they work on a puzzle by themselves. The teachers seem to understand shy children and make appropriate accommodations. They seem to have that “motherly instinct.” One of my questions was, “Would my child be a target if he is unable to communicate?” Good behavior is expected and the teachers watch and help guide children that are learning how to share, etc. The class sizes are 19-20 with a teacher and an aide so the child teacher ratio is ten to one.

My question is do I leave my child in his 3 hour, 3 day a week “safe” class at a private preschool or do I try the public school in this ESL/low income preschool class in the same school where he’ll be in Kindergarten? It’s half a day five days a week.

I am VERY concerned that he’ll condition himself to be mute if I don’t push him in appropriate ways. I want to move him along in a nice but productive way. He’s been in 2 different schools and in each setting he had a 6 month warm up time before he could really do regular activities with other children. I would hope that if he went into the public preschool class he would have his warm-up time there and in Kindergarten he would excel at his natural pace.

Is it better to leave him alone and let him be safe in this small private preschool for another year? Should we push him to progress in a public school with kids that have similar issues? Thank you so much for your advice! I value your opinion!

Answer

You have presented an interesting dilemma here. However, let me explain my perspective based on experience working with so many children in your child’s age range. Your child is YOUNG. The advantage is that as he begins to emerge as a verbal communicator he will begin to see himself this way often and in many different settings as much as possible.

I also take the stance that if a child has SM without other learning issues or severe emotional problems that I assume they will OVERCOME their anxiety. I therefore try to mainstream as much as possible focusing on lowering anxiety and building communication skills (nonverbal, transfer into verbal, verbal).

Therefore I would NOT recommend placing a child in a special preschool class that specializes in special needs If a regular classroom can meet his needs. Meaning, if he is comfortable in his present school and class AND the school is accommodating to helping him. Helping with pairing him with buddies, working one on one, working on communication progression, etc…then why move him at this time?

He will need to move into K the following year anyhow and many of the children with special needs may not go with him anyhow, so he will need to meet new children and build rapport anyway. WHY not focus next year in a safe and comfortable environment where he can continually progress communicatively…and build the confidence
?

If his sibling is in the school where he will be going to K, then by all means involve your son in the school as much as possible to get to know the school. Try to meet other moms with kids in PreK who will be in your son’s grade in K and work in getting to know them OUT of school to build the rapport and comfort. Also, since you have the ability to be in the school, you can observe different teachers and perhaps get involved early next spring with picking and choosing his teacher for K and specific children to be in his class (this should be part of the 504 or IEP Plan, that YOU be involved in choosing the teacher. and he should always be placed with children he knows)

Then, when he transfers to K, he will be comfortable in the environment, know some kids and be with the teacher of your choice…(whom he got to meet ahead of time, perhaps while she is setting up her new class for K). I hope this helps you.

My experience is to focus on the positive knowing he will overcome SM if the correct approach is taken…and to help your child be as comfortable as possible as much as possible….so he sees himself as a communicator. He will just grow with his skills, especially since you will be accommodating his needs!

Dr. Elisa Shipon-Blum

My daughter is in first grade. She has SM and she is not doing very well in school. She is at a reading level of 6. The teacher is very kind and has tried different strategies with her. She has not received any small group instruction or special ed. The teacher doesn’t want to stress her out so she lets her work at her own pace. We have been referred to the EMT process and retention has been suggested. What should we do?

Answer

Since I do not know your child, I cannot determine the exact cause of her reading difficulties. However, I can say that SM anxiety can cause a child to have problems academically. A question I have is how are they determining your child’s reading level? Obviously our children with SM cannot always speak or read out loud in class or even one on one with teachers. Has your teacher used home video taping to assess? This would be a good idea. For her to tell you what your daughter should read, then encourage this in your child at home…either with cassette tapes or video taping.

For many children with SM, especially ones with academic issues, retention is not usually the answer. The answer is in the form of accommodations. Perhaps an IEP or 504 Plan to help with her inability to speak in school…an alternative means of communication. Has additional tutoring been suggested over the summer? Are there other academic concerns? How is your daughter socially?

There are many variables to consider before retention should be considered. Holding a child back due to ‘lack of speaking’ and the schools inability to know how to accommodate is not the answer…the answer is in helping to determine WHY your child is having reading difficulties. Is there a learning issue? Or is this the result of anxiety…AND the school’s lack of accommodations to help your child succeed.

Dr. Elisa Shipon-Blum

Our daughter is age six and was diagnosed three years ago. She started school this year. She has begun giving problems in class saying that she feels ill when she has to do writing exercises, and begins crying when pressured. I get the same problem at home when she has to do homework (often, as she doesn’t finish her work in school.) I can cope at home, but how is the teacher supposed to react to this type of behavior in class? Are there any detailed articles on common behavioral patterns amongst SM children other than not speaking?

Answer

Selectively Mute children, like all anxious children, often display behavioral manifestations of inner stress. Physical complaints, such as tummy aches and headaches are the number one complaint that children with anxiety complain about. These pains are very REAL and are often associated with anxiety provoking stimuli.

Your daughter is not completely secure with her abilities and is afraid to make a mistake. Perhaps she associates doing this work with a lot of question being asked by the teacher. There are a number of reasons why she may be feeling anxious doing her work. We hear this often. SM children are socially anxious (over 90% of the time). As a result they have various phobia’s associated with social phobia. Fear of ‘performance’ or fear of ‘making a mistake’ is very common about our lil’ SMer’s. I suggest doing lots of workbooks, and making her ‘homework’ seem more laid back and playful until you can work out a plan with your treating physician or therapist.

Dr. Elisa Shipon-Blum

Answer

Playing the tape is enabling others to hear her voice…this is positive! Many children are scared and uncomfortable for others to hear their voices…so, I see this as step in the correct direction. However, what needs to be done now is to use her enjoyment (and comfort with taping) as PART of your treatment plan to help her progress communicatively. i.e, spending one on one time with you and her teacher and playing the tape where she begins to mouth the words to the tape…and then perhaps a game where she can turn on and off the tape while mouthing so the teacher can try to figure out whether it was her speaking or the tape! In addition, playing this similar game with peers, especially during playdates, then transferring this to the school environment where she can continue this game…especially with the child she is already whispering to. Using VERBAL CUES with a child who is whispering is a great way to stimulate speaking louder Also, the use of the verbal intermediary with her friend…whispering at a set distance and increasing the distance.

Dr. Elisa Shipon-Blum

M…… is a very happy 3 and three quarters. He was diagnosed with SM 2weeks ago. He has a lot of the symptoms but even though he doesn’t speak, his face is full of expression and full of smiles and giggles. When he went back to school after Easter, I gave his teacher all the information I had on SM, the following day I told him it was all right to whisper to teacher. Since then he hasn’t stopped whispering to her and friends. Is this normal? I have not been given any information on how to approach the problem, just to ignore it and not make a fuss over him not talking.

Answer

It is VERY common for children with SM to whisper; in fact, it is a good sign! The fact that M……… was mute prior to Easter, and is now whispering is progress. I would not ignore his success. Tell him how proud you are of him! Often, SM children will slowly begin to whisper, sometimes in a barely audible voice as they become more comfortable, and less anxious. As you know, SM children often do not manifest many outward signs of true anxiety, some seem quite content and relaxed in their environment and are happily ‘mute’. Because Michael is only 3 3/4 yrs old and already whispering, I think he is off to a great start!! As he becomes more comfortable with his whispering, try and encourage him to speak a bit louder. Instruct his teacher to use the phrase; “I can’t hear you M…….”. You will be surprised how well that works!!! Many SM children do not even realize they are whispering, so when you tell them that you cannot hear them, they will often speak a bit louder. Then, as time goes on, his speech will hopefully become more audible. Because it is the end of the school year, I encourage you to try and find out who will be in his class in the fall. Encourage playdates with the children and try and meet with his teacher during the summer (multiple times!). In fact, one method is to meet with his teacher OUT of school and just talk with her. Go into his new classroom as the fall approaches and let him play with the toys and get comfortable in the room. He will most likely speak normally to you when you are in the classroom. Try and be patient and encourage his progress!

Dr. Elisa Shipon-Blum

My daughter is 6 (in Kindergarten) and has SM. She seems to be getting better (talks quietly to close friends) but still will only whisper occasionally to her teacher (not to other teachers). On May 21 (Mon) each member of her class is supposed to read a paper about themselves (Kristen seems anxious but says she wants to do it-she says she was too embarrassed when they practiced in class). I am wondering if I should let her try it or should I intervene so that she doesn’t have a setback. I feel that she should try, but I don’t know if that is the right answer. Also, is it okay to take her to do something as a treat if she does read it (I don’t want to be negative but I think it is a little unrealistic at this point-but you never know and I don’t want to underestimate her, she does have the desire.)

Do you have an opinion (to try or not to try)? We have been making her SM a nonissue for several months now per the recommendation of the SM specialist in our area. Help?

Answer

I agree with you, if your child has never verbalized, it is unlikely she will start when ‘all eyes are on her.’ SM kids do this often, they say they will speak (because they really want to), but due to their anxiety level, they cannot. This can be very disheartening to the child, because they feel as though they could not do something as easy as ‘talk.’

A suggestion I have is to have her tape her assignment at home on a tape recorder. Tell her what you are going to do, see how she reacts. This often works well. She can then play the tape for the teacher alone (at first) and then to the class (if she is comfortable with this). When she does do this, reward her efforts and let her know how proud you are of her!

Dr. Elisa Shipon-Blum

My daughter M. is 8yrs. old and in second grade. She was always very shy speaking only to my husband and I, my son, her grandparents and some aunts and uncles. Today she speaks to everyone in our immediate family. In school she would only speak to her gym teacher privately. We have been seeing a therapist for over a year now. Since M. was diagnosed with SM I have read all your books and am very aware how to handle children with SM. The therapist and I are trying to educate M’s teachers on SM. I’ve been bringing her in early before any kids get in and sometimes M. will read some words to her teacher. I also taped her oral book reports for her teacher to hear. M has one very good friend that she will speak to in school. She feels very comfortable with this friend and because of her has been able to make new friends and join after school activities. Her teachers, especially the gym teacher, feel that M. is using this girl as a crutch. They want to separate them next year. I am totally against this because M. is less anxious around this other girl. I know how frustrating it is when you don’t get any communication. I think her teacher probably thinks she can cure M. by keeping her away from her friend. But I think keeping M. with kids she feels comfortable with can only help her. They seem to think she needs to have other friends. M. does have other friends she just can’t initiate friendships on her own.

My question to you is, “Should M. be separated from the only girl she can comfortably talk to?” Thank you in advance for your answer.

Answer

This is an excellent question and this comes up so often. There are a few angles to consider.

Your child DOES need to expand her friendships. You can do this NOW, in preparation for next year by using her present friend as an intermediary to build a rapport with other children. i.e, play dates. Include this other friend at first. Have a NEW buddy at school where the other child is present, but a NEW buddy is introduced more regularly and M. is paired with the new buddy for projects, as a messenger, etc. Work on communication skills with this new other friend…where questions are being asked…and M. can either answer via her present friend as an intermediary or speak directly to her by reading off a card or looking at a picture. Obviously, I do not know your child so I am not able to assess what exactly she is able to do, but these are methods of helping her to build rapport with other children.
Is your child SO dependent on this other child, and quite content that she does not have an interest in befriending another child? AND/OR
Is this other child feeling strapped or stifled due to M’s dependency?

It is common for the friends of our children to feel a bit strapped and for parents of the other child to feel this as well…and many will make the request that their child NOT be placed in your child’s class. This often upsets parents, such as yourself, tremendously because you sense the anxiety your child will have in school without having her best friend present. This is all the more reason why you need to actively work on expanding her friendships, because if the other parent insists on the separation then you are left with no choice.

ALSO, to the answer to your questions, about shouldn’t your child be placed with a friend, YES, by all means. However, in your child’s case, and based on the information you submitted to me, this is ONLY one person whom you are referring to. If you build rappport with MORE children as discussed above, then the school should place your child with at least one friend with whom she is comfortable and with whom she can speak.

Dr. Elisa Shipon-Blum

Our daughter K. has been diagnosed with SM, she is now 6 1/2 years old. She was seen by a psychiatrist, who did admit he had never treated a child with this before. We did all the standard things: sticker chart, awards, then went to negative reinforcement (made things much worse). We stopped going to the doctor and have just been working with K’s teacher. K started off first grade great. She whispered for 4 days in a row at school after only one week. So, we rewarded her (grandparents took her to dinner and movie). We thought “Hurray! She cured herself”. Well, since we made this big deal she has not said one word, whisper, or noise at school. School is the ONLY place she cannot talk. We have decided to stop mentioning her not talking at all, just ignoring it. Her teacher has her tape oral assignments and does not call on her at school to answer any questions that cannot be answered with gestures. Is this okay or are we enabling her too much? I am not sure if meds are the right way to go since she was talking until we made such a big deal out of it. I guess what I’m asking is, should we continue to “ignore” the problem, keep things how they are at school, or do we need to put some pressure on her, consider meds…?? She states she absolutely loves school and is eager to go every day, is very comfortable with her teacher, and has lots of friends.

Answer

Excellent question! I believe the reason your child stopped talking after the rewards and the ‘big deal’ was because she felt ‘pressure’. She did not want to let you down, and probably put too much pressure on herself, causing increase an in anxiety..hence, Selective Mutism. I have seen this happen quite a bit…just like you have described.

My advice is to stop talking about ‘talking’. Just let it go a bit. If you truly have done everything you can to help her with her mutism and she is not making much progress after some time, then I would consider a trial of medication. These kids truly have severe anxiety, and meds work great in the many cases of Selective Mutism. You are not enabling her mutism by allowing her to communicate nonverbally, you are simply allowing her to feel more comfortable and at the same time participate in the class. But, with the nonverbal communication, you will still need to encourage verbalization.

You mentioned she is taping lessons on the tape recorder. My advice would be to tape them at school! Perhaps after school you could just sit with her in the classroom after everyone has left. Tape the lesson right there! What you are doing is promoting vocalization in school. Since this is where her difficulties are, you need to work on vocalization in school. I also suggest going to school with your child and spending time in the room talking about all her school work and projects. These are just some of the many ideas you can do to help promote vocalization in school

My six year old daughter was diagnosed with SM about a year ago. She is making wonderful progress (she is up to 8.5 mg Prozac). She is speaking to about 8 classmates, her teacher and she is able to order her own food when out in public. Lately she is unable to speak to relatives if her father or I am nearby. She speaks to them comfortably when we aren’t close. Her doctor thinks it is her “independence”. I don’t think so. What can we do to help her feel comfortable speaking around us? We have never ridiculed her for speaking. It is hard to understand this latest twist. Thank you so much for your help.

Answer

Interesting question. Honestly, in my professional experience, the children who ‘stop speaking’ or become more uncomfortable when Mom, Dad or both parents are around, are usually the children who FEEL that their parents are really, really WANTING them to speak. In other words, perhaps you are DWELLING on her speaking and mentioning her NEEDING to speak that she is actually feeling anxious when you are around and/or WATCHING her when she is with others to SEE if she is speaking to them. My suggestion would be to STOP talking about TALKING and stop WATCHING her to SEE if she is speaking to certain people. Our kids are incredibly PERCEPTIVE to what others think and feel.

Dr. Elisa Shipon-Blum

My daughter is 5 yrs old. how do you use rewards and encouragement without increasing the “pressure” to talk? where can I get more info on specific goals that I can modify for my daughter (no access to a psychologist)? thanks!

Answer

EXCELLENT QUESTION! This is brought up often. First and foremost all pressure to speak needs to be removed. No mention of speaking, no asking your child if she spoke in school and to whom. Forget the word ‘talk.’

What your daughter needs is a behavioral treatment plan individualized to her needs. This plan will include ways to help your child MAKE progress. When she does you praise her for her efforts! You never tell a child she will be rewarded for speaking until she is well on her way to overcoming her SM and CAN speak in a situation. There are many ways to reward without mentioning speaking. i.e., for each time she gives her order in McDonalds she gets a sticker or star, for each time she answers the phone, she gets a sticker etc. See, there is no mention of speaking. Just subtly praising her.

Also, remember that the treatment of SM is not to get a child to speak. The treatment is to lower anxiety, build self-esteem and increase confidence in social situations. When this occurs, verbalization will automatically follow. 🙂

Dr. Elisa Shipon-Blum

I have reached a point of total frustration! My daughter is almost 7, in first grade. We have backed off the pressure to talk in school, allowing her to tape her assignments at home. She got very, very scared when I brought up having her tape them at school in her empty classroom as was suggested. So, I didn’t push it. Then she started having major meltdown tantrums after school. Anything would set her off. She kicks and screams and yells hurtful things (“I hate you, you are a bad mommy/daddy, no one likes me……..) after she cries for a bit, I grab her in a big bear hug and sit down on the floor with her and rock her and sing to her until she can catch her breath (she also hyperventilates during these). When she settles she will finally open up and tell me what is wrong. She is feeling isolated and alone at school and she thinks I’m not helping her anymore! So she decided I need to do something to help her. Since we haven’t found a doctor who has ever seen SM before I started giving her St. John’s wort to help with anxiety and I am going to make her start doing the taping with me at school later this week. I am in the process of working out the time with teacher, when we can have the class without teacher present. Anyway, she seems to want me to push her. Her original psychologist is very eager to have her back under his care, but he has never seen SM before and is interested only to increase his knowledge. I am not eager for her to be a guinea pig for him. But, I feel she may need meds and I would need a physician for that. I did find a MSW who had heard of SM before, but she was confident it was caused by abuse so I refuse to go to her. Help????? Background: K was diagnosed at 5 with SM. She talked a few times in kindergarten when she was kept after school and told she couldn’t go home until she talked. In first grade she started out talking and we goofed and praised her. She is in her words, “ready to talk but I just don’t know how”

Answer

You mentioned your daughter is on St John’s wart. Honestly, I am not an advocate of herbs in children. Truth is, Herbs are not adequately studied (as are pharmaceuticals ) and we simply do not know the exact mechanism and effects of the herbs. Because herbs work very nonspecifically you normally need quite a bit of herb to make a significant difference…this only leads to potential side effects. Although St John’s wart is used for Depression, I have seen individuals get anxious on St John’s wart. Perhaps your daughter’s tantrums and intense frustration is a direct result of the herb and increased anxiety. Tantrums, irritability, inflexibility, crying…etc are all anxiety effects. Please think about the use of herbs.

You mentioned going to a therapist. If the therapist or doctor does not understand SM, you should not go to them….if they have never dealt with SM, and are willing to learn and understand SM, you should consider them. As long as your practitioner is willing to learn and understand SM that is wonderful. We offer therapists the opportunity to learn about SM through our site. Encourage your practitioner to view our information.

Dr. Elisa Shipon-Blum

Our son was diagnosed at 5 years with SM. He saw a psychologist for about 6 months, but made no progress. She then referred him to a psychiatrist (Zoloft) and we had some limited progress (few words after school to teacher, spoke to his best friend). He went off meds due to side effects. Today, he is a happy, straight A student, plays on basketball, baseball, and soccer teams. Loves to play with his buddies, but he does this all without talking! He thinks it is perfectly normal and acceptable not to use speech to communicate because he does perfectly well without it. Any time we use the “talk” word, he becomes extremely upset.

Answer

Thank you for emailing us. I’m sorry to hear that your son is struggling with SM, but I’m happy he’s doing so well otherwise. Did your doctor try any other meds besides Zoloft? Prozac is often helpful for kids with SM. I’m also wondering if the psychologist specialized in treating childhood anxiety disorders. A therapist who does can often help an SM child make progress in small steps.

I would also stay away from talking about talking. Instead, focus on helping him communicate. If you can figure out where he is, communicatively, you can develop strategies to help him progress in the tiniest of steps. If he can’t order when in a restaurant, for example, have him point to what he wants or whisper it to you. It’s important to get him involved instead of just answering for him, but you have to get him involved where he’s comfortable and move gradually to the next step.

Dr. Lynn Lunceford, Clinical Psychologist

Answer

You are absolutely correct in not taking your child to the private psychologist who seems to have dealt with your son’s SM incorrectly. It is important that your son acknowledge his mutism, but in a positive and non-threatening manner. A suggestion would be to sit and talk with him during bedtime or other times you are alone. Have him RATE his scaredness in certain situations and even let him know that you TOO are scared of certain things. Share them with your son. Perhaps, have him rate his scaredness with heights of legos, blocks or by drawing pictures. Older children can write their thoughts and rate their anxiety in a journal. Using a feeling thermometer is also an idea that many have used.

Unfortunately, at this time we do not know of anyone in the Cleveland area who treats SM. Perhaps speak to your pediatrician and call your local children’s hospital. Be sure to interview the professional and get their view and approach to SM.

Dr. Elisa Shipon-Blum

My 4 year old daughter was selectively mute and since October 2001 has stopped speaking even within the family. She is going to therapy 2 times a week. I have seen improvement as she is now making sound words (Beep, Yuck, etc.) If I mention the fact that the expectation is for her to speak again she gets very upset and throws a tantrum. My doctor has encouraged me to not mention the speaking to her. What is your view on this? I do not want my child to think that I do not expect her to talk at some point in the future. She has become very comfortable with her pointing and made-up sign language to get her needs met. Thank you.

Answer

Before I answer this question, I am going to ask you to think of something that really, really scares you. Is it heights, being in a closed elevator, medical issues (cancer)? My point is, whatever scares you try to focus on the ‘feelings’ you get when you get scared. Then, understand that is what your daughter feels with speaking. Selective Mutism is a TRUE anxiety disorder that is incapacitating. Why your daughter stopped speaking at home is unknown to me. My experience leads me to believe that something ‘scared’ her and made her anxiety worse. i.e., Did you go away on a trip and she was separated from you? New baby? Increase pressure about speaking. In other words, if you daughter is NOT speaking at home, her SM is very, very severe and she has severe anxiety. Your approach needs to be to relieve pressure to speak 100%. Do not ask her to speak, do not let her know you are upset if she does not answer a friend or relative when they say hello.

Focus of therapy needs to be on lowering anxiety, not on speaking. From what you have said, ‘I do not want my child to think that I do not expect her to talk at some point in the future,’ it is obvious to me that you are implying to your daughter that she HAS to speak and you are not going to tolerate any other way. I can tell you that this approach is completely, 100% wrong. You need to take the ‘I understand you are anxious,’ approach and ‘I want to help you in everyway’ approach. You also want to praise her for her EFFORTS of trying to speak. Trust me, if she could speak, she would. Please try the following for 6 weeks: No talk about her talking., If she is mute, then so be it. If she uses sign language, accept it and see how this goes

Dr. Elisa Shipon-Blum

Answer

This is a very difficult question to answer without thorough knowledge of your daughter’s SM. The severity of her SM, level of independence, ability to handle new situations, is she going with friends, willingness to ‘want to go’ to sleep away camp are just a few questions I would need to know to adequately help you with this question. My initial instinct would be that sleep away camp would be VERY, VERY difficult for the average SM child – unless she has progressed with treatment to be able to ‘speak up’ when she needed to; for example, if she is feeling ill, has an emergency, gets lost, etc. I would not rely on a camp 24 hours a day, 7 days a week, to be able to take care of all your child’s needs and UNDERSTAND her SM. As you clearly know, dealing with an SM child can be quite frustrating. If it were my child, and she was severely SM and COULD NOT answer basic questions or SPEAK UP, I certainly would not send her to sleep over camp until I felt she could truly hold her own. I would worry that the anxiety created would cause a worsening of her condition.

Dr. Elisa Shipon-Blum

Answer

Yes, I remember your question quite well. I do not know your child, so I cannot say for sure whether her ‘lack of toilet training’ warrants medication. I do recommend that your treating professional work with you to figure out WHY she is not training. A question I have is, is she trained at home? If she REFUSES to go at home, there is more than just ‘SHY BLADDER/BOWEL syndrome.’ Again, I have not evaluated her, but believe that anxiety and constant attention (from others) about her TRAINING is making her more anxious.

A suggestion I have, is to lay low with the training for now. STOP talking about it for some time. If there is not a medical reason why she is not controlling her bowels/bladder you might want to just ‘let it go’ for a bit. Trust me, she will TRAIN when she sees others are not wearing diapers and going in their pants. She will not want to be embarrassed. Your constant attention to this is only making her more anxious. That is why I say to let it go for a bit and she how she does. My opinion is that when PRESSURE and ATTENTION is gone, she will train.

Our SM kids are quite controlling with their fears and anxieties. For whatever reason training has become a control issue (within herself) and she cannot seem to let it go. I recommend that you get therapy JUST for this. Dealing with SM is one thing, but this late of training is another issue.

YES, I believe medication would help her tremendously. However, it is your choice.

Dr. Elisa Shipon-Blum

I posted on the forum at the CAN site, but I also wanted to get your professional opinion about a problem we’re having. My son, A……, is 5 now and in Kindergarten. He’s been in “school” since he was 2 and was mute in school for the first 3 years. I am VERY happy to say that he is talking to his new Kindergarten teacher, even raising his hand in class! We’re very proud, and very thankful to you as well. You helped us back in Feb. with a treatment plan for him. Well, at the time, there were no “bathroom issues” with A…… Now there are many. He is wetting himself at school (and worse!) and it is also a problem at home. I’m just wondering if you think this is related to SM, because he is talking so well in school now. What do you think is going on? Thank you for any advice you can give.

Answer

I am thrilled that A….. is doing so well with his mutism! That is great!

A few questions that I have are:

1. Does A….. take medication for anything? If he does take medication, certain medications can cause this to happen in young children
2. Does A…… have BOWEL accidents as well? If does not, and urination is often, I would have him evaluated for a Urinary Tract Infection. Some of our SM kids develop kidney reflux from HOLDING it in so long (due to a variety of reasons- ‘shy bladder syndrome,’ not being able to ASK, etc.) As a result, they are more prone to Urinary Tract Infections.

If A….. is not on meds and does not have a UTI or any other medical issue, then I suggest working with a behavioral therapist to help him overcome this. Hope this has helped.

Dr. Elisa Shipon-Blum

Answer

We have no studies with the use of tricyclic medications and SM and bedwetting. As you know, imiprimine has anti-anxiety effects, so it is worth a try. My experience is that imiprimine does not work as effectively with anxiety and SM as does the SSRI’s. My experience is that as anxiety is lowered, the enuresis dissipates. I am not sure why this child has ‘wetting,’ but perhaps like other SM children, this child CANNOT ask to use the bathroom and over time has held it for so long that the sensation to ‘go’ has been altered a bit from holding in urine for so long. If it is nighttime issues, again, I have seen bedwetting dissipate when anxiety is lowered with behavioral therapy with or without SSRI therapy.

Dr. Elisa Shipon-Blum

Answer

Sounds like your son’s case of SM is very severe. From everything you have described (persistent SM at home, soiling in the past, severe separation anxiety) he has a very severe anxiety disorder. I am also concerned by his ‘behavior’. You did not describe, in detail, the characteristics of his negative behavior. But, it is not uncommon for anxious children to have co-morbid conditions… i.e., anxiety and conduct disorder. I would have a doctor evaluate him for ‘behavior’ disorders.

Many of the characteristics you have described can almost be classified as ‘obsessive compulsive’ another manifestation of anxiety. The fact that your son is so ‘obsessive and compulsive’ about not talking just goes to show you how controlled he is. Unfortunately the more severe the anxiety, the more pronounced the symptoms. I completely understand your frustration. I believe some of your son’s ‘acting out’ of bad behavior is due to his tremendous frustration over all of this. But, as mentioned a complete ‘behavior’ evaluation should be done. His mutism is not done maliciously or to ‘control’ you…but rather a manifestation of his severe anxiety. Very often, with severe anxiety, individuals need to feel some sort of control over their environment…in SM cases it is mutism.

You mentioned medication. I am curious as to how much Prozac, and then Paxil he was taking? I have had many patients who have been put on these medications by physicians, but did not show improvement due to too low of dosage. Also, if a physician did not SLOWLY titillate the dosage upwards…it is possible he was getting too high a dose too soon. With Prozac this could mean extreme hyperactivity and pronounced negative behavior.

I hope this information has helped you. I do believe your son needs further evaluation by a psychologist or physician. And, based on his severe anxiety manifestations, I would possibly consider medication again. There are a variety of different medications to choose from. One thought with your son may be LUVOX. This drug is approved for Obsessive Compulsive Disorder (type of anxiety) and may be a good choice for your son. Please keep us up to date on your son’s progress. I wish you the best of luck. You have a tough case to deal with.

Dr. Elisa Shipon-Blum

My daughter will be 5 in November. She has “mild” SM in that she speaks freely to peers, teachers aides (younger than teachers) and some friend’s parents. She does not speak to older teachers, grandparents, aunts and uncles, and most other adults. Also, she refuses to toilet train (has never and says she will never). We have been in therapy 3 months and the therapist wants to try Prozac during the next phase of treatment. We are concerned about her age and whether this is necessary. She seems very happy and relaxed as long as we don’t push her to verbalize or toilet train, but we do have to start pushing a little now and the therapist feels she would go very smoothly and quickly with the meds. We are inclined to wait and try some behavior therapy. Any advice? Thanks

Answer

I do not know the specifics about your child, but I can tell you from (a lot) of experience working with children in your child’s age range. Medication most definitely speeds the process. You mentioned that your child ‘does not seem anxious’ when you do not push her. However, children with SM do not necessarily LOOK anxious. Their mutism is a form of anxiety. If your child is MUTE, but looks comfortable, she is still anxious. You also mentioned that your child is not yet toilet trained. Although I am an advocate of ‘not pushing a child,’ your child is 5. Unless there is a medical reason (or psychological reason) there should be no reason as to why a 5 yr. old is still wearing diapers. ANXIETY can most definitely HALT toilet training progress. For many SM children who have had bathroom issues, medication has helped tremendously. Since the majority of children with SM have social anxiety, there is a condition called; ‘Paruresis,’ or shy bladder/bowel condition. We are learning that more and more children with SM and social anxiety have this disorder, which is a manifestation of social anxiety. Perhaps your child’s inability to train properly is partly due to Paruresis. Behavioral therapy and medication helps tremendously.

Dr. Elisa Shipon-Blum

My 15 year old daughter was diagnosed with SM at age 3. She has made much progress over the years with behavior modification. She now will speak when asked a question and will sometimes even ask the question. She has even given speeches at school. The problem is at present she has no friends. She had lots in elementary school but has found making friends in high school very difficult. She is not depressed and seems pretty content with things the way they are, but I’m concerned about her future. She has never tried medication.

Answer

Social withdrawal and isolation are an unfortunate side effect of untreated SM and social anxiety. Your daughter is a teen now. What does she say about her ‘lack of friends?’ You mention she is very content. If your daughter is unwilling to help herself there is little, if anything, that you can do to help her make friends. She needs to want to help herself.

If she wants help, I suggest you seek out a specialist who can help her with social anxiety. It sounds as if you have sought out help in the past. My advice would be to consider medication. Medication, such as Paxil, and other SSRI’s are excellent and help tremendously with social anxiety. However, be sure to use medication with a behavioral plan as well.

Dr. Elisa Shipon-Blum

Could you give me any advice to the best treatment plan for my 14 year old son? He is selectively mute in school and social settings, he has anxiety problems, and he is depressed in school, which is affecting his grades.

Answer

It seems that your son is manifesting the unfortunate ramifications of untreated anxiety; depression symptoms, falling grades, social withdrawal. He most definitely needs to be involved in treatment. Since I have not evaluated your son personally, I cannot make specific treatment recommendations. However, based on his age and debilitating symptoms, medication is a viable treatment approach WITH behavioral therapy to help him build the coping skills. Medication alone will help him to a point, it is the behavioral tactics that will help him build the necessary coping skills. Medication will enable for lowered anxiety, just enough, to do the behavioral tactics necessary to build the necessary coping skills.

Since over 90% of SM suffers have social anxiety, I will assume your son fits this profile. With this in mind, if you are unable to find a professional who understands SM, searching for a professional who understands social anxiety is an ideal choice. Focus of treatment behaviorally should be a combination of: Cognitive behavioral therapy using desensitization and positive reinforcement. Imagery and talk therapy also work well with our children. Goals of treatment should focus on helping your son communicate comfortably.

As mentioned in many other ASK THE DOC questions, building self-esteem is also crucial. Understanding SM as a communication anxiety will help you and your son understand the approaches that need to take place. i.e., is your son comfortable responding nonverbally? Initiating nonverbally? etc. In other words, your son’s individual characteristics will dictate the specific treatment tactics and techniques.

I also recommend that you read through the entire member site. There are many other ASK THE DOC questions that focus on your specific concerns. I cannot emphasize the importance of prompt treatment. With the symptoms your son is portraying, he needs treatment immediately.

Dr. Elisa Shipon-Blum

Answer

You bring up a very important issue! Thank you for this question. What you are describing is selective mutism. Whether it be adult or child, it is still mutism. Over 90% of the individuals who have SM also have social phobia. So, I am not at all surprised that you have been diagnosed with this.

Some of the research we are presently pursuing is the biological causes of SM. There are actual physiological reasons as to why you cannot talk! Did you know that when you are anxious, the muscles surrounding your vocal cords tense up??? Our theory is that with SM children, this is so severe that mutism is the result! SO, please understand that what is happening to you is not your fault, and although you are an adult, you still suffer from SM. The reason so many more kids have SM compared to adults is that many SM kids slowly develop some coping skills to deal with their mutism, and may end up as just severely socially phobic adults. If they had gotten proper help along the way, hopefully they would have overcome much of their social phobia and mutism as an adult.

In your situation, you should most definitely be receiving therapy, and I recommend medication as well. Medication does wonders for adults with severe social phobia. Good luck to you and keep us informed!

Dr. Elisa Shipon-Blum

What success rate is given to treating SM with the treatment starting with a child 15 years old? Would medication be the best way to treat SM at this age?

Answer

It is never to late too begin treatment for his Selective Mutism. Studies clearly indicate the earlier the treatment begins the better, but just as an adult can undergo successful treatment for an anxiety disorder, so can a teenager. As you know, Selective Mutism is primarily an anxiety disorder, so the means of treatment focus on treatment for anxiety.

I am assuming your child was already diagnosed by a professional; whether it was a psychiatrist, psychologist, pediatrician or family physician. Depending on the severity of your son’s condition, a treatment plan should be determined for him. The most common way to begin therapy would be in the form of behavioral modification (where your son’s selective mutism is gradually changed over time), i.e. if your son is mute in public places, we try to train him to “see himself ” talking in these places. Or we would give him specific goals of talking by using positive reinforcement.

Another form of therapy is cognitive behavior therapy (this is usually reserved for older teens and adults). This type of therapy focuses on re-training your son’s attitude towards specific anxiety provoking stimuli, i.e. if your son is mute in school, we try to get him to “realize” that school is a non-threatening place. Various techniques are used to encourage a more “cognitive” way of seeing a potentially anxious situation in a relaxing way.

Another popular way of treating Selective Mutism or anxiety is by using medication. The most popular medications used for Selective Mutism is the “selective serotonin reuptake inhibitors” (SSRI’s) such as Prozac, Paxil and Zoloft. This route of treatment is becoming more and more popular as studies are confirming safety and success with using this type of treatment.

A few words of advice: make sure to get your son into some sort of treatment immediately. The longer you wait, the more difficult it is to adequately treat, simply because a child/teen gets more and more set in their ways.

Dr. Elisa Shipon-Blum

When my Niece was fifteen years old a school psychologist wrote in her Individualized Education Plan that she has “selective mutism”. Although she accepted help in school with special education classes, she has always refused any treatment. She is now nineteen years old, out of high school, and very unsure of how to proceed in the world. What treatment is available for someone nineteen years old who has great difficulty expressing her needs to anyone? I know she is struggling and I would like to make helpful suggestions to her. She lives in New York City. Thank you for your consideration of my question.

Answer

As you probably know, most cases of Selective Mutism are due to severe social phobia. It sounds as if your niece was never really engaged in any treatment for SM or social phobia. My recommendation would be to see a physician or therapist who specializes in anxiety disorders for a formal diagnosis. They can also initiate treatment. Cognitive behavior therapy, performed by a trained therapist, is an excellent form of treatment for severe anxiety.

In addition, medication is used often for social phobia. The best approach for your niece would probably be a combination of medication and behavioral modification. I would investigate this if I were you. Your niece is not a small child, so you cannot force her to go for therapy. You can only make recommendations and encourage her.

Good luck!

Dr. Elisa Shipon-Blum