FAQ

Selective mutism (SM), formerly called elective mutism, is defined as a disorder of childhood characterized by an inability to speak in certain settings (e.g. at school, in public places) despite speaking in other settings (e.g. at home with family). SM is associated with anxiety and may be an extreme form of social phobia according to researchers and clinicians who are familiar with the disorder (Black & Uhde, 1995; Dow et al., 1995, Dummit et al., 1997, Kristensen, 2001; Leonard & Dow, 1995).

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, referred to by clinicians as the DSM-IV, (APA,1994) recognized that the social anxiety and avoidance characteristic of social phobia may be associated with SM, and thus, both diagnoses may be given. More than 90% of children with SM also meet the diagnostic criteria for social anxiety disorder, now termed social phobia (Black et al., 1996).

Diagnosis of other comorbid anxiety disorders are also commonly diagnosed with SM and social phobia (Biedel & Turner, 1998). The name change from “elective” to “selective mutism” in DSM-IV deemphasized the oppositional behavior connotation that a child elected not to speak and rather emphasized the characteristic of the disorder, that there are select environments in which speaking does not occur (APA, 1994). The term selective mutism is consistent with new etiological theories that focus on anxiety issues (Dow et al., 1995).

The current edition, DSM-IV-TR (APA, 2000) states that the following criteria must be met in order to qualify for a diagnosis of selective mutism:

An inability to speak in at least one specific social situation where speaking is expected (e.g., at school) despite speaking in other situations (e.g., at home); The disturbance has interfered with educational or occupational achievement or with social communication; The duration of the selective mutism is at least one month and is not limited to the first month of school; The inability to speak is not due to to a lack of knowledge of or discomfort with the primary language required in the social situation; and, The disturbance cannot better be accounted for by a communication disorder (e.g. stuttering) and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder.

Consistent with current research, SMA believes that Selective Mutism is best understood as a childhood social communication anxiety disorder. SM is much more than shyness and most likely on the spectrum of social phobia and related anxiety disorders. SM is NOT a child willfully refusing to speak.

Associated features of SM may include profound shyness, little eye contact, social isolation, fear of social embarrassment, withdrawal, clinging behavior, compulsive traits, negativism and oppositional behavior when attempting to avoid feared social situations, and temper tantrums, particularly at home. Since children are unable to communicate verbally, they may opt for using nonlinguistic cues such as gestures, nodding or shaking the head to get their messages across. A child may pull or push objects and obstacles, and in some cases, communicate in monosyllabic, short or monotone utterances or in an altered voice (APA, 2000). Some of these behaviors may not be present at the onset of SM. At the onset of SM, children may often stand motionless and expressionless due to anxiety and then slowly progress from nonverbal and non-communicative stages to communicative and verbal stages in treatment (Shipon-Blum, 2001). Some individual with social anxiety symptoms may also experience parureis, the fear of using public restrooms perhaps to fear of making sounds while urinating that others may hear (Stein & Walker, 2002).

There are a few ways to approach educating the other children about their classmate and/or SM, and this decision should be made on a case-by-case basis with input from the child/family. One option may be to read a story to the class featuring a protagonist with SM (e.g., Leo’s/ Lola’s Words Disappeared, Maya’s Voice, etc.) and talking about it in the context that the child in the story feels nervous about speaking in certain places. Its a great time to normalize anxiety in general– that while many of the students may not feel nervous about speaking in school, they may feel nervous about other things–like storms, or being separated from their parents, or taking a test. Such books could also lead to discussions about how students may help a classmate who does feel nervous about speaking in school by including them, not demanding them to speak, not making a big deal about it if they do hear the child speaking, and not speaking for the child. Depending on where the child is in terms of their symptoms, additional discussion about how to use choice questions to encourage speech (e.g., “During recess, would you rather swing or play tag?”) may also be appropriate. For some older students, there are several videos online explaining SM that may serve a similar purpose as the story but would be more developmentally appropriate to the audience.

One question school teams usually have in this process is “should we include the child in this discussion or should we do the story/video during a time that they are out of the class?” This is where the input of the child and their parents would come into play. Some kids with SM would be even more nervous being in the classroom, while others don’t mind at all and actually appreciate that their peers are learning more about them. It may be best to send home the book to be read with parents in advance so the child can “preview” the discussion so they can participate in the decision-making process.

It is probably also important to provide education on an individual level to specific kids who frequently interact with the child with SM. Usually, this is done on an incidental basis. If a teacher observes a classmate saying, “s/he doesn’t talk” or “s/he’s shy” or otherwise speaking on their behalf (e.g., “we like to play tag”), it is probably necessary to provide a gentle correction. Something like “Actually, our friend isn’t shy at all, but its hard for them to use their voice here at school right now” or “I can see that you want to be a good friend and that you’re trying to help ____ here by speaking for him/her. Its important to make sure we give him/her a chance to speak for themselves too! Just because s/he wanted to play tag yesterday doesn’t mean s/he will want to play tag today too.” Another situation that would likely require adult intervention would be if the child with SM did begin to speak at school in a limited way–e.g., with one friend on the playground– and the friend starts making a big deal about it (e.g., “___ just talked!! Say it again! Lisa, did you hear ____ just talked to me!!”) Something simple like, “I can see that its really exciting for you to have heard ___’s voice. I’m also very proud of ___ for being so brave here at school. Remember though, its important to not make a big deal about it because that may make ___ feel even more nervous” may be appropriate.

SMA offers a wealth of resources for parent use in informing professionals, teachers and others who interact with their child about selective mutism. We recommend that parents provide these resources to help educate others about SM. Family and Professional memberships with SMA also provide many opportunities for interaction with experts and experienced parents and teachers among other benefits to help educate yourself and others about SM. Advocacy for SM consists of educating oneself, educating others who interact with the child with SM, developing a plan to increase the child’s comfort and facilitate improvement at school and other social settings, and finding a treating professional who will help develop appropriate treatment and also serve as an advocate for the child.

Parents and professionals should remove all pressures and expectations for the child to speak. This conveys to the child that he/she is understood, that he/she is scared to speak and has difficulty speaking at times. Rest assured that most parents and professionals are “guilty” of using pressure or bribes with a child to encourage speaking before they learn more about SM, however, most report that removing these pressures and letting the child know that they understand has been the beginning of helping a child to overcome his/her symptoms.

DSM-IV-TR estimates that SM affects 1 in 1000 children referred for mental health treatment (APA, 2000). However, several researchers have suggested that the true prevalence of SM in the general population is largely underestimated (Bergman et al., 2002; Hayden, 1980; Hesselman, 1983; Kupietz & Schwartz, 1982; & Thompson, 1988). Recent studies show that SM is not as rare as it was previously believed to be but is comparable to other, widely known disorders of childhood. A study targeting a large sample of children in a Los Angeles, CA school district identified children who met the diagnostic criteria for SM and found a prevalence rate of 7.1 per 1,000 children (Bergman et al., 2002). A subsequent study in Israel found an almost identical prevalence rate (Elizur & Perednik, 2003). These numbers suggest that SM has a higher prevalence than autism (.5 per 1000), major depressive disorder (.4 to 3 per 1000), Tourette’s disorder (.5 per 1000), obsessive-compulsive disorder (.5 to 1 in 1000) and other well-known disorders. In comparison to other studies, which only accounted for diagnosed cases of SM, provides evidence that a large number of individuals with SM are undiagnosed or misdiagnosed. Parents of children with SM who enter treatment often report that their child was misdiagnosed with autism or another pervasive developmental disorder, mental retardation or oppositional-defiant disorder. Most are told (if anything) by uniformed professionals that there is nothing wrong with their child, that their child is “just shy,” or will grow out of this behavior. Thus, the lack of awareness among educators and treating professionals leads to delays in diagnosis and missed opportunities for treatment.

SM is slightly more common in females than in males. Although the duration of SM often lasts for several months, left untreated, it may sometimes persist longer and may continue for several years (APA, 2000). The average age of onset is 5 years, even though most parents report that their children’s symptoms began years earlier (Leonard & Dow, 1995). In his treatment of children with SM, Thompson (2000) found that children who establish speech in previously mute settings before age eight typically become verbal in school and social settings within one year. Children who demonstrated longer-term mutism were likely to continue their silence into upper grades and into adulthood (Thompson, 2000). While reports of older children and adolescents with SM are scarce, based on our collective clinical experience, individuals who to enter into treatment later may suffer from depression and other disorders in addition to SM but can make treatment gains and overcome SM without it continuing into adulthood.

Shyness is a normal personality trait. It is marked by a voluntary tendency to withdraw from people, particularly unfamiliar people. Everyone has some degree of shyness; it may be experienced a lot, a little bit or somewhere in between. Shyness, like other inheritable traits, such as height and eye color, is largely influenced by genes (Stein & Walker, 2002). Shyness is not a psychiatric disorder like SM, social phobia and avoidant personality disorder which all characterize different forms of extreme inhibition that interferes with a person’s daily functioning. People who are shy are able to function adequately in society. Shyness may fluctuate and change as a person matures and encounters new social challenges without treatment (Carducci, 1999). People with psychiatric disorders such as SM do not adapt well to social situations nor are they able to communicate effectively with others. They may have limited academic and occupational achievement and require treatment in order to overcome their symptoms and function at an adaptable level.

A trained professional familiar with SM and/or childhood anxiety disorders will generally begin by conducting a thorough assessment to accurately diagnose the condition, rule-out similar or comorbid conditions, and formulate a treatment plan. Information will be gathered about the child’s developmental history (including achievement of developmental milestones and whether or not there were any delays in hearing, speech and motor and cognitive development), family history (including determining whether or not other anxiety disorders are present in the family), behavioral characteristics, medical history, and significant stressors (including divorce, frequent moves or a death in the family). The treatment professional may also request permission to contact the child’s school, physician and other significant players in the child’s life to gain further information about the child’s behavior in other settings. It can also be helpful for the professional to view a videotape of the child in a comfortable setting and/or do an observation of the child before the child has met the professional so that the child’s behavior will not be influenced by the professional’s presence.

The professional will then arrange to meet with the child. While most children with SM will not speak to the treating professional, some may be comfortable in the treatment setting and speak normally, although this behavior does not rule out selective mutism. The “selective” nature of the mutism varies from child to child and setting to setting so this needs to be considered in conducting a thorough assessment. It is important that the professional develops rapport with the child and evaluates his/her behaviors, preferably in more than one setting. An appropriate professional will be able to interact with the child whether or not he or she is speaking and use appropriate methods to begin to develop a therapeutic relationship.

Because some children with SM may have difficulties with expressive language or other communication disorders, a speech and language evaluation might also be necessary. In addition, a physical exam (including testing of hearing), standardized testing, psychological assessment and developmental screenings are often recommended, especially if the diagnosis is not clear.

The use of medication is based on the understanding that SM is related to social anxiety and there are medications that have been shown to help social anxiety disorder (or social phobia) in adults. In recent years, it has become clear that anxiety problems are related to an imbalance in some of the chemical messengers, or, neurotransmitters, of the brain. In particular, the neurotransmitter called serotonin seems to be involved.

Antidepressant medication in the form of serotonin reuptake inhibitors (SSRI’s) such as Prozac, Paxil, Celexa, Luvox and Zoloft are often prescribed in the treatment of anxiety disorders. In addition to the SSRI’s there are other medications that affect several of the neurotransmitters instead of just serotonin. Examples are Effexor, Serzone, Buspar and Remeron. Although none of these medications are approved by the food and drug administration (FDA) for use in treating SM in children, it is common for doctors to prescribe medications when there is reason to believe that they are safe and effective for a particular use.

There are several small-scale studies that have shown these types of medications to be effective in the treatment of SM. Of the few experts who have treated large numbers of children with SM, most report that these medications are very helpful and have a large margin of safety. Side effects are minimal and can usually be avoided by starting the medication at a very low dosage level and increasing it very gradually. Many children with SM seem to respond to a very low dosage of these medications so there is no need to keep increasing to higher levels. When combined with appropriate behavioral or cognitive-behavioral therapy, the treatment success rates are dramatically higher.

When medication is used as part of a treatment plan, the goal is usually to have the child take the medication for 9-12 months. This seems to be a sufficient time period to allow the child to decrease anxiety, become accustomed to speaking in most settings and for treatment gains to be maintained after the medication is stopped. When it is time to discontinue medication, it should always be tapered off slowly under a doctor’s supervision to avoid adverse side effects that can occur if medication is decreased too quickly.
When should I use medication in my child’s treatment?

The decision about whether or not to use medication should be made by consulting with a doctor who has experience using the recommended medications with children. The choice is also dependent on parents’ comfort level. Parents are encouraged to become as educated as possible about the types of medications used for SM and other treatment options by asking many questions of their providers and reading the available literature in order to make an informed decision.

Medication is not always necessary in the treatment of SM but in many cases it appears to be very useful in helping the child to take the first steps in overcoming their anxiety. Until anxiety is lowered to a tolerable level, most children will have difficulty accomplishing even small goals toward speaking. This is especially true in cases in which the child has exhibited the SM symptoms for a long period of time, other available treatments have not helped the child to make improvement, or in cases where the child is also showing symptoms of depression. Medication is more likely to be prescribed in such cases where the mutism is more severe or chronic (such as with older children and adolescents).

Research-based treatments found effective for Selective Mutism

Some of the following information is excerpted from: Cohan, S.L., Chavira, D.A., and Stein, M.B. (2006). Practitioner Review: Psychosocial interventions for children with selective mutism: a critical evaluation of the literature from 1990–2005. Journal of Child Psychology and Psychiatry 47:11, 1085–1097.

Treatment for Selective Mutism can include psychotherapy and medication to address the anxiety that underlies the person’s inability to speak in certain situations. Some children with Selective Mutism also benefit from speech-language therapy, occupational therapy, sensory-integration therapy, and other interventions that may be recommended by the main treatment provider(s).

In psychotherapy, a psychologist or other professional will use some of the following approaches, depending on the individual child:

Behavioral and Cognitive-behavioral (CBT) strategies are the most widely supported psychological treatment for Selective Mutism.

Behavioral strategies: This refers to coming up with a step-by-step plan where the child gradually does more and more difficult speaking-type behaviors, as well as coming up with a system of positive reinforcement whenever the child is able to accomplish those behaviors.

There are several behavioral strategies. They are most effective to support the child to make and maintain gains in speaking when they are used together:

• Contingency management involves positive reinforcement of (or rewarding for) verbal behavior with initial reinforcement of nonverbal communication like pointing and whispering
• Shaping reinforcement is provided for approximations of the target verbal behaviors (e.g., mouthing words, whispering, talking on the telephone) and later for normal speech. A reinforcement menu (what types of rewards the child wants to earn and for what behaviors) is first developed in collaboration with the child.
• Stimulus fading interventions build on the success of contingency management and shaping by gradually increasing the number of people and places in which speech is rewarded. For example, the child may first be rewarded for speaking to a classmate to whom s/he already speaks outside of school. Gradually, other students are introduced into the group until the child is able to speak in the presence of a large group of peers. Stimulus fading can also be used in problematic situations that occur outside of school (e.g., talking to grandparents, ordering in fast food restaurants).
• Systematic desensitization traditionally involves the use of relaxation skills along with gradual exposure to successively more anxiety-provoking situations. In this type of intervention a hierarchy of feared speaking events is constructed and therapy consists of a series of imaginal and in vivo (real-life) exposures to feared situations.
• Social skills training may also be used to reduce anxiety and facilitate speech with peers and involves learning what to say to initiate conversations, how to take turns, making eye contact, and learning how to understand another person’s nonverbal behavior.
• (self-)modeling involves making video and/or audiotapes that have been edited to depict the child speaking in settings in which he or she has previously remained mute. The tapes are played repeatedly throughout the intervention, with the expectation that the child will become accustomed to hearing him- or herself speaking in these settings and will begin to believe in his or her ability to do so.

Cognitive strategies: This involves identifying anxious thoughts that contribute to the mute behavior. Introducing cognitive strategies is most useful for children age 7 and older, when they have developed the ability to become aware of their thoughts. Techniques include recognizing body symptoms of anxiety, identifying and challenging maladaptive beliefs, and developing a coping plan to deal with distress. For example, many selectively mute children have anxious thoughts or worries that people will make fun of their voice or what they want to say. Cognitive therapy teaches the child to understand that those thoughts are the product of worry (and are not real threats) and to coach themselves by telling themselves positive thoughts instead. Cognitive strategies should be added to behavioral strategies at a point in time determined by the treatment provider.

Other therapies commonly used alongside the behavioral or cognitive-behavioral treatment above, while not necessarily researched or supported by research as yielding gains in children with SM, are aimed at increasing the child’s self-esteem to strengthen the child emotionally by reinforcing areas of competence, belonging and acceptance as he/she completes the difficult work involved in these behavioral and cognitive-behavioral therapies. These may include learning new skills and/or encouraging participating in sports, music, arts, etc.

Medication

A medical doctor (psychiatrist, pediatrician) can prescribe medications that address the anxiety that underlies the child’s inability to speak in certain situations. Medications are most effective when combined with behavioral and/or other psychological strategies above, especially to help the child maintain gains in communication over time. In particular, the SSRI (selective serotonin reuptake inhibitors) have the most evidence for being useful in youth with anxiety conditions.

Speech-Language Therapy

The following is excerpted from Speech-Language Therapy and Selective Mutism. Contributed by: Evelyn R. Klein, PhD, CCC-SLP, BRS-CL and Sharon Lee Armstrong, PhD. For the full article see: http://144.208.78.72/~select79/resources/library/Speech%20and%20Language%20Issues/Speech-Language%20Therapy%20and%20Selective%20Mutism/view

Speech-language pathologists (SLPs) may contribute to the treatment benefits of children with selective mutism (SM), as speech and/or language impairments can co-occur with SM. In addition, SLPs are trained in working with pragmatic language that is greatly impacted by children with SM. For these children, simultaneous treatment using both behavioral strategies to help children feel more comfortable to speak and linguistically-based activities to foster language development are recommended. SLPs often follow a behavioral approach of setting goals with gradual increases in expectations. For example, The Ritual Sound Approach® (RSA) that is a component of Social Communication Anxiety Treatment (S-CAT) by Dr. Shipon-Blum (2010) has had good success in helping children communicate with greater ease. The behavioral technique of shaping is used to help modify and shape specific phonemes into blended sounds that represent real words. This approach starts with voiceless speech sounds that require less vocal effort in that they don’t engage the vocal cords. Children feel air move in and out of their mouths as they breathe, blow, and cough. Thus, voiceless speech sounds such as /h/ (similar to breathing), /k/ (similar to a cough), /s/, /t/, /p/, etc. are used because they are less audible than vowels or voiced consonant sounds such as /z/, /d/, /b/, /g/, etc. This behaviorally-based treatment helps the child think of sound-making from a mechanical standpoint (e.g. put lips together lightly, build up air pressure in the mouth and puff out air to produce the sound of /p/).

SLPs may also use augmented self-modeling, a technique that has promise for reducing anxiety when speaking (Kehle, Bray, Byer-Alcorace, Theodore, & Kovac, 2011).The child watches videotaped segments of herself or himself during a positive verbal interchange (often at home) and then visually (through playback) carries the communicative interchange into another setting that is often more challenging. Using video software, the child can get a virtual glimpse into communicating successfully in a setting that causes heightened anxiety. In many instances coordinating voice and speech while thinking of what to say (linguistically) becomes difficult for children with SM due to anxiety. Therefore, non-speech tasks may be used to help the children gain control of voicing. Once vocal control in non-speech tasks is adequate then speech can be introduced slowly and systematically to allow for success. A typical progression is as follows:

• Communicate by pointing, gesturing, or nodding (use games, toys, and age-appropriate projects)
• Communicate by drawing or writing (use games requiring these modalities)
• Talk through a recording device that is played when out of the room and then when in the room (as comfort increases)
• Talk to another person who speaks for the child (in front of others with increasing distance from the person’s ear)
• Talk to others using sounds (may be blended to form words)
• Talk to others using rehearsed or scripted language with and without visual prompts (develop charts to play guessing games – include phone as possible)
• Talks spontaneously using words or phrases (including phone)
• Talks spontaneously using sentences (including phone)

Children with SM who present with a language delay may benefit from treatment that includes basic vocabulary development, grammatical morpheme development, and work on sentence structure. For many children with SM, the goal will be to enhance social-pragmatic communication with work on enhancing descriptive language (vocabulary and describing), expository language (informing and explaining), narrative language (storytelling), and discourse for social communication (discussing and interacting).

SLPs may first work on nonverbal skills of social engagement and later include communication skills in joint activity routines. Speech articulation therapy may also be part of the treatment protocol for children who have speech production errors, either sound substitutions, distortions, omissions, or additions.

It should be noted that some children with SM believe they cannot speak in some settings and so they may not properly engage their respiration, voice, or articulation appropriately. Children with SM can get accustomed to not speaking and thereby assume the self-image of the child who does not talk (Omdal, 2007). This self-fulfilling prophecy is one that can persist without appropriate intervention. The earlier the intervention, the better!

Kehle, T.J., Bray, M.A., Byer-Alcorace, G.F., Theodore, L.A., & Kovac, L.M. (2011). Augmented self-modeling as an intervention for selective mutism. Psychology In The Schools, 49(1), 93-103.

Omdal, H. (2007). Can adults who have recovered from selective mutism in childhood and adolescence tell us anything about the nature of the condition and/or recovery from it? European Journal of Special Needs Education, 22(3), 237-253.

Shipon-Blum, E. (2010). Transitional stage of communication. Retrieved from Missinglink.pdf

Yes. Response rate to treatment for SM is inversely proportional to age. In other words, when any kind of appropriate therapy is begun at an early age, response is much quicker and greater. In his treatment of children with selective mutism, Thompson (2000) found that children who establish speaking in previously mute settings before age eight typically become verbal in school and other social settings within one year. The older a child is, the more he/she has become accustomed to the nonverbal behavior and the more difficult it is to change. This is why SMA advocates for early diagnosis and treatment.

Long-term effects of SM into adulthood have not been studied. However, there is some research indicating that untreated cases of social anxiety can develop into other problems including depression, avoidant personality disorder, and substance abuse problems; thus, the notion that people will outgrow SM on their own is a myth. Treatment of SM and social phobia (social anxiety disorder), however, has produced adults that are successful in society. SMA has drawn a few adults from throughout the nation who represent such success stories, including adults who have established careers as teachers and treating professionals and parents who have become strong advocates for their children.

If you have further questions regarding selective mutism, SMA members are encouraged to submit a question to Ask the Expert. In addition, it is advised that parents and professionals seek the help of treating professionals with knowledge of SM and/or related anxiety disorders.

Those with SM experience anxiety related to speaking and sometimes they may also be unable to make eye contact, nod their heads, point or make other nonverbal forms of communication when in a social situation that provokes anxiety. SM may be an extreme form of social phobia. Social anxiety and avoidance characteristic of social phobia may be associated with SM, and thus, both diagnoses may be given. More than 90% of children with SM also meet the diagnostic criteria for social anxiety disorder, now termed social phobia (Black et al., 1996). Diagnosis of other comorbid anxiety disorders is also commonly diagnosed with SM and social phobia (Biedel & Turner, 1998). The name change from ‘elective’ to ‘selective mutism’ in DSM-IV deemphasized the oppositional behavior connotation that a child elected not to speak and rather emphasized the characteristic of the disorder, that there are select environments in which speaking does not occur (APA, 1994). Thus a child’s reluctance to speak and engage socially should not be interpreted as an oppositional behavior but as avoidance due to anxiety. The term ‘selective mutism is consistent with new etiological theories that focus on anxiety issues (Dow et al., 1995).

The current edition of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, or DSM-IV-TR (APA, 2000), states that the following criteria must be met in order to qualify for a diagnosis of selective mutism:

(a) An inability to speak in at least one specific social situation where speaking is expected (e.g., at school) despite speaking in other situations (e.g., at home);
(b) The disturbance has interfered with educational or occupational achievement or with social communication;
(c) The duration of the selective mutism is at least one month and is not limited to the first month of school;
(d) The inability to speak is not due to a lack of knowledge of or discomfort with the primary language required in the social situation; and,
(e) The disturbance cannot better be accounted for by a communication disorder (e.g. stuttering) and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder.

A diagnosis of SM can only be made by a treating professional qualified to diagnose mental illness. While many parents and professionals unfamiliar with SM may identify many of the symptoms in their children, a formal diagnosis should be obtained to confirm that SM is present and not better accounted for by other disorders that also include the lack of speech as a presenting symptom.

Observation and clinical accounts of the behavior of children with SM are varied. It is important to realize that the majority of children and adolescents are as normal and appropriate as their peers when in a comfortable environment. Parents will often comment about how boisterous, sociable, humorous, inquisitive, talkative and even bossy and assertive these children are at home. However, what differentiates children with SM is their severe behavioral inhibition and inability to speak in certain social settings. When in these settings, children with SM feel as if though they are continuously “on stage” and experience many of the same symptoms that people have with stage fright. Some children with SM also report somatic complaints such as nausea, headaches, and stomachaches or may experience vomiting, diarrhea and an array of other physical symptoms before school or outings.

When in school or in other anxiety provoking settings, some children become much more withdrawn that others and may stand motionless and expressionless and may demonstrate awkward or stiff posture and body language. They may experience a great deal of emotions including anxiety, sadness and frustration but may not express these emotions visibly and some children have even been too inhibited to express feeling pain when injured on the playground. Many children with SM will turn away or hang their head to avoid eye contact, chew or twirl their hair or withdraw into a corner. Over time, some children learn to cope and participate in certain social settings by performing nonverbally or by talking quietly to a select few. There are also variations in the degree of outward anxiety or nervousness. Some children display facial expressions and body language that are obviously due to fear or nervousness. Others may appear outwardly calm and may be able to communicate nonverbally. It is the latter type of child that is most often misinterpreted as being defiant or oppositional since they do not show visible signs of being nervous.

Children with SM tend to have difficulty initiating and may be slow to respond even when it comes to nonverbal communication (e.g., pointing, nodding, shaking head no). This can be quite frustrating to the child and may lead to falsely low test scores and misinterpretation of the child’s cognitive abilities. It is for these reasons that assessment should be conducted by someone familiar with anxiety and how it may manifest in performance situations such as taking a test.

Social relationships can be very difficult for children with SM although some are well liked by peers. In many cases, classmates tend to take on a protective role and/or try to speak for the child with SM. Even for those fortunate enough to have supportive peers, there is no doubt that SM stifles social growth and development and limits social interaction. In worse case scenarios, some children are socially isolated, are victims of teasing and bullying and are completely unable to defend themselves. This seems to be more of a problem for older children and bullying may be more common for boys with SM than for girls.

No. Older children and adolescents also benefit from treatment. In fact, those who have had symptoms of social anxiety into adulthood have also been helped with treatment. Left untreated, SM is likely to persist into the upper grades of school and into adulthood (Thompson, 2000). Studies of adults with untreated social phobia (or social anxiety disorder) indicate that they are prone to developing more severe problems such as depression, suicidal ideation, substance abuse, limited occupational or educational achievement, avoidance and impaired social relationships. Social phobia also often co-occurs with other disorders, thus, older children and adolescents with SM may have other symptoms and diagnoses including depression, panic disorder, obsessive-compulsive disorder, and generalized anxiety disorder (Biedel and Turner, 1998). It is important that the child/adolescent receives an assessment to rule-out other problems that may be present along with SM. When in treatment, the child or adolescent will have a far greater opportunity to overcome his/her problems and be successful in adulthood.

The prognosis for children and adolescents who are treated for SM appears to be excellent. With appropriate treatment, SM is often overcome successfully. Without treatment, however, SM is more likely to persist and comorbid symptoms in addition to SM are common. Longitudinal studies showing the course of SM following treatment are needed, however, in clinical settings, most children with SM show significant improvement.

The average age of diagnosis is between 3-8 years when the child enters school and the non-speaking behavior becomes problematic (APA, 2000). However, many parents will say that their child displayed signs of excessive shyness and/or inhibition since infancy. Once a child enters school there is increased expectation to perform, interact and speak and SM becomes apparent. It is at this time that teachers will point out the severity of the problem including concerns that the child is not speaking and participating in activities.

SMA recommends that treatment be sought as soon as it is suspected that a child may have selective mutism (SM). It is especially important to seek help when it is clear that a child is having difficulty engaging in social situations, seems out of step with his/her peers, and is experiencing adverse consequences such as having difficulty adjusting to school, difficulty with social relationships or co-occurring symptoms such as depression. Treatment is not indicated during the first month of school when a child is adjusting to entering preschool or Kindergarten for the first time, as this behavior is developmentally appropriate for young children who are not yet familiar with the school routine and being around other adults and children. If the selectively mute behavior continues beyond the first month of school, however, a treatment should be considered.

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Research studies on SM are scarce. Most articles and textbooks descriptions are based on subjective findings of a very limited number of children. In some cases, medical and educational professionals have not been taught anything at all about SM and in other cases they have been given very little training on SM and even inaccurate and misleading information on the subject. When confronted with a child with SM, doctors, teachers and other professionals will often tell a parent that the child is just shy or that he/she with outgrow the behavior. Other professionals incorrectly interpret mutism as oppositional or defiant behavior where mutism is a means of manipulation and control. Still other professionals view SM as a variant of autism or an indication of severe learning disabilities. This misunderstanding leads to misdiagnosis and ineffective treatment strategies, as SM is best viewed as an anxiety disorder.

The diagnostic manual most widely used by treating professionals is the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, now in a Text Revision (APA, 2000). Of all the anxiety disorders, selective mutism and separation anxiety disorder are the only two listed in DSM-IV-TR under “Disorders Usually Diagnosed in Childhood.” All of the anxiety disorders listed in the “Anxiety Disorders” section, however, may also be applied to children. There is much more research available on the anxiety disorders classified as such in the DSM. Also, due to the current classification system, a clinician is less likely to encounter SM in the manual if they suspect anxiety in a child, as it does not fall into the anxiety category. To make SM even more isolated in the classification system, it is listed in a smaller sub-category of the childhood section of DSM called “Other disorders of Childhood.” This classification does not clearly suggest that SM is associated with anxiety, only that it is a childhood problem associated with not speaking. Thus, further research and education is needed to help more teachers and treating professionals to understand the symptoms of selective mutism, its association with social anxiety, and its treatment as an anxiety disorder.

The understanding of SM as an anxiety disorder related to shyness, social anxiety and inhibited temperament has increased in popularity over the last decade. Reports of children with SM indicate that most are shy, inhibited and anxious. These reports combined with clinical experience suggest that SM may be the manifestation of an inhibited temperament, or inborn personality of mood (Dow et al., 1995). There is some evidence that there is a genetic link between children with SM and anxious parents or family members. Most commonly, social phobia, avoidant personality disorder, and parents with a history of SM themselves were more prevalent in families with a child with SM than those without (Black & Uhde, 1995; Chavira et al., 2005; Kristensen, 2001). In addition, most children with SM also have one or more other anxiety disorders, especially social phobia (Black & Uhde, 1995; Dummit et al., 1997). Other common comorbid anxiety disorders include separation anxiety disorder, generalized anxiety disorder and specific phobias (Dummit et al., 1997).

Behaviorally inhibited children may also have a decreased threshold of excitability in the almond-shaped area of the brain called the amygdala. The amygdala receives and processes signals of potential threat and sets off a series of reactions that will help individuals protect themselves. In anxious individuals, the amygdala seems to overreact and set off these responses even when the individual is not really in danger. In the case of SM, the anxiety responses are triggered by social interactions and settings where speaking is expected including school, the playground or social gatherings. Although there may be no logical reason for the fear, the feelings that the child with SM experiences are just as real as if an actual threat or danger were present.

Other factors may also contribute to the development of SM. A significant number of children with SM also have expressive language disorders and some come from bilingual family environments (Kristensen, 2000; Elizur & Perednik, 2003). While these factors do not cause SM, they can contribute to a child’s anxiety with speaking. The child may become more self-conscious about his or her speaking skills and may have increased fear of being judged negatively by others.

A stressful environment may also be a risk factor in the development and maintenance of SM. Although earlier reports of SM suggested that a history of abuse and trauma may be associated with the development of SM, there is no evidence that there is a causal relationship between trauma and SM (Black & Uhde, 1995). However, if significant stressors are present, they may contribute to the SM by exacerbating the child’s already present anxiety.