Understanding Selective Mutism
Brochure

A Silent Cry for Help!
© Copyright

What is Selective Mutism?

Selective Mutism is a psychiatric disorder most commonly found in children, characterized by a persistent failure to speak in select settings, which continues for more than 1 month. These children understand spoken language and have the ability to speak normally. In typical cases, they speak to their parents and a few selected others. Sometimes, they do not speak to certain individuals in the home. Most are unable to speak in school, and in other major social situations. Generally, most function normally in other ways, although some may have additional disabilities. Most learn age-appropriate skills and academics. Currently, Selective Mutism, through published studies, appears to be related to severe anxiety, shyness and social anxiety. Selective Mutism may be associated to a variety of things, but the exact cause is yet unknown.

These children may respond, or make their needs known, by nodding their heads, pointing, or by remaining expressionless or motionless until someone correctly guesses what they want. The majority of these children express a great desire to speak in all settings, but are unable to due to anxiety, fear, shyness and embarrassment. Many do participate in activities non-verbally. The withdrawn behavior is not usually obvious until the child begins school. Sometimes, even then, the child is viewed as shy and it is assumed that the shyness is temporary and will be outgrown. By the time Selective Mutism is recognized, if it is recognized, the child has usually experienced at least 2 years in which no verbalization has become a way of life. The behavior becomes increasingly difficult to change because of the lapse of time without intervention.

How Did Selective Mutism Get its Name?

Selective Mutism was first reported by a German physician, Kussmaul, in 1877. He described physically normal children who developed mutism in certain situations. He called the condition “Asphasia Voluntaria”, meaning voluntary mutism. Later, an English physician, Tramer (1934) described several similar cases and coined the term “Elective Mutism”. He suggested that this term be used to classify children who spoke only to certain people, (e.g. family members or close friends), but not to others. It is our opinion that the word “elective” is suggestive of a preference; therefore the term implies a deliberate decision not to speak. As previously noted, through our efforts, the term was changed to Selective Mutism in the DSM IV (1994) to imply a less oppositional or willful component. Accordingly the Foundation name has been changed to “Selective Mutism Foundation, Inc.” (1993).

What are the First Symptoms of Selective Mutism?

The first symptoms of Selective Mutism are usually noticeable between the ages of 1 to 3 years. These symptoms may include shyness, a reluctance to speak in some settings, and a fear of people. Although there may be a predisposition to Selective Mutism at birth, the symptoms become obvious when the child is requested to respond verbally and/or interact in social situations, including preschool, elementary school and community environments.

Is Selective Mutism Caused by Abuse?

Fortunately, current research has discarded this theory. However, due to the misunderstanding and misdiagnosis of the symptoms some parents have been suspected or accused of child abuse. Sexual abuse has been suspected as well. The Selective Mutism Foundation, Inc. wishes to emphasize the vital need to clarify these unjust assumptions. The suspicion or accusation of parental child abuse is devastating and has caused tremendous grief and deterred many families from seeking help for their children. There is always a possibility that some children who have been abused do not speak. However, the abuse may not be specific to immediate family members, but could occur from any adult; or even other children. We advise contacting the appropriate agencies only if there is a definite indication of abuse.

What Causes Selective Mutism?

The cause has not been established. Recent systematic research studies suggest the possibility of a genetic influence or vulnerability for Selective Mutism. The majority of families who have contacted the Foundation have described either themselves or other family members as previously or currently experiencing Selective Mutism, extreme shyness, social anxiety, or other anxiety disorders.

How is Selective Mutism Diagnosed?

The crucial diagnostic element is that the child has the ability to comprehend spoken language and to speak normally, but usually fails to do so in select settings. These children will display reasonably appropriate verbal and interactive skills at home in the presence of a few individuals with whom they feel at ease. The term Selective Mutism should distinguish individuals who demonstrate selectivity with whom they speak and are comfortable with, from individuals who speak to no one. Populations, which should be excluded, are immigrants who speak another language, have no history of the disorder, and experience Selective Mutism for a short period of time, and those who suddenly and temporarily stop speaking due to a traumatic event. In these cases the mutism is usually transient.

Do Individuals Experiencing Selective Mutism Have Associated Behaviors?

Yes. Associated behaviors may include no eye contact, no facial expression, immobility, or nervous fidgeting when confronted with general expectations in social situations. These symptoms do not indicate willfulness, but rather an attempt to control rising anxiety.

Some may withdraw by pulling back when approached or touched and exhibit different forms of body language. In many cases the body language has been misinterpreted as abuse, however, we have found that these behaviors stem from anxiety. Based on responses to the Foundation, we suspect that some may have Obsessive-Compulsive Disorder (OCD) or Tourette Syndrome type symptoms, and a variety of phobias as well.

Is There a Relationship Between Selective Mutism and Autism?

No. Selective Mutism is sometimes erroneously mistaken for Autism. The striking difference between the two is that Autistic individuals have limited language ability, while individuals experiencing Selective Mutism are capable of speaking and normally do so in comfortable situations.

What is the Diagnostic and Statistical Manual of Mental Disorders (DSM IV)?
How has the classification of Selective Mutism in the DSM IV affected diagnosis and treatment? The DSM IV is the most widely used diagnostic reference book utilized by mental health professionals in the United States . The DSM is usually revised at 10 or more year intervals. Due to the lack of research on Selective Mutism, the diagnostic criteria had to be ascertained by examining existing publications. The previous available publications presented various theories, many of which described children experiencing Selective Mutism as refusing to speak, and displaying controlling, manipulative, oppositional, and angry behaviors. Due to this, as we perceive, mischaracterization of Selective Mutism children, Selective Mutism’s association
with anxiety had been neglected, and parents had been frequently blamed for causing Selective Mutism.

The efforts of this Foundation, including providing research participants for published, legitimate scientific studies was instrumental in influencing important changes, including improved diagnostic guidelines and renaming the disorder from Elective Mutism (DSM III and DSM III-R) to Selective Mutism 313.23 in the DSM IV (1994). Another important change brought about by our efforts resulted in replacing the term “refusal to speak” with “failure to speak”; thereby eliminating the notion that non-verbalization is intentional.

How is Selective Mutism Treated?

Behavior management programs based on the treatment of phobias have proven to be somewhat successful. Techniques should be consistent, and should include desensitizing the child by providing short-term goals, positive reinforcement, and rewards to motivate the child to speak. Pressure, including punishment, bribery, or consequences are harmful. One-word responses should be elicited at first, with gradual requests for more. After extensive treatment, some have been able to speak spontaneously in some, if not all social situations.

Various medications, known to be effective in treating adults with anxiety and/or social anxiety have been effective for many children, usually in conjunction with behavioral treatment. Several articles, which provide behavioral strategies, can be found in major libraries and journals that publish studies.

Is Selective Mutism Limited to Children?

No. Some children do experience Selective Mutism for short periods of time while others experience this problem for many years. Based upon some literature and individual responses to the Foundation, Selective Mutism can be a persistent disorder, which can become intractable over time. Some adults report they are still struggling with symptoms of Selective Mutism, while others have overcome it. Many adults, who now able to speak socially, report having one or a combination of anxiety, depression and panic attacks.

When Should Selective Mutism be Treated?

There are 2 chief factors in determining when treatment is necessary, age and severity. If the mutism persists for more that 2 months, or another dominant language is not interfering, and if there are no verbal responses at all, treatment should begin immediately. For the child who exhibits mild symptoms, such as responding in a soft voice, and interacts with others, treatment may not be necessary unless the symptoms continue for many months. It is sometimes difficult to know if or when to intervene, as there are variant degrees of the disorder. Many children improve over time without treatment, while with others, the disorder becomes intractable.

For those experiencing severe forms of Selective Mutism, immediate intervention is advisable because the symptoms can increase. Generally speaking, a younger child has a good chance of recovering, if treated, because of the shorter interval of time where no verbalization has occurred in school or in other major settings.

How Can Parents Help Their Child Who is Experiencing Selective Mutism?

Parents can help their child by providing every opportunity for socialization and speaking. Behavioral techniques should be implemented in all social environments where verbalizing is difficult. Parents should consider contacting their teachers, principal, school psychologist, school counselor, or social worker. These individuals can play a very important role in assisting families and implementing a consistent treatment plan in school.

Do Children Experiencing Selective Mutism Have Special Education Needs?

Selective Mutism is not associated with learning or other impairments, therefore, special education programs should be cautiously considered. There are no special education programs in public schools available for these children. Individual programs would need to be designed. Most programs can be implemented within the regular education environments. Others may require coordination between regular and special education, a 504-accommodation plan, or school staff, depending on the skill level and resources available within the school district.

How Can Educational Evaluators Assess the Skills of a Child Experiencing Selective Mutism?

Professionals will need to modify their typical assessment strategies when working with these children. As these children may fail to verbalize, evaluation scores do not reflect their true academic levels, IQ’s, or potential. In order to avoid placing these children into inappropriate educational settings, evaluators need to be particularly cautious. An effort should be made to evaluate the child at home with the parent present. The child can be asked to read into a tape recorder at home. Some skills and speech and language samples may be obtained and assessed over the telephone, as many children experiencing Selective Mutism will verbally respond. Testing material that is used for the hearing impaired should be utilized as well. One of our goals is to promote the development of appropriate testing material for those children who may have additional disabilities.

How Can Teachers Assist a Student Who is Experiencing Selective Mutism?

Teachers play an integral part in helping students who are experiencing Selective Mutism. By understanding that the symptoms are not intentional will reduce the frustration and anger which teachers often disclose. Consistent behavioral strategies should and can be easily implemented in the classroom. Strategies should focus on encouraging, not forcing the child to speak. Praise and rewards for speaking, and participation in classroom tasks (e.g. monitor), will all contribute to lowering the anxiety, while helping the child to feel integrated, positive, and independent.

How Many People Have Selective Mutism?

Some published literature suggests that Selective Mutism is rare, and found in less than 1 percent of child guidance, clinical, and school social casework referrals. However, based on the overwhelming responses to the Foundation, we suspect that it is far more prevalent than originally assumed. Some publications suggest a slightly higher percentage of females experiencing Selective Mutism than males. However, due to unreported, undiagnosed and misdiagnosed cases, the ratio is unknown.