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  • Selective Mutism’s Overview, Causes, Symptoms and Treatment

    By Mohammed Adil Sethi, Content Team Academic

    Selective Mutism (SM) is an anxiety disorder; it is not a very frequent but a severe type of disorder in which a person can speak fluently but remains mute in some situations only (Muris & Ollendick 2021). However, if not treated correctly, SM can persist throughout childhood and into the adolescent and adult periods of a person’s life. People diagnosed with SM and their families, educators, and caregivers need to know about this condition.

    Overview of Selective Mutism

    SM affects individuals most often in childhood and usually becomes apparent between the ages of 2.5 and 4 years (Steains et al. 2021). One should be able to differentiate between SM and mere social shyness or introversion. Whereas shy children may take time before they can come out and freely intermingle, basically children with SM suffer from such an intense sense of anxiety that it freezes them to the vocal extent of their ability in certain social environments. For example, while the child may be quite vocal about expressing himself or herself in the comfort of home, in school, or in the presence of strangers, the child may not utter a single word.

    For many years, it used to be associated with trauma or wilful silence. However, recent studies indicate that there is a significant correlation between SM and such psychological conditions as social phobia. Freud described a specific type of withdrawal called social Mutism or SM, in which the child can speak physically yet refuses to do so because of anxiety.

    Causes of Selective Mutism

    Genetic Predisposition and Family History: SM often seems to be inherited or passed from one generation of the family to another. SM is common among children with an inherited tendency for anxiety disorders, including social anxiety (Pereira et al. 2020).

    Temperament and Personality: Children who are born introverted or are self-conscious are at a higher risk of developing SM. These children may easily respond to stimuli from the environment and may even be overwhelmed by anxiety in social relations (Haggerty et al. 2022).

    Environmental and Social Factors: SM in children can develop due to stressors such as bullying, family conflict, or changes in the environment, for example, moving to a new country. However, adolescents who experience elevated levels of stress or those whose parents are overprotective, or controlling are also at higher risk (Koskela et al. 2024).

    Co-occurring Conditions: SM is frequently comorbid with other anxiety disorders, such as social anxiety disorders and concerns about speech and language. SM may develop in children with language problems or those who have speaking disorders that stress them when speaking (Gensthaler et al. 2020).

    Symptoms of Selective Mutism

    SM is one of the anxiety disorders presenting itself as a condition in which one can speak fluently in some contexts but finds it exceedingly difficult to in other situations, particularly those that are demanding socially (Mizzi & Sant, 2021). These are instinct reflexes that can lead to a full-blown aphonia, rigidity of the muscles of the face and body, averting eye contact, and little social interaction. Some use sign language other than speech, thus, write or gesticulate; use only simple sounds like ‘uh-uh’ for ‘no.’ Some patients may speak very little and only in low tones, very slowly or in a whisper; may speak with an abnormal pitch or tempo. These are not symptoms of ‘no talk syndrome’ but rather transient vocal responses to severe anxiety overwhelming the child, hence the need for positive ways to respond to the child.

    Diagnosis of Selective Mutism

    SM is usually diagnosed by a mental health expert, for instance, a psychiatrist or a psychologist. Sometimes, a speech-language pathologist or speech therapist might be consulted to exclude other illnesses that can concur and may cause such symptoms. Diagnosis involves some behaviours that are presented, as well as an evaluation of the experiences of the affected person and other factors.

    SM diagnosis is based on DSM-5, in which the mental disorder manifests through the presence of a preoccupation with one’s appearance and bodily image. The key criteria include:

    1. The inability to speak and the inability to speak when there are prerequisites for its use while the ability to speak in situations that do not require the use of speech
    2. Communicative impairment causes reduced communication, including in social, educational, or occupational domains.
    3. The condition continues for more than one month without the individual being able to return to their normal activities.
    4. The inability to speak is not because the child is ignorant of the language or is unable to comprehend it.

    Treatment of Selective Mutism

    Cognitive-Behavioural Therapy (CBT): CBT is the most effective treatment for SM, as it decreases anxiety and teaches the person to speak more. Methods of CBT include exposure therapy, where the child is gradually exposed to speaking in more difficult situations and rewarded for acts of bravery.

    Behavioural Therapy: According to Esmail et al. (2021), positive reinforcement techniques such as shaping, stimulus fading, and contingency management are also common. Shaping involves teaching the child to use different signals to talk, starting with leading the child from the use of gestures toward full speech. These are stimulus fading, which assists the child to come from talking in familiar places to new places, and contingency management, which uses reward systems to encourage good behaviours.

    Speech Therapy: When the child has one or more speech/ language disorders, speech and language therapy can play a significant role in the intervention. There are several reasons why a patient may be referred to a speech therapist, one of which is to manage individual speech phobia. At the same time, he/she is taken through a series of exercises and activities that enhance effective communication.

    Parent and Teacher Involvement: According to Slobodin et al. (2024) SM typically occurs in school settings, the parents and teachers ought to be involved in the management of the condition. Faculty members can also design ideal classrooms where children can express themselves while the parents can further promote helpful language patterns at home.

    Prognosis and Coping Strategies

    SM can be overcome with early intervention so that the prognosis of children with this disorder is often favourable (Hong et al. 2023). Nevertheless, most children outgrow the occurrence, while the rest can control their symptoms as they advance in age. Nonetheless, if it persists with no interference, SM extends to adulthood, entailing difficulties at work and in social relations.

    Some techniques that can be employed when managing SM are creating a conducive environment that will enable the patient to feel comfortable, especially when around people who are close to them; the patient is advised to set specific goals that concern the communication that is involved in a particular social activity, the patient is then gradually exposed to the problematic aspects of social activities. Parents and especially teachers should also avoid pushing the child to talk since this only worsens the situation, and the child gets more agitated.

    Conclusion

    Selective Mutism is a very severe but very treatable illness. If the individual with SM seeks therapy and support when necessary, the person can learn to overcome the fear and can speak in public. SM should be treated with treatment paradigms, blending mental health workers, teachers, and family members to care for such individuals.

    References

    1. Muris, P., & Ollendick, T. H. (2021). Selective mutism and its relations to social anxiety disorder and autism spectrum disorder. Clinical child and family psychology review, 24(2), 294-325. 1) https://doi.org/10.1007/s10567-020-00342-0
    2. Steains, S. Y., Malouff, J. M., & Schutte, N. S. (2021). Efficacy of psychological interventions for selective mutism in children: A meta‐analysis of randomized controlled trials. Child: care, health and development, 47(6), 771-781.  
    3. https://doi.org/10.1111/cch.12895
    4. Pereira, C. R., Ensink, J. B., Güldner, M. G., Kan, K. J., de Jonge, M. V., Lindauer, R. J., & Utens, E. M. (2020). Effectiveness of a behavioral treatment protocol for selective mutism in children: Design of a randomized controlled trial. Contemporary clinical trials communications, 19, 100644. https://doi.org/10.1016/j.conctc.2020.100644
    5. Haggerty, D., Carlson, J. S., & Kotrba, A. (2022). A pilot feasibility study of an intensive summer day camp intervention for children with selective mutism. Children, 9(11), 1732. https://doi.org/10.3390/children9111732
    6. Koskela, M., Jokiranta-Olkoniemi, E., Luntamo, T., Suominen, A., Sourander, A., & Steinhausen, H. C. (2024). Selective mutism and the risk of mental and neurodevelopmental disorders among siblings. European Child & Adolescent Psychiatry, 33(1), 291-302. https://doi.org/10.1007/s00787-022-02114-3
    7. Gensthaler, A., Dieter, J., Raisig, S., Hartmann, B., Ligges, M., Kaess, M., … & Schwenck, C. (2020). Evaluation of a novel parent-rated scale for selective mutism. Assessment, 27(5), 1007-1015. https://doi.org/10.1177/1073191118787328
    8. Vogel, F., & Schwenck, C. (2021). Psychophysiological mechanisms underlying the failure to speak: a comparison between children with selective mutism and social anxiety disorder on autonomic arousal. Child and Adolescent Psychiatry and Mental Health, 15, 1-17. https://doi.org/10.1186/s13034-021-00430-1
    9. Slobodin, O., Shorer, M., Friedman Zeltzer, G., & Fennig, S. (2024). Interactions between parenting styles, child anxiety, and oppositionality in selective mutism. European Child & Adolescent Psychiatry, 1-11. https://doi.org/10.1007/s00787-024-02484-w
    10. Esmail, M. E., Alharbi, M. B., Alayed, I. S., Alqahtani, M. S., Aldeeb, H. F., Alanazi, Y. H., … & Doshi, T. A. (2021). Definitions, importance, and application of selective mutism questionnaire in the primary care setting. International Journal of Community Medicine and Public Health, 8(12), 1. https://dx.doi.org/10.18203/2394-6040.ijcmph20214451
    11. Hong, N., Herrera, A., Furr, J. M., Georgiadis, C., Cristello, J., Heymann, P., … & Comer, J. S. (2023). Remote intensive group behavioral treatment for families of children with selective mutism. Evidence-based practice in child and adolescent mental health, 8(4), 439-458. https://doi.org/10.1080/23794925.2022.2062688
    12. Mizzi, B., & Sant, M. (2021). Professionals’ experiences of selective mutism in children: An interpretative phenomenological analysis. https://doi.org/10.14614/SELECTIVEMUTISM/8/21

  • The Value of a Recovery Plan

    By Craig Souter, Content Team Contributor

    At some point in life, most people have felt that things have been out of control, whether that was challenges at work, too many assignments in their studies, too many life events happening at once, or a big demand on their social time. However, there is one tactic which is always helpful in the face of feeling out of control – to have a plan!

    What anxiety challenges make a plan useful?

    Anxiety is no different to the challenges stated above. In fact, arguably, the value of a plan with anxiety can be even greater. This is because in the face of anxiety we are presented with two key challenges:

    • Chaos! Anxiety tends to throw so many overwhelming challenges your way all at once. These could include physical symptoms, mental symptoms, impact on your life circumstances, or simply overbearing emotions. It can easily feel like you are out of control and so it’s difficult to respond to them all with a calm rational mind.  
    • Indecision! When your threat response is activated, your ability to think things through logically is inhibited. You are very often almost frozen into action or flighted into escape. This can mean that the choice of what to do next can seem almost impossible.

    How does a plan help?

    Setting time aside to create a plan that aligns with your goals for recovery and living your best life can help you in the following ways:

    • It helps you to take an active control in a situation that otherwise feels unmanageable.
    • It brings together all the knowledge and useful skills you’ve learnt into one place so that you can decide how you want to use them.
    • It stops your actions from being dependent on how anxiety is making you feel. For example, if you have allocated time for exercise, then your goal will be to exercise even if you are feeling anxious.
    • It helps you to hold yourself accountable to ensure that you are putting in the effort you want for relaxation and recovery.

    How do you go about creating an anxiety plan?

    Start by identifying the elements of anxiety recovery that you’ve decided are important for you. There are lots of different articles on Home – NoPanic regarding different skills that you can learn, but here are some that you may acquire: 

    • A chosen physical activity you want to stick to
    • preferred relaxation exercises
    • breathing techniques
    • a commitment to a regular balanced diet
    • thought management
    • support (e.g. counselling, mentoring)
    • social engagement

    Look at each of these and, over a manageable period – let’s say a week –  consider how much of each you want to achieve. These are your goals.

    Now draw up a simple plan for the next week, probably split something like morning, afternoon and evening. If you have any commitments you must meet (e.g. work) plot them in. Now consider when you will fit in your recovery plan activities. You’ll have to be:

    • Realistic; don’t turn this into another source of stress trying to fill every minute with tasks that you must complete or else you’ve failed. This is just creating a way to beat yourself up.
    • Challenging; remember this is your life and your well-being, you have to come first, otherwise you will struggle to be there for anybody else, so consider where you can create space to engage in your recovery activities.

    Pitfalls and Tips

    Once you’ve got your plan, take note of the following:

    • DO NOT let this be a weapon to punish yourself with. Life happens and you won’t always be able to complete every task. This plan is there to help guide you, not beat you.
    • DO learn and adapt. If the plan is not working for you, adjust it. It’s your life and your plan, you are allowed to learn from it and make it better.
    • DO use the plan whenever you are struggling and feel lost. Consider reflecting that right now things are tough, but you have a plan, and you know that by pushing on with the plan, you will get to a better place in the end.
    • TALK to somebody about how it’s going. As with everything anxiety-related, being stuck in your head is tough, speak to a friend, a family member or our helpline. Tell them what is working and what isn’t with your plan.

    Take control and best of luck!

    If you would like support with your recovery from anxiety, try our CBT-Focused Mentoring Services.