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Author: Rachele Diliberto, Ph.D., Boys Town Nevada Behavioral Health

Five-year-old Nina is chatty and outgoing at home, but she clings to her mother and does not answer questions from adults while out in public. Nina has been in kindergarten for three months, and her teacher has noticed she does not speak to other kids or teachers and avoids eye contact when others ask her questions. The teacher asked her parents whether she has speech difficulties because she has never heard her speak at school. At first, Nina's parents believed their daughter was "simply shy," and that she would outgrow this. Now, they are concerned and wonder if this is something beyond just being shy.

Historical accounts of children who did not communicate in select situations can be traced to the late 19th century. In 1877, Adolf Kussmaul proposed the term "aphasia voluntaria," which described children who would not speak in certain situations, even though they had the capacity to do so.

Today, this condition is called selective mutism (SM) (formerly, elective mutism), and is understood as a childhood anxiety disorder characterized by a child's or adolescent's inability to speak in one or more social settings (e.g., at school, in public places, with adults) despite being able to speak comfortably in other settings (e.g., at home with family). As in Nina's case, selective mutism is usually first recognized when a child enters school and begins to interact with new adults and peers. Recent estimates indicate that approximately 1% of elementary school-aged children meet the criteria of this disorder.

Where does the mutism occur and how do these kids communicate?

  • The school environment is the most common location for mutism. Some children with selective mutism don't speak to any peers at school, but some do speak to select friends.
  • Often, youth rely on other forms of communication (pointing and nodding, facial expressions, writing and utterances) to function in the community and school.
  • Anxiety is a hallmark of the disorder, as demonstrated by withdrawal, avoiding eye contact, clinging and looking to adults to answer for them, and a "stiff" body posture.

How do I know if my child is struggling with selective mutism?

  • Selective mutism is related to shyness, social anxiety and inhibited temperament (e.g., fearful of new experiences, slow to adapt to new situations).
  • There is some evidence to indicate a genetic link between children with selective mutism and anxiety in their parents or family members.
  • Overreaction is the threat signal of the brain that lets a person know when danger is present. Anxiety is triggered by social interactions and settings where speaking is expected, including school, the playground or social gatherings. Although an actual danger or threat may not be present, the feelings the child experiences are just as real as if there was an actual threat or danger.
  • Some children with selective mutism also have expressive language disorders and some come from bilingual family environments. These factors alone do not cause selective mutism but may contribute to a child's anxiety about speaking. Specifically, the child may be self-conscious about his or her speaking skills and may have increased fear over being evaluated by others.

While mutism may be viewed as a strategy a child uses to reduce anxiety in social situations, anxiety actually worsens (is negatively reinforced) when the demand for speaking is taken away (e.g., someone answers for the child or no response is given) and the child begins to rely more consistently on others to communicate for him or her. The diagram below illustrates how mutism may be maintained.

Behavioral Conceptualization

How is selective mutism treated?

Selective mutism is commonly treated with behavioral therapy. The aim of therapy is to reward speaking behavior and remove opportunities for children to rely on their parents or other caregivers to speak for them or to respond in nonverbal ways (e.g., pointing, writing answers to questions). Pressure to communicate usually worsens the anxiety and the mutism. Therefore, the therapist works with the child and his or her family to help the child gradually build confidence to speak in progressively more difficult and anxiety-provoking situations where the child has been mute in the past. Throughout this process, the therapist works with the family to reduce "rescuing" behaviors so the child can practice speaking in various social situations, including at school and in the community.

Medication may also be considered when consistent implementation of therapy strategies and techniques are not enough, and the child's or adolescent's anxiety renders him or her unable to make progress with speaking in anxiety-provoking situations. The first-line medication treatment for anxiety in children and adolescents is a class of medications known as selective serotonin reuptake inhibitors (SSRIs). Medications are most effective when combined with behavioral therapy strategies, especially to help the child maintain progress in communication over time.

The American Academy of Child and Adolescent Psychiatry (https://aacap.org) has a resource center where parents can learn more about medication for anxiety in children and find answers to commonly asked questions. It can also help parents find a child psychiatrist in their area. (I encourage families that are considering medication treatment to discuss potential benefits and side effects/risks with a child psychiatrist before making a decision.)

The following resources can provide more information and help locate a treatment provider: