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Selective Mutism in Children and Youth: Information for Parents and Caregivers

Summary: It is normal for many people to be shy, but when that shyness is so extreme that it stops a person from speaking outside the home (e.g. at school, or other public situations), then it may be a condition known as selective mutism.
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“She won't speak to anyone…”

Jane is 6 years old and can dance and sing in front of her family…. she might even be the next Idol! But in music class she is paralyzed by fear and can’t say a word.

 

Jay is a 7 year old boy who plays soccer with his brothers and talks excitedly about his favorite World Cup team. Yet, at recess time, he stands alone watching the other kids play soccer and doesn’t speak when others ask him if he wants to play. Some of the kids think he’s a snob, and so they ignore him.

 

Mary is a 5 year old girl who talks at home with all her brothers, sisters and parents… but she has never spoken to anyone outside her home.

What is Selective Mutism?

Everyone gets shy from time to time. In fact, having just enough shyness can be helpful because it can protect us from doing things that may be embarrassing or awkward. But when shyness keeps a child or teen from speaking, then it may be a condition called selective mutism.

 

Selective mutism is a severe anxiety disorder where a child is:

  • Not able to speak (or ‘mute’) in certain situations (for example, at school or public places)
  • Able to speak where she feels relaxed (like at home)

Children with selective mutism are not being mute ‘on purpose’. They are not trying to ‘control’ a situation by being mute. Not speaking is the way they protect themselves from severe anxiety.

 

Because anxiety is at the root of selective mutism, punishing, pressuring or making a child feel guilty won’t help at all. Trying to force a child to speak can make a child even more anxious and can backfire, making the mutism even worse.

 

On the other hand, anything you can do to to help a child feel safer, to reduce their anxiety, can make it easier for them to speak in situations that make them afraid. Helping children take small steps to facing their fears is one of the best ways to help a child overcome mutism.

Signs and Symptoms of Selective Mutism 

Most children with selective mutism look and act like any other child, when they are in a comfortable situation. But when they are in other situations, like school or other social settings, they feel very anxious.

 

Before or during social interactions, a child with selective mutism may:

  • Withdraw or ‘shut down’ when in the situation that makes them so anxious
  • Refuse to follow adult’s directions, and seem disobedient or defiant (for example, refusing to go somewhere that makes them feel anxious)
  • Avoid the stressful situation or activity
  • Complain of stomach aches or headaches
  • Stare into space, avoid eye contact or not smile
  • Have trouble saying simple things like ‘hello’, ‘goodbye’ or ‘thank you’

Other Issues Often Seen 

Children with selective mutism may also have:

  • Other anxiety problems such as 
    • Social anxiety disorder (9 out of 10 children with selective mutism meet criteria for social anxiety disorder)
    • Difficulty being away from parents (separation anxiety)
  • Some form of speech or language problems
  • Daytime wetting or bed wetting (enuresis), which indicates an immature neurologic system. 

What Causes Selective Mutism?

Factors that contribute to selective mutism may include:

  • Genetics: Children with selective mutism likely have a sensitive "alarm system". Humans all have an "alarm system" that activates when we perceive danger. It allows us to be ready to ‘fight’ or flee danger. It is this alarm that allowed us to survive as hunter gatherers, and be able to survive physical threats such as being attacked by deadly sabre tooth tigers. In children with selective mutism, the alarm system is overly sensitive, and gets turned on, such as in social situations. 
  • Environment and experience: Children with selective mutism may also be mute in certain situations, perhaps because they have learned that this is a way to self-regulate their distress. When children feel a social situation is ‘dangerous’, they stay quiet, hide behind their parents or try to avoid the situation in other ways. When others respond by speaking for them or moving on, they feel less anxious. So these children learn that not speaking or avoiding social interaction helps them feel less anxious, and this behaviour becomes a pattern.

How Can I Help my Child?

Do’s

  • Get help early. This is important, because the longer that the selective mutism lasts, the harder it is to treat.
  • Strengthen your relationship with your child. Children with selective mutism feel the most secure when they are closely connected with their parents. Ways to connect include being physically close but also emotional closeness. Ways to foster emotional closeness and attachment include: 
  • Spend regular, qualitytime with your child. Try to set aside some special time each day where each of your children gets a turn to have you all to himself. This is not always easy, especially if you’re a single parent or have more than one child. But even 15 minutes of special time for each child every weekday can make a difference. Make this special time longer on weekends or whenever possible.
  • Choose activities that promote conversation. Board games, throwing a ball around, baking, crafts or Lego will give you lots of chances for your child to talk about feelings and emotions. Video games are not the best choice for 1:1 time, as they don’t give the same chances for eye contact and talking.
  • Create a safe space for expressing feelings. Name feelings and let your child see how you handle feelings in a positive way. Let your child know that whatever she is feeling is OK. You don’t have to share all of your child’s feelings, but acknowledge them (“I can see how that might have made you feel angry”). Don’t tell your child that what they are feeling is wrong. Give your child a chance to vent while you listen and support.
  • Make separations easier for your sensitive child by having goodbye rituals. When you say ‘goodbye’, remember to mention of when you’ll see each other again. You could remind your child of something you’re looking forward to doing with them (Pancakes for breakfast? Taco night? Working on that puzzle later?). This will be very reassuring for your child. You can add a hug or a kiss, or maybe even a secret family handshake  

Don’ts

  • Don’t force your child to speak, this will only make the anxiety worse.

  • Don’t ignore the problem. Parents may hear that their child is just shy and will outgrow the selective mutism. But there are serious consequences for a child who can’t communicate or speak to others:
    • It can be hard to make friends. Not having friends or being isolated can put children at risk for teasing or bullying.
    • It can impact a child's learning. Your child won’t be able to ask questions or ask for help. Teachers can find it hard to assess your child’s learning needs. Your child will not be able to take part in group work or learn important presentation skills. Over time, problems at school can affect your child’s self esteem, make anxiety or depression worse or make your child feel isolated. Children in these situations sometimes refuse to go to school.
  • Don’t blame your child for being ‘manipulative’. Remember, anxiety is at the root of this-your child is not trying to control things by not speaking. Your anger and frustration will only make things worse. All children do well if they can. When they can’t, it’s because they don’t have the skills they need. Fortunately, there are effective treatments for selective mutism.

How is Selective Mutism Treated?

Seek professional treatment with an experienced mental health professional (e.g. psychologist, speech/language therapist, psychiatrist) if your child is mute for a month or more.  

Counseling/Psychotherapy Strategies

Part 1 

  • Teaching the child about self-regulation, that their nervous system can be
    • "Green", which is the calm zone. We learn, work, play, and talk about problems best in the green zone. 
      • When we are calm, we can use "coping thoughts" in order to help us cope better. 
    • "Yellow", which is getting stressed out. 
      • When stressed, we might still be able to talk a bit about our problems, we might be able to use some coping thoughts to calm down, but often just want someone to comfort us emotionally, like a hug or listening or empathy. 
      • We might be able to do strategies like deep breathing when yellow.  
    • "Red", which is when we are overwhelmed.
      • When overwhelmed (aka "Fight/Flight/Freeze"), our rational brain shuts down, and we may not be able to talk about things, nor process things at all.  This helps us understand why when a child is mute, just telling them to relax and talk just doesn't work. 
      • We may need to reduce sensory input, use a calm, soothing tone of voice, and often times, just give someone time and space. 
    • "Shut down", which is when we are so overwhelmed, we might just shut down, dissociate, withdraw. 
  • Trying to understanding your child's nervous system by 
    • Identifying what helps your child feel calmer and safer, e.g. "green zone" . 
    • Identifying what triggers your child to feel stressed, e.g. "yellow zone"
    • Identifying what triggers your child to become overwhelmed, e.g. "red zone".  
    • Create a written self-regulation plan for the child that lists the child's zones, their triggers, and what helps in each zone. 

Part 2

  • After understanding the child's nervous system better, the goal is to structure daily routines and activities to try to get the child more into the green zone. 

Part 3

  • Once the child is felt to be mostly in the "green zone" and not "yellow", "red" or overwhelmed most of the time, then one can proceed with behavioural strategies to gradually improve your child's ability to face stressful situations (such as communication)  
  • Behavioural are done by identifying a goal, and then working towards that goal step-by-step. The child is exposed to more and more challenging social situations in a step-wise fashion. 
    • For example
      • Encouraging structured social activities with other children (for example, a team sport or club)
      • Working from the ‘inside’ outwards, by encouraging talking with close family and relatives. You then might try having one friend play with your child at home, gradually increasing the number of friends and different locations (playground or school).
      • Starting with structured activities (like watching movies, board games, sports) where your child will feel less pressure to speak
      • Progressing to more unstructured activities (free play, dramatic play)
    • Example of a hierarchy with ordering food at a restaurant. 
      • Your child could start by pointing to menu items. 
      • You can have your child respond with ‘yes’ or ‘no’ in front of the server to questions you ask, or could say what they want with a prompt from you.
    • At school
      • Working with the school, they may identify a child or two that your child is most comfortable with, and place your child nearer that child.
      • As your child becomes comfortable with that child, other quiet, gentle child might be introduced and more contact encouraged. 
    • At home
    • Ask your child if they have a friend they'd like to invite over.
    • One might start with your house.
    • Next step could be the school playground on a weekend.
  • How to reinforce your child?
    • Don’t make it a big deal when your child does speak. 
    • Do calmly acknowledge what your child said, and carry on. When you have a quiet moment later, you could say something like, “You spoke very politely to the waiter in the restaurant. Thank you for doing that. How did you manage to do that?"

Medications

Despite non-medication strategies such as behavioural strategies, is there still significant selective mutism? 

If so, then consider seeing your family physician about the possibility of medications. Medication can help reduce anxiety to allow the treatment plan to have a greater effect. Antidepressants known as SSRIs (selective serotonin reuptake inhibitors) have the most evidence for helping children and youth with anxiety conditions. Medications can be prescribed by a family physician, pediatrician or psychiatrist.

Working with the School

Meet with your child’s teacher, without the child around.  

 

School staff who may be able to help include teacher(s), the school psychologist, guidance counselor, etc. 

Hopefully the school will be familiar with selective mutism. If not, you can provide the school with a copy of this handout. 

Key messages for teachers and school staff are that the student:  

  • Is not being defiant or stubborn by not speaking
  • Communicates better when she is feeling calm and less anxious. Blame, teasing, humiliation and coercion do not help her to speak
  • May need to use non-verbal communication at first

You can also:

  • Ask the teacher if it is possible to have a greeting ritual ("Good morning, hope you had a good evening last night!"), as well as a goodbye ritual at the end of the school day ("Have a great day, I'm looking forward to seeing you tomorrow!").
  • Educate other students (and school staff). Give the teacher permission to tell other students and staff about anxiety in general (or if you feel comfortable enough, your child's difficulties), at a time when your child is not in the classroom. The teacher might say something such as “Everyone has a bit of shyness. Some people are just a little bit shy, where some people are very shy. The good news is that there are things that all of us can do to help someone feel included, even if they are shy.”

Meeting with parents, teacher and the child  

  • It is important to introduce your child to the people she feels anxious speaking around (for example, a teacher or child care provider). It is also important to let your child know that he can trust and feel safe with that person.
  • If your child is anxious speaking in front of the teacher, have a meeting with the teacher without your child. This will give you a chance to get to know the teacher. You can then arrange a time to meet the teacher with your child. 
  • Let your child know that you have already met the teacher, and that your child can feel comfortable with him.
  • For example, you can say something like, "I'd like you to meet Mrs. So and So. You know what? She's really into dogs, just like you. In fact, she has a dog of her own. I think she's really nice, and I think you're going to get along with her."

Example of a Step-By-Step Hierarchy, from Easiest to Hardest

If your goal is to have your child have a conversation with another person, such as a teacher or peer, here is an example of some steps to get there:

 

First steps 

  • Simply being around the another person without talking, e.g. playing Lego beside the teacher, or listening to the teacher talk
  • Non-verbal communication, like using gestures or writing

Next steps

  • Whispering to teacher or classmates
  • Using a ‘regular’ voice and giving yes/no answers (e.g. to closed ended questions like “Did you have a fun time last night?”)
  • Using a ‘regular’ voice and giving longer, more complex answers to open ended questions like “What did you do last night?”

Later steps

  • Having a conversation with another person in full sentences

The idea is to go step-by-step towards the eventual goal. If a child struggles with a step, then one can find a simpler, lower step to go back to, just like in the weight lifting analogy earlier.

Positive Feedback

Do positively reinforce with gratitude instead of praise. 

  • Managing anxiety and trying things that make you afraid takes courage. 
  • When your child is able to take positive steps, express gratitude, e.g. "Thank you for ____. It makes me so happy when you ____." 
  • Note that many children are sensitive to praise, e.g. "Good job for ___!" As a result, it is often better to just keep it low key. 

Don't add to the child's stressed out nervous system through negative reinforcement such as punishment 

  • With selective mutism, a child is unable to speak because their sensitive nervous system is overwhelmed. As a result, punishment will just add to their stress, and be counterproductive. Don't yell either, as that also increases stress to their nervous system. 

Remember, if your child had asthma...

  • Would you punish your child for having an asthma attack? 
  • Would you reward your child for not having an asthma attack?

Authors

Written by members of the Mental Health Information Committee at the Children’s Hospital of Eastern Ontario (CHEO), in collaboration with the Selective Mutism Group (Aimee Kotrba, Ph.D. & Lisa Kovac, Ed.S.)

References

Black B, Uhde TW. Treatment of elective mutism with fluoxetine: a double-blind, placebo-controlled study. J Am Acad Child Adolesc Psychiatry. 1994 Sep;33(7):1000-6.

Coloroso, Barbara. Kids are Worth it! 2002 Harper-Collins

 

Kumpulainen K. Phenomenology and treatment of selective mutism. CNS Drugs. 2002;16(3):175-80.

 

Neufeld, G. Holding On to Your Kids, 2002. Discusses the concept of attachment in depth, and how parents can attach with their children.

 

Dr. Elisa Shipon-Blum: Understanding Selective Mutism: A Guide to Helping Our Teachers Understand, retrieved Aug 15, 2005 from http://www.selectivemutism.org/pdf/teachers.pdf

License

Under a Creative Commons License.  You are free to share, copy and distribute this work as in its entirety, with no alterations. This work may not be used for commercial purposes.

For the full license, visit http:// creativecommons.org/licenses.by-nc-nd/2.5/ca/

Disclaimer

Information in this fact sheet may or may not apply to your situation. Your health care provider is the best source of information about your situation.

Date Posted: Nov 4, 2008
Date of Last Revision: May 30, 2020

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