Information on Selective Mutism for Parents and for Medical, Mental Health, and Educational Professionals
We receive many requests for information on Selective Mutism. Here are some answers to commonly asked questions.
How and when should selective mutism be treated by a professional?
How can parents, teachers, and school counselors help the child with selective mutism?
Selective mutism is a psychiatric disorder of childhood characterized by persistent failure to speak in one or more major social situations, including school, despite ability to comprehend spoken language and to speak. The disorder was first described in 1934, and there have been many case reports and small case series published in the psychiatric literature since then. Prior to the initiation of a research program under the direction of Dr. Bruce Black in 1990 (initially at the National Institutes of Health in Bethesda, Maryland and subsequently at New England Medical Center in Boston), the disorder had never been studied systematically. Children manifesting the disorder characteristically refuse or are very reluctant to talk in school and to strangers. The severity of the disorder varies, from children who have never been heard to speak in school to those who do speak in school, but are markedly reluctant to do so. The term “speech reluctance” has also been used to describe this condition. All children affected with this disorder speak normally with individuals with whom they are very familiar and comfortable, such as immediate family or very familiar peers. Some affected children speak more freely with peers than with adults. Although symptoms may be apparent from the preschool years, the disorder generally does not come to clinical attention until the child starts school. Transient manifestations of speech reluctance after starting school are not uncommon. Persistent forms of the disorder are less common.
At the present time, we cannot say with certainty what causes selective mutism. There may be different causes for different individuals. Our research to date indicates that most children with this disorder are very shy and anxious when interacting with unfamiliar persons, or in any situation where they feel that they are the center of attention or are being observed or evaluated. As they become more accustomed to and comfortable in a particular social situation, they are more likely to talk. It seems likely that this extreme shyness or self-consciousness (or “social anxiety” as it is referred to by psychiatrists) is the central cause of the disorder. In fact, it seems likely that in many cases selective mutism is no more than an extreme shyness or an early childhood form of “public speaking anxiety.” Many of the children we have studied have parents or siblings who have suffered from selective mutism or from extreme shyness. This observation, as well as what we know about the hereditary basis of extreme shyness, suggests that a vulnerability or tendency to develop the disorder is passed on genetically, just as a tendency to develop diabetes or heart disease may be passed on.
There is no substantial evidence to support any other cause. For example, physical or sexual abuse, neglect, other types of psychological trauma, and dysfunctional family relationships have all been proposed in the past as possible causes of selective mutism. However, our research has found no evidence that this is the case, and we do not believe there is any reason to suspect or look for evidence of past abuse unless there is some other reason to believe that it has occurred. Parents or teachers sometimes express the opinion that, “The child is just being stubborn! He [or she] can talk if he [she] wants to.” In our experience, this does not seem to be an adequate explanation. Indeed, most children with selective mutism do not seem to be any more stubborn or oppositional than the average child. However, in some cases, it seems that the child and those around the child are so accustomed to the child not speaking that it becomes difficult for the child to “break out of the mold.” As some children have told us, “I can’t talk now. Everyone will look and say ‘He talked! He talked!’” Of course, this fear of speaking is not at all the same as willful stubbornness.
How and when should Selective Mutism be treated by a professional?
Many children seem to improve over time without any specific treatment. The younger the child and the shorter the interval of time that the child has been in school without talking, the more likely it seems to be that the child will start talking without any treatment. However, some children may continue to have significant problems with extreme shyness, even after they start talking in school.
Although individual psychotherapy, play therapy, psychoanalysis, and family therapy have frequently been recommended for children with selective mutism, there is no evidence to date that these types of treatment are likely to be of substantial benefit. Our experience suggests that these treatments are not helpful in most cases, and may occasionally actually be harmful. Treatment with certain medications has been shown to be safe and very helpful for some children. A specific type of psychotherapy known as cognitive-behavioral therapy (or CBT) is often helpful, when provided by a therapist who has had intensive training and experience in using this method of treatment. The CBT therapist works with the child and his or her teacher and parents to develop a plan to assist the child in very slowly increasing his or her vocalization, with frequent praise and encouragement, and working at a pace that the child is comfortable with.
The process of deciding when and how to treat a child with selective mutism is a complex one. Multiple factors must be considered, including: How severe is the selective mutism, and how much is it interfering with the child’s academic and social development? Does the child seem to be improving without treatment? What are the relative risks and side effects of different types of treatment? Do the child and his or her family have access to a skilled CBT therapist or pediatric psychopharmacologist (a physician with special expertise in the use of medication to treat psychiatric conditions in children)? How do the parents and the child feel about treatment, including treatment with medication?
For children who have been in school for less than 3 to 4 months, we usually do not recommend any treatment, unless there are other significant problems in addition to the selective mutism and shyness. In these cases, watching and waiting is usually the wisest course. However, even when no specific treatment is indicated, we can sometimes be helpful to parents and schools by providing recommendations on how they might best deal with the child’s reluctance to speak. For children who have been in school more than 3 to 4 months, we do usually recommend a trial of CBT with an experienced therapist. For more severe or persistent cases, we also usually recommend a trial of treatment with a medication called fluoxetine (Prozac).
How can parents, teachers, and school counselors help the child with selective mutism?
It is important to understand that the child with selective mutism is genuinely frightened of or uncomfortable with speaking in school. He or she is not “just being stubborn.” Gentle and consistent encouragement, support, and reassurance are most likely to be helpful. Any progress in verbal or non-verbal communication should be praised and encouraged, even if it is merely progress from complete silence to barely audible whispers. Because many children with selective mutism are very uncomfortable being made the center of attention, it is sometimes best to offer the praise and encouragement privately, rather than, for example, praising them loudly in front of the whole class or another teacher. Struggles between the child and adults, particularly regarding speaking, should be avoided as much as possible. Attempts to pressure, demand, or force the child to speak, to trick the child into speaking, or to punish or shame the child for not speaking are most often counter-productive. Finally, unless there are other specific indications, we recommend that the child with selective mutism remain in regular classes, rather than in classes for children with emotional disabilities or speech and language impairments. This may require some flexibility on the part of teachers and school administrators. We believe a willingness to find ways to help the child communicate and learn in a regular classroom setting is usually in the best interests of the child.
Copyright © 2000 Bruce Black, M.D. All Rights Reserved.