Clinical Reference Systems: Pediatric Advisor 10.0

WHAT IS SELECTIVE MUTISM?

The primary feature of selective mutism is the failure to speak in social situations, including school, despite the ability to speak and to understand spoken language. It was formerly referred to as "elective mutism."

CHARACTERISTICS OF SELECTIVE MUTISM

Some parents may notice their child is overly "shy" when he or she enters preschool or kindergarten and seems unable to talk to others in the new class. The parents may have noticed that the child had a limited group of people he or she spoke to before attending school. Then, after the child is in school for several months, the parents find the child is not talking there.

Some characteristics of selective mutism are:

1. Persistent failure to speak in social situations where talking is expected (such as school, Sunday school, play groups, around parents' friends), even though the child can speak in other situations (such as to family members).

2. The situations of "nontalking" begin to interfere with the child's social development and academic achievement.

3. The difficulty lasts longer than a month.

4. The child has no other problems with language, such as lack of knowledge of the language or a communication disorder such as stuttering.

5. The disorder occurs in about one child per 1,000; it is seen twice as often in girls.

6. These children often appear shy, afraid, or anxious. In the past, their silence was thought to be stubborn behavior. It is now thought that the anxious feeling makes them unable to speak.

Many parents are confused by their children's inability to speak because their children are often very outgoing and animated at home. Some children will talk easily on the phone to people they are unable to talk to face-to-face.

CAUSES OF SELECTIVE MUTISM

The cause of selective mutism is not clear. Over the years, experts have suggested that an unpredictable environment, being a witness to a family conflict, experiencing a trauma before age three, or being overly attached to one's mother could cause the mutism. More recently, researchers are suggesting that selective mutism is a sign of an anxiety disorder. Social phobia is an anxiety disorder in which people fear situations where they might say or do something embarrassing. People with this disorder often fear speaking in public or to strangers. People with social phobia often report being fearful of speaking when they were very young.

TREATMENT OF SELECTIVE MUTISM

As children become older, there are fewer reports of selective mutism. This means that some children are able to begin speaking in public places without special help. Experts suggest that if the problem has lasted at least 6 months, parents should get professional help for their child.

Selective mutism is relatively rare. Your child's doctor should refer you to a therapist who is knowledgeable about the disorder and has treated it before. It is important that the therapist get a very thorough medical, social, and psychological history from the child and family. Any treatment plan must involve the parents and address how this behavior should be managed at home.

It is also important to include school personnel in the treatment plan. Many times teachers are as confused as the parents and are unable to find out how much the child is learning. Often the treatment plan includes an educational in-service program for the teacher as well as specific recommendations for increasing the number of people the youngster will communicate with.

A number of treatments have been reported by speech therapists, social workers, psychologists, and psychiatrists. The best results appear to be from behavioral therapy. Behavioral therapy is a treatment approach that helps families identify the behavior of concern and then plan a structured way to change it.

Many treatment plans begin by observing the youngster through a one-way mirror while he or she plays with the parents. This is a good way to determine if there are any problems with language development that are causing the mutism. If there are no language problems and interaction appears appropriate, then a "fade-in" procedure may be used to begin including the therapist in the family group. When the youngster is talking freely with the therapist, then the therapist can begin to help the youngster slowly expand the variety of people with whom he or she is able to talk. Often a reward system (reinforcement system) of some type is used as well. At some point it is also necessary to include school personnel in the treatment plan.

In some recently reported cases in which anxiety was a clear factor, medication has been used along with behavioral therapy to help the child overcome selective mutism. This treatment should only be considered if the child has not responded to behavioral interventions and is supervised by a pediatric psychiatrist familiar with the disorder.

RECOMMENDATIONS FOR PARENTS

1. Provide many opportunities for your child to observe you talking in a relaxed manner in a number of different situations such as in the neighborhood with friends, at school gatherings, and while ordering at fast food restaurants.

2. Always reinforce any attempt your child makes to speak in a public place by gently patting his or her shoulder or providing verbal praise in a soft voice.

3. Don't force talking or ridicule your child for not speaking. This is usually unsuccessful and often makes the child more anxious.

4. Don't talk about your child's "problem" to relatives or friends when the child is present. This also may make the child more anxious.

5. Provide many opportunities for the child to continue to speak in an environment in which he or she is comfortable. Generally that means in small groups of people with whom your child is familiar. If your child is more comfortable in the home, it may be helpful to invite friends over frequently to encourage this interaction.

6. Many children who are shy begin to speak in new places after they have become familiar with the teacher, new children, or the place. If this does not occur and the shyness begins to affect a child's ability to progress academically and socially, it is time to seek professional help.

REFERENCES

Foundation for Elective Mutism
Caroline Miller, codirector
P.O. Box 13133
Sissonville, West Virginia 25360-0133

Foundation for Elective Mutism
Sue Leszczyk, codirector
P.O. Box 450632
Sunrise, Florida 33345-0632