Let’s Learn About SM …
Selective Mutism is a complex childhood anxiety disorder characterized by a child’s inability to speak and communicate effectively in select social settings, such as school. These children are able to speak and communicate in settings where they are comfortable, secure, and relaxed. This is very brief description; below are some frequently asked questions (FAQ) about Selective Mutism. Feel free to check them out.
Note: This information is adapted from Dr. Elisa Shipon-Blum’s handout: “WHAT is Selective Mutism? A GUIDE to Helping Parents, Educators and Treatment professionals Understand Selective Mutism as a Social Communication Anxiety Disorder”. All rights reserved.
Children with Selective Mutism often have severely inhibited temperaments. Studies show that individuals with inhibited temperaments are more prone to anxiety than those without shy temperaments. Most, if not all, of the distinctive behavioral characteristics that children with Selective Mutism portray can be explained by the studied hypothesis that children with inhibited temperaments have a decreased threshold of excitability in the almond-shaped area of the brain called the amygdala. When confronted with a fearful scenario, the amygdala receives signals of potential danger (from the sympathetic nervous system) and begins to set off a series of reactions that will help individuals protect themselves. In the case of children with Selective Mutism, the fearful scenarios are social settings such as birthday parties, school, family gatherings, routine errands, etc.
Some children with Selective Mutism have Sensory Processing Disorder (DSI) which means they have trouble processing specific sensory information. They may be sensitive to sounds, lights, touch, taste and smells. Some children have difficulty modulating sensory input which may affect their emotional responses. DSI may cause a child to misinterpret environmental and social cues. This can lead to inflexibility, frustration and anxiety. The anxiety experienced may cause a child to shut down, avoid and withdraw from a situation, or it may cause him/her to act out, have tantrums and manifest negative behaviors.
Some children (20-30%) with Selective Mutism have subtle speech and/or language abnormalities such as receptive and/or expressive language abnormalities and language delays. Others may have subtle learning disabilities including auditory processing disorder. In most of these cases, the children have inhibited temperaments (prone to shyness and anxiety). The added stress of the speech/language disorder, learning disability, or processing disorder may cause the child to feel that much more anxious and insecure or uncomfortable in situations where there is an expectation to speak.
More studies are necessary to fully assess speech/language abnormalities and Selective Mutism as well as processing disorders and Selective Mutism. It is important to note that there are many children with Selective Mutism who are early speakers without any speech delays/disorders or processing disorders.
It is important to realize that the majority of children with Selective Mutism are as normal and as socially appropriate as any other child when in a comfortable environment. Parents will often comment how boisterous, social, funny, inquisitive, extremely verbal, and even bossy and stubborn these children are at home! What differentiates most children with Selective Mutism is their severe behavioral inhibition and inability to speak and communicate comfortably in most social settings. Some children with Selective Mutism feel as though they are on stage every minute of the day! This can be quite heart-wrenching for both the child and parents involved. Often, these children show signs of anxiety before and during most social events. Physical symptoms and negative behaviors are common before school or social outings.
It is important for parents and teachers to understand that the physical and behavioral symptoms are due to anxiety and treatment needs to focus on helping the child learn the coping skills to combat anxious feelings.
It is common for many children with Selective Mutism to have a blank facial expression and never seem to smile. Many have stiff or awkward body language when in a social setting and seem very uncomfortable or unhappy. Some will turn their heads, chew or twirl their hair, avoid eye contact, or withdraw into a corner or away from the group seemingly more interested in playing alone.
Others are less avoidant and do not seem as uncomfortable. They may play with one or a few children and be very participatory in groups. These children will still be mute or barely communicate with most classmates and teachers.
As social relationships are built and a child develops one or a few friendships, he/she may interact and even whisper or speak to a few children in school or other settings but seem to be disinterested or ignore other classroom peers. Over time, these children learn to cope and participate in certain social settings. They usually perform nonverbally or by talking quietly to a select few. Social relationships become very difficult as children with Selective Mutism grow older. As peers begin dating and socializing more, children with Selective Mutism may remain more aloof, isolated, and alone.
Children with Selective Mutism often have tremendous difficulty initiating and may hesitate to respond even nonverbally. This can be quite frustrating to the child as time goes by. The child’s nonverbal communication may go on for many years, becoming more ingrained and reinforced unless the child is properly diagnosed and treated. Ingrained behavior often manifests itself by a child looking and acting normally but communicating nonverbally. This particular child cannot just start speaking. Treatment needs to center on methods to help the child unlearn the present mute behavior.
Most children are diagnosed between 3 and 8 years old. In retrospect, it is often noted that these children were temperamentally inhibited and severely anxious in social settings as infants and toddlers, but adults thought they were just very shy. Most children have a history of separation anxiety and being slow to warm up. Often it is not until children enter school and there is an expectation to perform, interact and speak, that Selective Mutism becomes more obvious. What often happens is teachers tell parents the child is not talking or interacting with the other children. In other situations, parents will notice, early on, that their child is not speaking to most individuals outside the home.
If mutism persists for more than a month, a parent should bring this to the attention of their child’s physician.
Children who suffer from Selective Mutism speak in at least one setting and are rarely mute in all settings. Most have inhibited temperaments and manifest social anxiety. For children with Selective Mutism, their mutism is a means of avoiding the anxious feelings elicited by expectations and social encounters.
Children with traumatic mutism usually develop mutism suddenly in all situations. An example would be a child who witnesses the death of a grandparent or other traumatic event, is unable to process the event, and becomes mute in all settings.
It is important to understand that some children with Selective Mutism may start out with mutism in school and other social settings. Due to negative reinforcement of their mutism, misunderstandings from those around them, and perhaps heightened stress within their environment, they may develop mutism in all settings. These children have progressive mutism and are mute in/out of the home with all people, including parents and siblings.
Most, if not all, of the characteristics of children with Selective Mutism can be attributed to anxiety.
Temperamental Inhibition: Timid, cautious in new and unfamiliar situations, restrained, usually evident from infancy on. Separation anxiety as a young child.
Social Anxiety Symptoms: Over 90% of children with Selective Mutism have social anxiety. Uncomfortable being introduced to people, teased or criticized, being the center of attention, bringing attention to himself/herself, perfectionist (afraid to make a mistake), shy bladder syndrome (Paruresis), eating issues (embarrassed to eat in front of others).
Social Being: Most children with Selective Mutism want friends, and need friends. This differentiates Selective Mutism from other disorders such as the autistic spectrum disorders. Most children with Selective Mutism have appropriate social skills, but some do not and need help to develop proper social skills.
Physical Symptoms: MUTISM, tummy ache, nausea, vomiting, joint pains, headaches, chest pain, shortness of breath, diarrhea, nervous feelings, scared feelings.
Appearance: Many children with Selective Mutism have a frozen-looking, blank, expressionless face and stiff, awkward body language with lack of eye contact when feeling anxious. This is especially true for younger children in the beginning of the school year or then suddenly approached by an unfamiliar person. They often appear like an animal in the wild when they stand motionless with fear! The older the child, the less likely he/she is to exhibit stiff, frozen body language. Also, the more comfortable a child is in a setting, the less likely a child will look anxious. For example, the young child who is comfortable and adjusted in school, yet is mute, may seem relaxed, but mutism is still present. One hypothesis is that heightened sympathetic response causes muscle tension and vocal cord paralysis.
Emotional: When the child is young, he/she may not seem upset about mutism since peers are more accepting. As children age, inner turmoil often develops and they may develop the negative ramifications of untreated anxiety (see below).
Developmental Delays: A proportion of children with Selective Mutism have developmental delays. Some have multiple delays and have the diagnosis of an autistic spectrum disorder, such as Pervasive Developmental Disorder, Aspergers, or Autism. Delays include motor, communication and/or social development.
Sensory Integration Dysfunction (DSI) symptoms, Processing Difficulties/Delays: For many children with SM, sensory processing difficulties are the underlying reason for being ‘shut down’ and their mutism. In larger, more crowded environments where multiple stimuli are present (such as the classroom setting), where the child feels an expectation, sensory modulation specifically, sensory defensiveness exists. Anxiety is created causing a ‘freeze’ mode to take place. The ultimate ‘freeze mode’ is MUTISM.
Common symptoms: Picky eater, bowel and bladder issues, sensitive to crowds, lights (hands over eyes, avoids bright lights), sounds (dislikes loud sounds, hands over ears, comments that it seems loud), touch (being bumped by others, hair brushing, tags, socks, etc), and heightened senses, i.e., perceptive, sensitive, Self-regulation difficulties (act outing, defiant, disobedient, easily frustrated, stubborn, inflexible, etc.).
Within the classroom, a child with sensory difficulties may demonstrate one or more of the following symptoms; withdrawal, playing alone or not playing at all, hesitation in responding (even nonverbally), distractibility, difficulty following a series of directions or staying on task, difficulty completing tasks. Through research it’s dictated that sensory processing difficulties may or may not cause ‘learning’ or academic difficulties. Many children, especially, highly intelligent children can compensate academically and actually do quite well. MANY focus on their academic skills, often leaving behind ‘the social interaction’ within school. This tends to be more obvious as the child ages. What is crucial to understand is that many of these symptoms may NOT exist in a comfortable and predictable setting, such as at home. In some children, there are processing problems, such as auditory processing disorder, that cause learning issues as well as heightened stress.
Behavioral: Children with Selective Mutism are often inflexible and stubborn, moody, bossy, assertive and domineering at home. They may also exhibit dramatic mood swings, crying spells, withdrawal, avoidance, denial, and procrastination. These children have a need for inner control, order and structure, and may resist change or have difficulty with transitions. Some children may act silly or act out negatively in school, parties, in front of family and friends. WHY? These children have developed maladaptive coping mechanisms to combat their anxiety.
Co-Morbid Anxieties: Separation anxiety, Obsessive Compulsive Disorder (OCD), hoarding, Trichotillomania (hair pulling, skin picking), Generalized Anxiety Disorder, Specific phobias, Panic Disorder.
Communication Difficulties: Some children may have difficulty responding nonverbally to others, i.e., cannot point/nod in response to a teachers question, or indicate thank you by mouthing words. For many, waving hello/goodbye is extremely difficult. However, this is situational. This same child can not only respond nonverbally when comfortable, but can chatter nonstop! Some children may have difficulty initiating nonverbally when anxious, i.e., have difficulty or are unable to initiate play with peers or go up to a teacher to indicate need or want.
Social Engagement Difficulties: When one truly examines the characteristics of a child with Selective Mutism, it is obvious that many are unable to socially engage properly. When confronted by a stranger or less familiar individual, a child may withdraw, avoid eye contact, and ‘shut down,’ not only leaving a child speechless but preventing him/her from engaging with another individual. Greeting others, initiating needs and wants, etc., are often impossible for many children. Many shadow their parents in social environments often avoiding any social interaction at all. The common example given is; ‘A child in grocery story can sing, laugh and talk loudly, but as soon as someone confronts him/her, the child freezes, avoids and withdraws from social interaction.’ As the child ages, freezing and shutting down rarely exist, but the child remains either noncommunicative or will respond nonverbally after an indeterminate amount of warm up time.
MUTISM is just one of the many characteristics that children with Selective Mutism portray.
Studies of Selective Mutism are scarce. Most research results are based on subjective findings based on a limited number of children. In addition, textbook descriptions are often nonexistent or information is limited, and in many situations, the information is inaccurate and misleading. As a result, few people truly understand Selective Mutism. Professionals and teachers will often tell a parent, the child is just shy, or they will outgrow their silence. Others interpret the mutism as a means of being oppositional and defiant, manipulative or controlling. Some professionals erroneously view Selective Mutism as a variant of autism or an indication of severe learning disabilities. For most children who are truly affected by Selective Mutism, this is completely wrong and inappropriate!
Research indicates that children who seem oppositional in nature often have parents, teachers, and/or treating professionals who have pressured them to speak for months, perhaps years. Mutism not only persists in these children, but is negatively reinforced. These children may develop oppositional behaviors out of a combination of frustration, their own inability to make sense of their mutism, and others pressuring them to speak.
As a result of the scarcity and, often, inaccuracy of information in the published literature, children with Selective Mutism may be misdiagnosed and mismanaged. In many circumstances, parents will wait and hope their child outgrows their mutism (and may even by advised to do so by well-meaning, but uninformed professionals). However, without proper recognition and treatment, most of these children do NOT outgrow Selective Mutism and end up going through years without speaking, interacting normally, or developing appropriate social skills. In fact, many individuals who suffer from Selective Mutism and social anxiety who do not get proper treatment to develop necessary coping skills may develop the negative ramifications of untreated anxiety. (See below)
Findings indicate that the earlier a child is treated for Selective Mutism, the quicker the response to treatment, and the better the overall prognosis. If a child remains mute for many years, his/her behavior can become a conditioned response where the child literally gets used to non-verbalizing. In other words, Selective Mutism can become a difficult habit to break!
Because Selective Mutism is an anxiety disorder, if left untreated, it can have negative consequences throughout the childs life and, unfortunately, pave the way for an array of academic, social and emotional repercussions such as:
Depression and manifestations of other anxiety disorders
Social isolation and withdrawal
Poor self-esteem and self-confidence
School refusal, poor academic performance, and the possibility of quitting school
Underachievement academically and in the work place
Self-medication with drugs and/or alcohol
Suicidal thoughts and possible suicide
According to the US Surgeon General, our country is in a state of emergency as far as childrens mental health is concerned. 10% of children suffer from mental disorders, but less than 5% of these children are actually receiving treatment. Anxiety disorders are the most common mental illnesses among children and adolescents.
Parents should speak with their family physician or pediatrician and/or seek out a psychiatrist or a therapist who has experience with Selective Mutism. However, please note that having experience with Selective Mutism does not guarantee that the treatment approach and understanding is correct. In fact, a clinician with less experience, yet who has an excellent understanding of Selective Mutism may be an ideal choice for your child!
This information is adapted from Dr. Elisa Shipon-Blum’s handout: “WHAT is Selective Mutism? A GUIDE to Helping Parents, Educators and Treatment professionals Understand Selective Mutism as a Social Communication Anxiety Disorder”. All rights reserved.