Research studies on SM are scarce. Most articles and textbook descriptions are based on subjective findings from a limited number of children. In some cases, medical and educational professionals have not been taught about SM, and in other cases, they have received little training and even inaccurate and misleading information on the subject. A common misconception that doctors, teachers, and other professionals often share is that a child with SM is simply shy or that they will outgrow the behavior on their own. Other professionals incorrectly interpret mutism as oppositional or defiant behavior used as a means of manipulation and control. Some also incorrectly view selective mutism as a variant of autism or an indication of severe learning disabilities. As SM is best understood as an anxiety disorder, this misunderstanding leads to misdiagnosis and ineffective treatment strategies.

Currently, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) is the standard diagnostic manual for treating professionals (APA, 2013). One advancement of the DSM-5 that has helped improve understanding of selective mutism is its reclassification as an anxiety disorder rather than a disorder first diagnosed in infancy. Small steps forward like this show an increased awareness of SM, but further research is still needed to help more teachers and treating professionals understand the symptoms of selective mutism, its association with social anxiety, and its treatment as an anxiety disorder.

(Sources: https://www.apaservices.org/practice/reimbursement/icd-diagnostic/dsm-5?_ga=2.122049805.703081241.1609966823-1318883550.1609966823 and https://www.ncbi.nlm.nih.gov/books/NBK519711/table/ch2.t2/)

There is no single cause of SM, but it is generally understood to be an anxiety disorder related to shyness, social anxiety, and inhibited temperament in which speaking situations are avoided and this avoidant behavior gets reinforced over time. Some evidence suggests a genetic link between children with SM and anxious parents or family members. There is further evidence that behaviorally inhibited children have a decreased threshold of excitability in the amygdala, the area of the brain that receives and processes signals of potential threats. Disorders such as expressive/receptive language and communication disorders may increase a person’s risk for developing SM. Some research also suggests that being bilingual may increase a person’s risk for developing SM as compared to monolingual speakers. Although extremely rare, traumatic or stressful events may be related to the onset of SM. The majority of people with SM do not report a history of traumatic events.

Evidence-based treatments that are effective for SM

Some of the following information is excerpted from: Cohan, S.L., Chavira, D.A., and Stein, M.B. (2006). Practitioner Review: Psychosocial interventions for children with selective mutism: a critical evaluation of the literature from 1990–2005. Journal of Child Psychology and Psychiatry 47:11, 1085–1097.

Treatment for Selective Mutism can include psychotherapy and medication to address the anxiety that underlies the person’s inability to speak in certain situations. Some children with Selective Mutism also benefit from speech-language therapy, occupational therapy, sensory-integration therapy, and other interventions that may be recommended by the main treatment provider(s).

In psychotherapy, a psychologist or other professional will use some of the following approaches, depending on the individual child:

Behavioral and Cognitive-behavioral (CBT) strategies are the most widely supported psychological treatment for Selective Mutism.

Behavioral strategies: This refers to coming up with a step-by-step plan where the child gradually does more and more difficult speaking-type behaviors, as well as coming up with a system of positive reinforcement whenever the child is able to accomplish those behaviors.

There are several behavioral strategies. They are most effective to support the child to make and maintain gains in speaking when they are used together:

• Contingency management involves positive reinforcement of (or rewarding for) verbal behavior with initial reinforcement of nonverbal communication like pointing and whispering
• Shaping reinforcement is provided for approximations of the target verbal behaviors (e.g., mouthing words, whispering, talking on the telephone) and later for normal speech. A reinforcement menu (what types of rewards the child wants to earn and for what behaviors) is first developed in collaboration with the child.
• Stimulus fading interventions build on the success of contingency management and shaping by gradually increasing the number of people and places in which speech is rewarded. For example, the child may first be rewarded for speaking to a classmate to whom s/he already speaks outside of school. Gradually, other students are introduced into the group until the child is able to speak in the presence of a large group of peers. Stimulus fading can also be used in problematic situations that occur outside of school (e.g., talking to grandparents, ordering in fast food restaurants).
• Systematic desensitization traditionally involves the use of relaxation skills along with gradual exposure to successively more anxiety-provoking situations. In this type of intervention a hierarchy of feared speaking events is constructed and therapy consists of a series of imaginal and in vivo (real-life) exposures to feared situations.
• Social skills training may also be used to reduce anxiety and facilitate speech with peers and involves learning what to say to initiate conversations, how to take turns, making eye contact, and learning how to understand another person’s nonverbal behavior.
• (self-)modeling involves making video and/or audiotapes that have been edited to depict the child speaking in settings in which he or she has previously remained mute. The tapes are played repeatedly throughout the intervention, with the expectation that the child will become accustomed to hearing him- or herself speaking in these settings and will begin to believe in his or her ability to do so.

Cognitive strategies: This involves identifying anxious thoughts that contribute to the mute behavior. Introducing cognitive strategies is most useful for children age 7 and older, when they have developed the ability to become aware of their thoughts. Techniques include recognizing body symptoms of anxiety, identifying and challenging maladaptive beliefs, and developing a coping plan to deal with distress. For example, many selectively mute children have anxious thoughts or worries that people will make fun of their voice or what they want to say. Cognitive therapy teaches the child to understand that those thoughts are the product of worry (and are not real threats) and to coach themselves by telling themselves positive thoughts instead. Cognitive strategies should be added to behavioral strategies at a point in time determined by the treatment provider.

Other therapies commonly used alongside the behavioral or cognitive-behavioral treatment above, while not necessarily researched or supported by research as yielding gains in children with SM, are aimed at increasing the child’s self-esteem to strengthen the child emotionally by reinforcing areas of competence, belonging and acceptance as he/she completes the difficult work involved in these behavioral and cognitive-behavioral therapies. These may include learning new skills and/or encouraging participating in sports, music, arts, etc.

Medication

A medical doctor (psychiatrist, pediatrician) can prescribe medications that address the anxiety that underlies the child’s inability to speak in certain situations. Medications are most effective when combined with behavioral and/or other psychological strategies above, especially to help the child maintain gains in communication over time. In particular, the SSRI (selective serotonin reuptake inhibitors) have the most evidence for being useful in youth with anxiety conditions.

Speech-Language Therapy

The following is excerpted from Speech-Language Therapy and Selective Mutism. Contributed by: Evelyn R. Klein, PhD, CCC-SLP, BRS-CL and Sharon Lee Armstrong, PhD. For the full article see: http://www.selectivemutism.org/resources/library/Speech%20and%20Language%20Issues/Speech-Language%20Therapy%20and%20Selective%20Mutism/view

Speech-language pathologists (SLPs) may contribute to the treatment benefits of children with selective mutism (SM), as speech and/or language impairments can co-occur with SM. In addition, SLPs are trained in working with pragmatic language that is greatly impacted by children with SM. For these children, simultaneous treatment using both behavioral strategies to help children feel more comfortable to speak and linguistically-based activities to foster language development are recommended. SLPs often follow a behavioral approach of setting goals with gradual increases in expectations. For example, The Ritual Sound Approach® (RSA) that is a component of Social Communication Anxiety Treatment (S-CAT) by Dr. Shipon-Blum (2010) has had good success in helping children communicate with greater ease. The behavioral technique of shaping is used to help modify and shape specific phonemes into blended sounds that represent real words. This approach starts with voiceless speech sounds that require less vocal effort in that they don’t engage the vocal cords. Children feel air move in and out of their mouths as they breathe, blow, and cough. Thus, voiceless speech sounds such as /h/ (similar to breathing), /k/ (similar to a cough), /s/, /t/, /p/, etc. are used because they are less audible than vowels or voiced consonant sounds such as /z/, /d/, /b/, /g/, etc. This behaviorally-based treatment helps the child think of sound-making from a mechanical standpoint (e.g. put lips together lightly, build up air pressure in the mouth and puff out air to produce the sound of /p/).

SLPs may also use augmented self-modeling, a technique that has promise for reducing anxiety when speaking (Kehle, Bray, Byer-Alcorace, Theodore, & Kovac, 2011).The child watches videotaped segments of herself or himself during a positive verbal interchange (often at home) and then visually (through playback) carries the communicative interchange into another setting that is often more challenging. Using video software, the child can get a virtual glimpse into communicating successfully in a setting that causes heightened anxiety. In many instances coordinating voice and speech while thinking of what to say (linguistically) becomes difficult for children with SM due to anxiety. Therefore, non-speech tasks may be used to help the children gain control of voicing. Once vocal control in non-speech tasks is adequate then speech can be introduced slowly and systematically to allow for success. A typical progression is as follows:

• Communicate by pointing, gesturing, or nodding (use games, toys, and age-appropriate projects)
• Communicate by drawing or writing (use games requiring these modalities)
• Talk through a recording device that is played when out of the room and then when in the room (as comfort increases)
• Talk to another person who speaks for the child (in front of others with increasing distance from the person’s ear)
• Talk to others using sounds (may be blended to form words)
• Talk to others using rehearsed or scripted language with and without visual prompts (develop charts to play guessing games – include phone as possible)
• Talks spontaneously using words or phrases (including phone)
• Talks spontaneously using sentences (including phone)

Children with SM who present with a language delay may benefit from treatment that includes basic vocabulary development, grammatical morpheme development, and work on sentence structure. For many children with SM, the goal will be to enhance social-pragmatic communication with work on enhancing descriptive language (vocabulary and describing), expository language (informing and explaining), narrative language (storytelling), and discourse for social communication (discussing and interacting).

SLPs may first work on nonverbal skills of social engagement and later include communication skills in joint activity routines. Speech articulation therapy may also be part of the treatment protocol for children who have speech production errors, either sound substitutions, distortions, omissions, or additions.

It should be noted that some children with SM believe they cannot speak in some settings and so they may not properly engage their respiration, voice, or articulation appropriately. Children with SM can get accustomed to not speaking and thereby assume the self-image of the child who does not talk (Omdal, 2007). This self-fulfilling prophecy is one that can persist without appropriate intervention. The earlier the intervention, the better!

Kehle, T.J., Bray, M.A., Byer-Alcorace, G.F., Theodore, L.A., & Kovac, L.M. (2011). Augmented self-modeling as an intervention for selective mutism. Psychology In The Schools, 49(1), 93-103.

Omdal, H. (2007). Can adults who have recovered from selective mutism in childhood and adolescence tell us anything about the nature of the condition and/or recovery from it? European Journal of Special Needs Education, 22(3), 237-253.

Shipon-Blum, E. (2010). Transitional stage of communication.

What is Evidence-Based Treatment?

The term evidence-based treatment (also known as evidence-based practice) refers to intervention approaches that are informed by formal research findings and integrated with a provider’s clinical experience in the context of patient characteristics, culture, and preferences.

There are several terms that are often used interchangeably to refer to evidence-based treatment, including “evidence-based practice,” “science-based treatment,” “research-based treatment,” etc. All of these terms aim to emphasize the importance of using the best available research findings to tailor an empirically-supported treatment to an individual’s unique needs.

“Empirically-supported treatment” (EST) is a more specific term that is used to describe a treatment method that has been specifically and rigorously tested through numerous and well-designed research studies that shows positive results for a specific population and for a specific problem.

Most often, providers in the community who are providing evidence-based treatment (EBT), are using empirically-supported treatments (EST) to inform their practices. This means that they are integrating the principles and some of the methods from these well-studied ESTs into their own treatment approach, which also takes into account their clinical expertise and characteristics specific to their patient. As most patients present with more complexity than what is targeted in a research study, it is difficult to deliver an ESTs in the exact way that they are studied. Therefore, the best practice is when a provider uses an EST to inform the way they approach treatment, which is called Evidence-Based Treatment (EBT) or Evidence-Based Practice (EBP).

When deciding whether or not to use medication as part of your child’s treatment plan, consult with a doctor who has experience using the recommended medications for children with selective mutism. This choice is also dependent on your comfort level. We encourage parents of children with selective mutism to be as educated as possible about the types of medications used for SM (for example, one commonly used medication is Prozac) as well as other treatment options. Research indicates that medication may be warranted in the following circumstances:

• If SM symptoms are severe
• If your child has had a poor response to behavioral therapy or cognitive behavioral therapy in the past
• If your child is not meeting the goals or benchmarks for treatment as expected
• Has numerous other co-occurring disorders
• There is a strong family history of anxiety and/or depression
• In adolescents or young adults who have not had successful treatment to date.

For more information on medication use in youth with SM, please go here.

Don’t hesitate to ask your provider any questions you may have and read all the available literature on treating SM so you can make an informed decision.

Check out the Selective Mutism Association’s Online Library for a vast collection of accurate and evidence-based information on SM.

There are several ways you can approach educating other children about their classmate and selective mutism. The decision to do so should be made on a case-by-case basis with input from the child, their family, and clinician (if in treatment services). Once you have received the OK, try these tactics:

• Read a story featuring a protagonist with selective mutism. Check out the SMA bookstore for titles such as Leo’s/Lola’s Words Disappeared, Maya’s Voice, and more. When taking this approach, talk about SM in the context of the child in the story feeling nervous about speaking in certain places. You can also use this as an opportunity to normalize anxiety in general. Relate it to how other students may feel nervous about other things, such as storms, being separated from their parents, or taking a test. This can also lead to discussions about how students may help a classmate with selective mutism: include them in activities, do no not demand that they speak, do not make a big deal about it if the child does speak, and do not speak for the child. Depending on where the child is in terms of their symptoms, additional discussion about how to use choice questions to encourage speech—e.g., “During recess, would you rather swing or play tag?”—may also be appropriate.
• Share videos about selective mutism. For some older students, watching a video that explains SM serves a similar purpose as a storybook but is more developmentally appropriate for the audience.

Before using any tactics, however, decide if it’s better to have the child included in the class discussion or if it would be better if they are not present. It is crucial to have the input of the child and their parents, as it may make some children with SM even more nervous to be in the classroom during the discussion, while others might not mind at all and would appreciate that their peers are learning more about them. Try sending home the book (or video) with the child with selective mutism so they can review it with their parents, preview the discussion, and be a part of the decision-making process.

It may also be necessary to provide education on an individual level to specific students who frequently interact with the child with SM. Usually, this is done on an individual basis. Phrases such as the following may require gentle correction:

• “[Name] doesn’t talk.”
• “[Name] is shy.”
• Forms of speaking on their behalf, such as, “We like to play tag.”

Correction can look like:

• “She does talk and she is working on using her brave voice here, but doesn’t talk to you quite yet.”
• “Actually, our friend isn’t shy at all, but it’s hard for them to use their voice here at school right now.”
• “I can see that you want to be a good friend and that you’re trying to help [Name] by speaking for them. It’s important to make sure we give them a chance to speak for themselves too! Just because [Name] wanted to play tag yesterday doesn’t mean they will want to play tag today too.”

Another situation likely to require adult intervention would be if the child with SM did begin to speak at school in a limited way—e.g., with one friend on the playground—and the friend makes a big deal about it. Something simple such as the following interaction may be appropriate:

Student: [Name] just talked!! Say it again! Did you hear that [Name] just talked to me?

Teacher: (Take child to the side) I can see that it’s really exciting for you to have heard [Name]’s voice. I’m also very proud of [Name] for being so brave here at school. Remember, though, it’s important not to make a big deal about it because it may make [Name] feel even more nervous.

There are various clinical accounts and other observations of the behavior of children with selective mutism. The majority of these children and adolescents speak normally and at an appropriate age level when in a comfortable environment. Parents often comment on how boisterous, sociable, humorous, inquisitive, talkative, and even bossy and assertive these children are at home. What differentiates children with SM from others is their inability to speak in certain social settings. In these settings, many children with SM feel as if they are continuously “on stage” and experience many of the same symptoms that people have with stage fright. Some children with SM also report somatic complaints such as nausea, headaches, and stomachaches or may experience vomiting, diarrhea, and an array of other physical symptoms before school or outings. Other behavioral differences have also been observed. Here’s a full rundown on the signs, symptoms, and traits of children with selective mutism.

Along with the regular signs and symptoms of selective mutism, associated features may include:

• Profound shyness
• Little eye contact (in uncomfortable settings)
• Social isolation
• Fear of social embarrassment
• Withdrawal
• Clinging behavior
• Compulsive traits
• Attempts to avoid feared social situations due to anxiety
• Temper tantrums, particularly at home

Additionally, since a child with SM is unable to communicate verbally, they may opt for using nonlinguistic cues such as gestures, nodding, or shaking the head to get their message across. A child may also communicate in monosyllabic, short, or monotone utterances or with an altered voice (APA, 2000).

Some of these behaviors may not be present at the onset of SM. At the onset of SM, children may often be motionless and expressionless due to anxiety and then slowly progress from nonverbal and non-communicative stages to communicative and verbal stages in treatment (Shipon-Blum, 2001). Many youth with SM may have difficulty asking to use the restroom resulting in enuretic behaviors. This may also result from co-occurring social anxiety symptoms that can lead to paruresis, or “shy bladder syndrome,” the fear of using public restrooms—often caused by anxiety around making sounds while urinating that others may hear (Stein & Walker, 2002). Other common comorbid issues may include difficulty eating in front of others or difficulty separating from known/comfortable adults such as parents.

DSM-5 classified selective mutism as a relatively rare disorder, with point prevalence rates ranging between 0.03 % and 1% (APA, 2013). However, several researchers have suggested that the true prevalence of SM in the general population is largely underestimated (Bergman et al., 2002; Hayden, 1980; Hesselman, 1983; Kupietz & Schwartz, 1982; & Thompson, 1988). Some studies show that SM is not as rare as it was previously believed to be but is comparable to other, widely known disorders of childhood.

A study targeting a large sample of children in a Los Angeles school district identified children who met the diagnostic criteria for SM and found a prevalence rate of 7.1 per 1,000 children (Bergman et al., 2002). A subsequent study in Israel found an almost identical prevalence rate (Elizur & Perednik, 2003). In comparison with other studies, which only accounted for diagnosed cases of SM, these studies suggest that a large number of individuals with SM are likely undiagnosed or misdiagnosed and that SM may not be as rare as previously thought. Parents of children with SM who enter treatment often report that their child was misdiagnosed with autism or another pervasive developmental disorder, mental retardation, or oppositional-defiant disorder. Most are told by professionals that there is nothing wrong with their child, that their child is “just shy,” or will grow out of this behavior. Thus, the lack of awareness among pediatricians, treating professionals, and educators often leads to delays in diagnosis and missed opportunities for treatment.

SM is slightly more common in females than males. The average age of onset is five years, even though most parents report that their children’s symptoms began years earlier (Leonard & Dow, 1995). In his treatment of children with SM, Thompson (2000) found that children who establish speech in previously mute settings before age eight typically become verbal in school and social settings within one year. Children who demonstrated longer-term mutism were likely to continue their silence into upper grades and adulthood (Thompson, 2000). While studies  of older children and adolescents with SM are scarce, based on our collective clinical experience, individuals who enter into treatment later may suffer from depression and other disorders in addition to SM but can make treatment gains and overcome SM without it continuing into adulthood.

A trained professional familiar with SM or anxiety disorders generally evaluates a child for SM by conducting a thorough assessment. This is key to accurately diagnosing the condition, as it helps rule out similar or comorbid conditions and lead to the formulation of a more effective treatment plan. The treating professional then gathers information about the child’s developmental history, family history, behavioral characteristics, medical history, and significant stressors. They may also request permission to contact the child’s school, physician, and other significant people in the child’s life to gain further information about their behavior. Viewing a video of the child in a comfortable setting or observing them in advance of this meeting can also be helpful. Further analysis would then take place during a subsequent meeting between the child and the professional. Read a full overview of how someone is evaluated and diagnosed with selective mutism.

The use of medication in the treatment of SM comes from understanding that SM is related to social anxiety, and medications have been shown to help social anxiety and other related disorders in adults. Several small-scale studies have shown that SSRIs and other anxiety medications effectively treat SM. When combined with appropriate behavioral or cognitive-behavioral therapy, the treatment success rates are dramatically higher.

• Research indicates that medication may be warranted in the following circumstances:
• If SM symptoms are severe
• If your client has had a poor response to behavioral therapy or cognitive behavioral therapy in the past
• If the client is not meeting the goals or benchmarks for treatment as expected
• Has numerous other co-occurring disorders
• There is a strong family history of anxiety and/or depression
• In adolescents or young adults who have not had successful treatment to date.

Find out more about treating SM with medication.