Selective mutism has grown up! Selective mutism is an anxiety disorder that affects about 1 in 200 children, where the defining clinical feature is ability to speak normally at home or to family, but failure to speak in other situations where speech is called for. This perplexing disorder was previously housed in the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence section in DSM-IV. As of DSM-5, however, selective mutism has moved to the Anxiety Disorders section, something of a promotion. As the “new” anxiety disorder, selective mutism is sure to begin to attract much more attention from mental health providers, researchers, and the general population.
What is Selective Mutism?
The lack of speech that comes with selective mutism is not due to unfamiliarity with the language, a communication disorder, or an Autism Spectrum Disorder. The typical sufferer is a preschooler or kindergartner whose parents report that their child was “always a bit clingy and shy,” but they weren’t really aware there was a problem until they heard from the teacher, several months into the school year, that their child had yet to speak to anyone. However, the disorder can—and does—continue into middle childhood and beyond.
Selective mutism was, until the DSM-III, termed “elective mutism” and was theorized to represent some form of passive-aggressive oppositionality or a child’s attempts to manipulate adults. Research from the 90s and 00s, however, showed elevated rates of anxiety among these children as well as their family members, particularly social anxiety. Currently, selective mutism is considered an early and pernicious form of social phobia.
How Does This Present Itself in Children?
As a specialist in selective mutism, I see all sorts of presentations of the disorder. Some children will freely talk to their parents in front of others; some will only speak to their parents if they cannot be overheard. Some children will speak to teachers but not peers, others to peers but not teachers. Some children will happily participate in every activity at school that does not involve talking, others “shut down” immediately upon entering the school building and have to be led from one activity to the next. This last type of children are often so inhibited that they will not indicate they have to use the bathroom, and are prone to having accidents while at school.
The one commonality in presentation is that their parents always—always—tell me “we don’t understand this—she’s a chatterbox at home!” Another common feature is that functioning is very impaired, and during the very critical developmental period of early childhood. These children don’t speak at school, so they have difficulty making friends (thereby missing out on developing social skills) and difficulty participating fully in the classroom or on the sports field (so other, crucial developing skills are compromised).
Treating Selective Mutism
There are no official treatment guidelines yet, but behavioral therapy has garnered the most support in the scientific literature. There is also some published studies supporting SSRIs, such as Prozac or Zoloft, and these medications are generally used as an adjunctive to behavioral treatment.
My favorite thing about treating selective mutism is that the kids generally get better! Behavioral techniques, combined with training parents and teachers in those behavioral techniques, can result in sometimes very rapid resolution of symptoms, sometimes slow and steady improvement. Regardless of pace, when the child begins to speak (or “gets unstuck” as I like to term it with my families), their lives improve stunningly: The miserable child is now happy, the already happy child is happier still. Friends are made; teachers are answered; hands are proudly raised in class. Participation in sports and other social activities, once dreaded, is now a joy. And because talking is so intrinsically self-reinforcing, selectively mute children, once cured, tend not to relapse. The kid gets to be a kid! What more is there to say?