Selective mutism (formally known as elective mutism) is a disorder that usually occurs during childhood. It is when the child does not choose to speak in at least one social setting. However, the child can speak in other situations. Selective mutism typically occurs before a child is 5 years old and is usually first noticed when the child starts school.
*Teachers are vital in helping diagnose SM because the mutism usually occurs at school*
What are some signs or symptoms of selective mutism? Symptoms are as follows: consistent failure to speak in specific social situations (in which there is an expectation for speaking, such as at school) despite speaking in other situations.
not speaking interferes with school or work, or with social communication.
lasts at least 1 month (not limited to the first month of school).
failure to speak is not due to a lack of knowledge of, or comfort, with the spoken language required in the social situation
not due to a communication disorder (e.g., stuttering). It does not occur exclusively during the course of a pervasive developmental disorder (PPD), schizophrenia, or other psychotic disorder.
Selective mutism is described in the 2000 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR: pp.125-127).
Children with selective mutism may also show:
anxiety disorder (e.g., social phobia)
fear of social embarrassment
social isolation and withdrawal
How is selective mutism diagnosed?
A child with selective mutism should be seen by a speech-language pathologist (SLP), in addition to a pediatrician and a psychologist or psychiatrist. These professionals will work as a team with teachers, family, and the individual.
It is important that a complete background history is gathered, as well as an educational history review, hearing screening, oral-motor examination, parent/caregiver interview, and a speech and language evaluation.
The educational history review seeks information on:
previous testing (e.g., psychological)
The hearing screening seeks information on:
possibility of middle ear infection
The oral-motor examination seeks information on:
coordination of muscles in lips, jaw,and tongue
strength of muscles in the lips, jaw, and tongue
The parent/caregiver interview seeks information on:
any suspected problems (e.g., schizophrenia, pervasive developmental disorder);
environmental factors (e.g., amount of language stimulation)
child's amount and location of verbal expression (e.g., how he acts on playground with other children and adults)
child's symptom history (e.g., onset and behavior)
family history (e.g., psychiatric, personality, and/or physical problems)
speech and language development (e.g., how well does the child express himself and understand others)
The speech and language evaluation seeks information on:
expressive language ability (e.g., parents may have to help lead a structured story telling or bring home videotape with child talking if he or she refuses to do so with the SLP)
language comprehension (e.g., standardized tests and informal observations)
verbal and non-verbal communication (e.g., look at pretend play, drawing)
To contact a speech-language pathologist, visit ASHA's Find a Professional.
What treatments are available for individuals with selective mutism?
The type of intervention offered by an SLP will differ depending on the needs of the child and his or her family. The child's treatment may use a combination of strategies, again depending on individual needs. The SLP may create a behavioral treatment program, focus on specific speech and language problems, and/or work in the child's classroom with teachers.
A behavioral treatment program may include the following:
Stimulus fading: involve the child in a relaxed situation with someone they talk to freely, and then very gradually introduce a new person into the room
Shaping : use a structured approach to reinforce all efforts by the child to communicate, (e.g., gestures, mouthing or whispering) until audible speech is achieved
Self-modeling technique: have child watch videotapes of himself or herself performing the desired behavior (e.g., communicating effectively at home) to facilitate self-confidence and carry over this behavior into the classroom or setting where mutism occurs
If specific speech and language problems exist, the SLP will:
target problems that are making the mute behavior worse;
use role-play activities to help the child to gain confidence speaking to different listeners in a variety of settings; and
help those children who do not speak because they feel their voice "sounds funny".
Work with the child's teachers includes:
encouraging communication and lessening anxiety about speaking;
forming small, cooperative groups that are less intimidating to the child;
helping the child communicate with peers in a group by first using non-verbal methods (e.g., signals or cards) and gradually adding goals that lead to speech; and
working with the child, family, and teachers to generalize learned communication behaviors into other speaking situations.
To contact a speech-language pathologist, visit ASHA's Find a Professional.
What other organizations have information on selective mutism?
This list is not exhaustive, and inclusion does not imply endorsement of the organization or the content of the Web site by ASHA. K12 Academics NYU Child Study Center Selective Mutism Foundation
Selective Mutism and Childhood Anxiety Disorders Group
How is medication used in the treatment of SM?
The use of medication is based on the understanding that SM is related to social anxiety and there are medications that have been shown to help social anxiety disorder (or social phobia) in adults. In recent years, it has become clear that anxiety problems are related to an imbalance in some of the chemical messengers, or, neurotransmitters, of the brain. In particular, the neurotransmitter called serotonin seems to be involved.
Antidepressant medication in the form of serotonin reuptake inhibitors (SSRI's) such as Prozac, Paxil, Celexa, Luvox and Zoloft are often prescribed in the treatment of anxiety disorders. In addition to the SSRI's there are other medications that affect several of the neurotransmitters instead of just serotonin. Examples are Effexor, Serzone, Buspar and Remeron. Although none of these medications are approved by the food and drug administration (FDA) for use in treating SM in children, it is common for doctors to prescribe medications when there is reason to believe that they are safe and effective for a particular use.
There are several small-scale studies that have shown these types of medications to be effective in the treatment of SM. Of the few experts who have treated large numbers of children with SM, most report that these medications are very helpful and have a large margin of safety. Side effects are minimal and can usually be avoided by starting the medication at a very low dosage level and increasing it very gradually. Many children with SM seem to respond to a very low dosage of these medications so there is no need to keep increasing to higher levels. When combined with appropriate behavioral or cognitive-behavioral therapy, the treatment success rates are dramatically higher.
When medication is used as part of a treatment plan, the goal is usually to have the child take the medication for 9-12 months. This seems to be a sufficient time period to allow the child to decrease anxiety, become accustomed to speaking in most settings and for treatment gains to be maintained after the medication is stopped. When it is time to discontinue medication, it should always be tapered off slowly under a doctor's supervision to avoid adverse side effects that can occur if medication is decreased too quickly.
When should I use medication in my child's treatment?
The decision about whether or not to use medication should be made by consulting with a doctor who has experience using the recommended medications with children. The choice is also dependent on parents' comfort level. Parents are encouraged to become as educated as possible about the types of medications used for SM and other treatment options by asking many questions of their providers and reading the available literature in order to make an informed decision.
Medication is not always necessary in the treatment of SM but in many cases it appears to be very useful in helping the child to take the first steps in overcoming their anxiety. Until anxiety is lowered to a tolerable level, most children will have difficulty accomplishing even small goals toward speaking. This is especially true in cases in which the child has exhibited the SM symptoms for a long period of time, other available treatments have not helped the child to make improvement, or in cases where the child is also showing symptoms of depression. Medication is more likely to be prescribed in such cases where the mutism is more severe or chronic (such as with older children and adolescents).