Selective Mutism in Children and Youth
Selective mutism is a severe childhood anxiety disorder where a child is ‘mute' (unable to speak) in certain situations such as school. It is ‘selective', because the mutism usually doesn't occur in all situations. In situations where the child feels relaxed, like at home or with close friends and family, the child may be able to speak normally. The difference between selective mutism and a child who is shy is determined by the intensity of the anxiety, presence of avoidance behaviours, and the persistence of the child being unable to speak in situations where s/he is usually expected to speak.
Selective mutism typically starts when a child enters school. Many children with selective mutism are shy and hesitant to speak at the start of school. These children will typically speak comfortably by the end of the school year.
In cases where the mutism persists, it is known as persistent selective mutism. Though less commonly seen, if not treated this may persist even through secondary school.
If you suspect your child is selectively mute, you should first speak to your doctor, to rule out any underlying medical conditions. The doctor can then help with any necessary referrals to more specialized services, which may include seeing a psychologist or speech-language pathologist. Typical treatments used include:
- Assessment and consultation with a Speech-Language Pathologist who can develop a step-by-step approach to verbal communication in environments where the child does not speak.
- Cognitive behaviour therapy (CBT), which helps individuals cope with anxiety by focusing on changing their thoughts and behaviours.
- Working with school staff including teachers, school counsellors, and educational psychologists to create a treatment plan for school
- Medications, which can be prescribed by a physician. Medications are generally reserved for situations where anxiety has not responded to non-medication treatment, or when the anxiety is so severe that counselling is not possible.
Remember that your child with mutism is not being mute ‘on purpose,' or trying to ‘control' a situation by being mute. These children want to be able to speak however they are blocked by severe anxiety.
Since anxiety is the underlying cause, the best way to help is to say or do things which help your child feel more calm, relaxed or less anxious. Conversely, pressuring the child, using guilt trips, punishing or forcing the child to talk is not helpful as that worsens the anxiety.
When your child with selective mutism is not around, talk with others (friends, family, school staff or students) to educate them. Though the exact wording will need to be adjusted depending on who the audience is, one might say something like:
- "You know how some people are very shy? ____ is so shy, that it's actually a condition called "selective mutism", which is a type of severe anxiety.
- "The good news is that there are things that all of us can do to help ___ feel more relaxed so s/he'll talk."
- Don't try to make him talk. Don't say to others, "he doesn't talk". It's okay to say, "he's just a bit shy, so we need to accept him as he is." Don't make a big deal if he speaks, because that might just get him more nervous. Just be cool if he speaks, act as if everything is normal and continue on."
- "Treat her the same way you'd want someone to treat you! Be nice to her and include her in activities - ask if she wants to play or join in."
There are many ways to help a child think (cognitive strategies) and behave (behavioral strategies) to overcome selective mutism.
Cognitive strategies. Selectively mute children may have ‘worry thoughts' about others hearing their voice, or asking them questions about ‘why they do not talk'. Teaching the child ‘coping thoughts' can help in overcoming those worries. Examples of coping thoughts include, "My voice sounds fine", "It's okay to worry about my voice from time to time", "They're not laughing at me".
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. It is essential to work together with the child and have the child's agreement on what the step-by-step plan will be. If a child is unable to have success it probably means that the steps were too ambitious and need to be reduced.
Step-by-step approach to non-verbal / verbal communication. Since talking (verbal communication) is the most difficult type of communication, accept that the child may need to work up to that. Encourage the child to start by using easier forms of communication such as gestures or writing; progressing up to whispering or speaking to a familiar person in front of others; then yes/no questions, then one word answers, etc. Eventually, the child will be able to speak in full sentences. In general try to avoid direct questions and extended eye contact, as this might increase anxiety in your child. Talking to your child, making comments, and including them in conversation without direct pressure to participate, are good strategies to use in your daily life.
Go step by step. It is easiest for the child to communicate with close family and friends. Accept that the child will need to gradually work up to others such as other adults, teachers and peers. Children with selective mutism benefit from a gradual approach to encouraging communication with others. The steps you take in encouraging communication may vary by environment or communication partners. The following are some examples of step-by-step, or ‘exposure hierarchy' approaches that may enable your child to communicate with other family/friends and at school (please note that these are only general guidelines and suggestions)
One ‘exposure hierarchy' for family/friend situations might be:
- Begin by creating opportunities for your child to communicate with close family. In time, you can progress to relatives and friends.
- Start with structured activities (e.g. watching movies, board games, sports) where there is less pressure on the child to speak. Do not place pressure on your child to speak or communicate. Allow for relaxed nonverbal participation in these activities.
- When you feel that your child is less anxious in these situations, or you have noticed some attempts at communication (nonverbal or verbal, with you or others), move up to more unstructured activities (e.g. where the children are simply playing freely)
Coping strategies that your child might use include whispering, speaking through their parent to others, nonverbal communication (e.g. pointing, gestures), and allowing themselves to be overheard speaking to their parents in the presence of others.
One ‘hierarchy' for school situations might be:
- Take the child to his/her school, when few people are around, to allow your child opportunities to speak to familiar people in this new environment.
- Encourage the child to invite peers over at home. Hopefully, as the child feels more comfortable with peers at settings outside of school, h/she will eventually be able to also talk to those peers at school.
- Eventually bring a friend or two with whom your child is comfortable with, to school and allow the children to play when other children are not present. Groups with only a small number of children are helpful, and also allow parents to spend time with their child within the class.
- Often a child will communicate with peers before they are comfortable enough to communicate with school staff.
- Prior to speaking at school, your child might show a decrease in anxiety, and an increase in their willingness to participate nonverbally and use nonverbal communication (e.g. pointing).
- Positive reinforcement for verbalization should only be introduced when, and only when, anxiety is lowered and the child feels comfortable and is obviously ready for some subtle encouragement.
Increase Self-Esteem and Confidence. Give praise for the effort, not the outcome. Praising a child who tried but failed is better in the long run, than praising a child who was successful, but who didn't put any effort into it.
- Figure out what the child is good at, and praise and encourage those strengths. E.g. if the child is musical, then show off and praise his/her musical skills. E.g. if the child is good at a particular sport, then show off and praise those skills.
- Be positive! Make encouraging comments to your child
- Build rapport with new people or environments around activities your child enjoys
For Parents and Teachers
- Helping Your Child With Selective Mutism: Steps to Overcome a Fear of Speaking, Angela McHolm, Charles Cunningham, Melanie Vanier, Aug 2005
- Cat's Got Your Tongue?: A Story for Children Afraid to Speak, by Charles Schaefer, Judith Friedman, 1992, ages 4-8
- The Selective Mutism Group at www.selectivemutism.org.
Written by the eMentalHealth.ca Team. Special acknowledgements to Nicole Roberts, speech-language pathologist for comments and suggestions.
Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.
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Date of Last Revision: Jun 21, 2013