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Selective Mutism in Children and Youth: Information for Parents and Caregivers

Summary: It is normal for many people to be shy, but when that shyness is so normal that it stops a person from speaking outside the home (e.g. at school, or other public situations), then it may be a condition known as selective mutism.

“She won't speak to anyone…”

Jane is 6 years old and can dance and sing in front of her family…. she might even be the next Idol! But in music class she is paralyzed by fear and can’t say a word.

 

Jay is a 7 year old boy who plays soccer with his brothers and talks excitedly about his favorite World Cup team. Yet, at recess time, he stands alone watching the other kids play soccer and doesn’t speak when others ask him if he wants to play. Some of the kids think he’s a snob, and so they ignore him.

 

Mary is a 5 year old girl who talks at home with all her brothers, sisters and parents… but she has never spoken to anyone outside her home.

What is Selective Mutism?

Everyone gets shy from time to time. In fact, having just enough shyness can be helpful because it can protect us from doing things that may be embarrassing or awkward. But when shyness keeps a child or teen from speaking, then it may be a condition called Selective Mutism.

 

Selective Mutism is a severe anxiety disorder where a child is:

  • Not able to speak (or ‘mute’) in certain situations (for example, at school or public places)
  • Able to speak where she feels relaxed (like at home)

Children with Selective Mutism are not being mute ‘on purpose’. They are not trying to ‘control’ a situation by being mute. Not speaking is the way they protect themselves from severe anxiety.

 

Because anxiety is at the root of Selective Mutism, punishing, pressuring or making a child feel guilty won’t help at all. Doing these things can even be harmful. Trying to force a child to speak can make a child even more anxious and can backfire, making the mutism even worse.

 

On the other hand, anything you can do to reduce a child’s anxiety can make it easier for them to speak in situations that make them afraid. Helping children take small steps to facing their fears is one of the best ways to help a child overcome mutism.

How do I know if my child has Selective Mutism?

Most children with Selective Mutism look and act like any other child, when they are in a comfortable situation. But when they are in other situations, like school or other social settings, they feel very anxious.

 

Before or during social interactions, a child with Selective Mutism may:

  • Withdraw or ‘shut down’ when in the situation that makes them so anxious
  • Refuse to follow adult’s directions, and seem disobedient or defiant (for example, refusing to go somewhere that makes them feel anxious)
  • Avoid the stressful situation or activity
  • Complain of stomach aches or headaches
  • Stare into space, avoid eye contact or not smile
  • Have trouble saying simple things like ‘hello’, ‘goodbye’ or ‘thank you’

Children with Selective Mutism may also have:

  • Social Anxiety Disorder (9 out of 10 children with Selective Mutism meet criteria for Social Anxiety Disorder)
  • Difficulty being away from parents (Separation Anxiety)
  • Some form of speech or language problems
  • Daytime wetting or bed wetting (enuresis)

How does Selective Mutism develop?

Two main factors are involved in Selective Mutism:

 

  1. Family History: Most children with Selective Mutism have a family history of anxiety traits.

    Our brains have a hard-wired ‘fear system’. This ‘turns on’ when we feel we are in danger. It allows us to be ready to ‘fight’ or flee danger. In children with Selective Mutism, this ‘fear system’ gets ‘turned on’ easily by social situations. These children over estimate the danger in these situations, and become very anxious.
     
  2. Environment and experience: Children with Selective Mutism 'learn' behaviours that will help reduce their anxiety.

    When children feel a social situation is ‘dangerous’, they stay quiet, hide behind their parents or try to avoid the situation in other ways. When others respond by speaking for them or moving on, they feel less anxious. So these children learn that not speaking or avoiding social interaction helps them feel less anxious, and this behaviour becomes a pattern.

How can I help my child?

Do’s

 

  • Get help early. This is critical. The longer that the Selective Mutism lasts, the harder it is to treat, because the behaviours children use to avoid speaking become reinforced. This makes changing their behaviours more difficult.

     
  • Build on the bond between parents and children. Children with Selective Mutism feel the most secure when they are around their parents and less secure around others. It’s important to strengthen and build on this attachment. This will help children become more confident.
    • Spend time with your child. Try to set aside some special time each day where each of your children gets a turn to have you all to himself. This is not always easy, especially if you’re a single parent or have more than one child. But even 15 minutes of special time for each child every weekday can make a difference. Make this special time longer on weekends or whenever possible.
    • Choose activities that promote conversation. Board games, throwing a ball around, baking, crafts or Lego will give you lots of chances for your child to talk about feelings and emotions. Video games are not the best choice for 1:1 time, as they don’t give the same chances for eye contact and talking.
    • Create a safe space for expressing feelings. Name feelings and let your child see how you handle feelings in a positive way. Let your child know that whatever she is feeling is OK.
    • You don’t have to share all of your child’s feelings, but acknowledge them (“I can see how that might have made you feel angry”). Don’t tell your child that what they are feeling is wrong. Give your child a chance to vent while you listen and support.
    • Make separations easier for your sensitive child by having goodbye rituals. When you say ‘goodbye’, remember to mention of when you’ll see each other again. You could remind your child of something you’re looking forward to doing with them (Pancakes for breakfast? Taco night? Working on that puzzle later?). This will be very reassuring for your child. You can add a hug or a kiss, or maybe even a secret family handshake 
       
  • Do get professional help if things are not improving on their own.

Don’ts

  • Don’t force your child to speak, this will only make the anxiety worse.

     
  • Don’t ignore the problem. Parents may hear that their child is just shy and will outgrow the Selective Mutism. But there are serious consequences for a child who can’t communicate or speak to others:
  • It can be hard to make friends. Not having friends or being isolated can put children at risk for teasing or bullying.
  • It can impact a child's learning. Your child won’t be able to ask questions or ask for help. Teachers can find it hard to assess your child’s learning needs. Your child will not be able to take part in group work or learn important presentation skills. Over time, problems at school can affect your child’s self esteem, make anxiety or depression worse or make your child feel isolated. Children in these situations sometimes refuse to go to school.
  • Don’t blame your child for being ‘manipulative’. Remember, anxiety is at the root of this-your child is not trying to control things by not speaking. Your anger and frustration will only make things worse. All children do well if they can. When they can’t, it’s because they don’t have the skills they need. Fortunately, there are effective treatments for Selective Mutism.

How is Selective Mutism treated?

Seek professional treatment with an experienced mental health professional (e.g. psychologist, speech/language therapist, psychiatrist) if your child is mute for a month or more.

 

Treatment will focus on:

  • Reducing your child’s anxiety
  • Helping teachers and other adults understand Selective Mutism and develop reasonable expectations for communication.
  • Developing a communication hierarchy and helping your child to gradually face fears at a reasonable pace.

Treatment approaches depend on the child, but may include:

 

1. Behavioural Strategies

 

These are step-by-step plans to help a child gradually take part in more communication. These plans often include ‘reward’ systems for when the child makes progress. They involve:

  • Gradually exposing your child to more and more social situations in non threatening ways, without ‘pushing’ or overwhelming your child.
  • Encouraging structured social activities with other children (for example, a team sport or club)
  • Working from the ‘inside’ outwards, by encouraging talking with close family and relatives. You then might try having one friend play with your child at home, gradually increasing the number of friends and different locations (playground or school).
  • Starting with structured activities (like watching movies, board games, sports) where your child will feel less pressure to speak
  • Progressing to more unstructured activities (free play, dramatic play)

 

Helping your child in public settings:

  • Give your child chances to communicate in a public setting.
  • Encourage your child to take part in ordering food at a restaurant. For example, your child could start by pointing to menu items. You can have your child respond with ‘yes’ or ‘no’ in front of the server to questions you ask, or could say what they want with a prompt from you.
  • Take advantage of any chance for communication: paying at the grocery store, checking out a library book or saying ‘thank you’ to the bus driver.
  • Don’t make it a big deal when your child does speak. Calmly acknowledge what your child said, and carry on. When you have a quiet moment later, you could say something like, “You spoke very politely to the waiter in the restaurant-I think he appreciated that”.

Helping your child in school settings:

  • Take your child into school, when few people are around, so your child can practice communicating.
  • Encourage your child to invite children home to play. Hopefully, as your child feels more comfortable with friends outside of school, she will eventually be able to speak with these friends at school.
  • When you feel your child is ready, bring your child with a friend or two to play at school when no one else is around. This may mean the playground on a weekend, or the gym or a classroom after school. To play inside the school, you will probably need to speak with your child’s principal first.
  • Once your child is comfortable with this, have the teacher come around when your child is playing. Later on, other students can be introduced.

2. Cognitive-behavioral (CBT) strategies:

 

These strategies help children handle their anxiety. Many selectively mute children have ‘worry thoughts’ about others hearing their voice, or asking them questions about why they do not talk. Teaching children ‘coping thoughts’ helps them to overcome these worries. Examples of coping thoughts include, ‘My voice sounds fine’, ‘Its okay to worry about my voice from time to time’, ‘They’re not laughing at me’. These strategies work very well with the behavioural strategies outlined above.

 

3.Medications

 

Medications may be helpful for children whose Selective Mutism does not respond to various behavioral approaches. Medication can help reduce anxiety to allow the treatment plan to have a greater effect. Antidepressants known as SSRIs (selective serotonin reuptake inhibitors) have the most evidence for helping children and youth with anxiety conditions. Medications can be prescribed by a family physician, pediatrician or psychiatrist.

Working with the School

Meet with your child’s teacher, without the child around.  Parents need to take the lead to approach school staff about their child’s Selective Mutism.

 

School staff who may be able to help:

  • Teachers
  • School psychologists
  • Guidance counselors
  • Behaviour therapists
  • Principals or Vice-principals
  • Speech-language pathologists
  • Social workers

Hopefully the school will be familiar with Selective Mutism. If not, you can provide the school with a copy of this handout. You can also share key messages about Selective Mutism. Make sure to let teachers and school staff know that your child:

  • Is not being defiant or stubborn by not speaking
  • Communicates better when she feels less anxious. Blame, teasing, humiliation and coercion do not help her to speak
  • May need to use non-verbal communication at first

You can also:

  • Ask the teacher if it is possible to have a greeting ritual ("Good morning, hope you had a good evening last night!"), as well as a goodbye ritual at the end of the school day ("Have a great day, I'm looking forward to seeing you tomorrow!").
  • Educate other students (and school staff). Give the teacher permission to tell other students and staff about anxiety in general (or if you feel comfortable enough, your child's difficulties), at a time when your child is not in the classroom. The teacher might say something such as “Everyone has a bit of shyness. Some people are just a little bit shy, where some people are very shy. The good news is that there are things that all of us can do to help someone feel included, even if they are shy.”

Meeting with parents, teacher and the child

 

It is important to introduce your child to the people she feels anxious speaking around (for example, a teacher or child care provider). It is also important to let your child know that he can trust and feel safe with that person.

 

If your child is anxious speaking in front of the teacher, have a meeting with the teacher without your child. This will give you a chance to get to know the teacher. You can then arrange a time to meet the teacher with your child.
 

Let your child know that you have already met the teacher, and that your child can feel comfortable with him.


For example, you can say something like, "I'd like you to meet Mrs. So and So. You know what? She's really into dogs, just like you. In fact, she has a dog of her own. I think she's really nice, and I think you're going to get along with her."

Parenting Styles and Selectively Mute Children

Most parenting styles can be divided into 3 main types:

 

1. Authoritative

 

Most children do best when parents have an ‘authoritative’ parenting style. With selectively mute children, this is even more important. Authoritative parenting means parents are warm, gentle and supportive, but also have reasonable rules and expectations for behaviour. Harsh, punishing and rigid parenting approaches will not help a child at all. Finding the middle ground between being too permissive (parent educator Barbara Coloroso calls this being a ‘jellyfish’), and being too authoritarian (Coloroso calls this being a ‘brick wall’) isn’t easy. An ‘authoritative’ or ‘back-bone’ parent tries to find this balance.

 

Authoritative means:

  • Spending time with your children and youth, talking, doing activities or just hanging out to build a warm, healthy relationship.
  • Giving your children and youth guidance and rules so they can figure out how to be responsible.
  • Giving your children and youth more freedom as they show more responsibility.

2. Too permissive (Jelly fish parenting)

  • Not enough rules
  • Not concerned enough
  • Not taking problem behaviours seriously
  • Not protecting enough
  • Giving too much independence

3. Too authoritarian (Brick wall parenting)

  • Too many rules
  • Too concerned
  • Taking behaviour problems too seriously
  • Being over protective
  • Not giving enough independence

Reducing anxiety and changing behaviours one step at a time

 

1. First, you need to work with your child, a psychologist and your child’s school to come up with a plan. To do this, you’ll need to:

  • Figure out what your child’s long-term goals are. “What do you want to be when you grow up?” ”What do you want to do in the future?”
  • Find some way to help your child understand how being able to talk to others will help him to reach his future goals. For example, “Being a police officer sounds like a great idea. So do you know what needs to happen so you can become a police officer? You’ll need to finish high school, then go to police school. And we’ll need to help you have the confidence so you can talk.”

 

2. Set specific goals, starting with things that are easiest to do and work up to things that are the most difficult. Explain that you don’t expect her to be able to do the hardest things right away. But by taking small steps every day, she can ‘get there’.

 

For example, you might say something like,

  • "What would happen if I gave you 100 lbs to lift right now? It’d probably be too much! So say that we wanted you to one day be able to lift 100 lbs. How would we do it? We’d start you step-by-step – we’d give you 1 lb to lift. And if you could lift that, what would we do? That’s right, we’d give you 2 lbs. And if you could lift that? That’s right, we’d give you 3 lbs. And let’s say that 3 lbs was too much? Well, we could go back down to 2 lbs, or we could go part-way, down to 2 ½ lbs… Then, if you could lift the 2 ½ lbs, we could go back up to 3 lbs….”=

Example of a step-by-step hierarchy, from easiest to hardest

If your goal is to have your child have a conversation with another person, such as a teacher or peer, here is an example of some steps to get there:

 

Starting steps

  • Simply being around the another person without talking, e.g. playing Lego beside the teacher, or listening to the teacher talk
  • Non-verbal communication, like using gestures or writing

Middle steps

  • Whispering to teacher or classmates
  • Using a ‘regular’ voice and giving yes/no answers (e.g. to closed ended questions like “Did you have a fun time last night?”)
  • Using a ‘regular’ voice and giving longer, more complex answers to open ended questions like “What did you do last night?”

Hardest steps

  • Having a conversation with another person in full sentences

The idea is to go step-by-step towards the eventual goal. If a child struggles with a step, then one can find a simpler, lower step to go back to, just like in the weight lifting analogy earlier.

Celebrate success!

Managing anxiety and trying things that make you afraid takes courage. Take note of when your child takes a step forward and speaks in situations he finds difficult. But take care-enthusiastic praise can make your children’s anxiety worse, because it brings more attention to the problem. A warm smile, a wink, a touch or a calm, quiet word is all that is needed.

 

You might also acknowledge your child’s effort and success with a family treat like a special dinner or dessert, a family ‘toast’, or a family outing. Be sure to include your other children as well, for example “Let’s have a little celebration. Kevin was able to ask his teacher a question today, and Sarah’s been doing a great job tidying up after school. Why don’t we all walk over to the store to get some ice cream after dinner tonight?”

 

Remember-punishing a child for not speaking will not help. Punishment will only make the anxiety worse, making it even harder for your child to speak. If your child isn’t able to take an expected step forward, move down a step for a bit. Let your child get more comfortable at that step, and then try to move ahead again.

 

Remember, if your child had asthma...

  • Would you punish your child for having an asthma attack? 
  • Would you reward your child for not having an asthma attack?

Authors

Written by members of the Mental Health Information Committee at the Children’s Hospital of Eastern Ontario (CHEO), in collaboration with the Selective Mutism Group (Aimee Kotrba, Ph.D. & Lisa Kovac, Ed.S.)

References

  1. Black B, Uhde TW. Treatment of elective mutism with fluoxetine: a double-blind, placebo-controlled study. J Am Acad Child Adolesc Psychiatry. 1994 Sep;33(7):1000-6.
  2. Coloroso, Barbara. Kids are Worth it! 2002 Harper-Collins
  3. Kumpulainen K. Phenomenology and treatment of selective mutism. CNS Drugs. 2002;16(3):175-80.
  4. Neufeld, G. Holding On to Your Kids, 2002. Discusses the concept of attachment in depth, and how parents can attach with their children.
  5. Dr. Elisa Shipon-Blum: Understanding Selective Mutism: A Guide to Helping Our Teachers Understand, retrieved Aug 15, 2005 from http://www.selectivemutism.org/pdf/teachers.pdf

License

Under a Creative Commons License.  You are free to share, copy and distribute this work as in its entirety, with no alterations. This work may not be used for commercial purposes.

For the full license, visit:  http:// creativecommons.org/licenses.by-nc-nd/2.5/ca/

 

Contact the Mental Health Information Team if you would like to adapt these for your community!

Disclaimer

Information in this fact sheet may or may not apply to your child. Your health care provider is the best source of information about your child’s health.

 

 

Date Posted: Nov 4, 2008
Date of Last Revision: Jun 15, 2014

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