The development of speech is one of the most important childhood milestones. Coos lead to “ba-bas” to first words to first sentences. But what if your child stops speaking? Or doesn't seem to be developing speech at all? While there are many reasons why a child’s speech development might be delayed or impaired, from hearing loss to tonsil complications, one answer might be selective mutism (when a child is unable to communicate), which a type of anxiety disorder.
“Typically, people with selective mutism are able to communicate in familiar settings and with close and familiar people but may struggle to do so in more novel environments like in school, with strangers, or even with extended family,” explains Dr. Lisa Kovac, a board certified behavior analyst and school psychologist based in Orlando, Florida who specializes in the treatment of children with selective mutism. She says research study statistics suggests the disorder has an incidence rate of about 7.1 per 1,000 and is slightly more common in girls than in boys. “However, the presentation can vary widely, with some being able to communicate nonverbally and others not; some not speaking to strangers and some do; some only speaking to kids and not adults and others vice versa; some speaking on the phone but not in person or the opposite, etc.”
Is selective mutism just a child refusing to speak? No. Historically, the disorder was called elective mutism, but that term is outdated as it suggested the afflicted made a choice to stay silent. Selective mutism is different. The person who has selective mutism is unable to speak. “There is even some emerging research that vocal cords may exhibit some paralysis in these uncomfortable situations,” says Dr. Becca Laptook, a licensed clinical chid psychologist who specializes in the treatment of childhood anxiety and selective mutism. This is reassuring as many times, people assume that a child with selective mutism is simply being uncooperative.
Signs of Selective Mutism
So how is selective mutism diagnosed? That’s up to a psychologist, psychiatrist, social worker, speech/language pathologist, or any professional who has a background training in childhood anxiety disorders, explains Dr. Kovac. However, she says, it's not too difficult to diagnose. Two different communication patterns must be present: typical communication when the child is comfortable, and an inability to communicate when they are uncomfortable.
“For some children this inability to communicate might be verbal behavior like talking, but it can also be nonverbal behavior too (e.g. like having a hard time looking at people, “freezing” their body when someone talks to them, etc.). There are specific diagnostic criteria that need to be met as outlined by the Diagnostic and Statistical Manual – Fifth Edition (DSM-5),” she says.
Typically the disorder is diagnosed when a child enters school, in preschool or kindergarten. “Signs may have been present earlier, but this is generally when impairment is first observed and becomes a notable concern,” she explains. And the earlier it can be diagnosed the better. “The longer the person remains selectively mute, the harder it is to treat.”
If there is any trouble diagnosing the disorder, explains Dr. Laptook, it’s when the connection between anxiety and the inability to speak is not made. "Early on, it may be more apparent that certain situations create more anxiety and discomfort and therefore a lack of communication. However, over time, it may not be as obvious that there is a connection to anxiety, and people may seem comfortable in interactions in many ways and still not be able to speak in those situations," she explains. "Additionally, oftentimes kids who have been struggling with selective mutism for a while may not appear to be overtly anxious in settings where they are not able to communicate, this is often misinterpreted as oppositional behavior."
While selective mutism is an anxiety disorder, Dr. Laptook wants people to know that it’s a myth that it’s caused by traumatic events.
“Anxiety is in part genetic, and sometimes the parent of the child with selective mutism also had symptoms of it themselves when they were a child,” she says. “Also, sometimes very well-meaning parents can inadvertently reinforce the selective mutism by protecting their child and answering for them.”
As with all anxiety, there are certainly major life transitions or traumatic events that can be of influence. "These stressors would not be the cause of the selective mutism but rather would be a way of understanding what factors might be contributing to a level of anxiety that the child was experiencing," says Dr. Laptook. In other words, "people can have a predisposition for certain tendencies and traits that are then brought out through life stressors. For selective mutism, this may be apparent in some cases and others not," she says.
It’s important to get treatment by a qualified person (psychologist, speech language pathologist, social worker, or behavior analyst). These individuals can help guide parents in the most appropriate strategies including valuations to determine where the child is able to communicate comfortably “and then implement small steps to help the child transition those skills to the environment where they are uncomfortable,” says Dr. Kovac.
What does that look like? “If a child will talk to a friend in the home but not at school, you may begin by setting up playdates outside of the home (but not at school), then on the school playground, then in the school hallway, then in the classroom before school starts, then at the back of the classroom during the school day, then at their desk in the classroom," explains Dr. Kovac.
“There’s also different communication strategies that can be used such as a warm-up time where no questions are asked, forced choice questions (“would you like the red crayon, the blue crayon, or something different”) and allowing a longer wait time before a child answers a questions (5 seconds),” she says. “A key to successful treatment also includes modifying the responses and behaviors of those around the child, as often parent, teacher, and other adults may be inadvertently promoting the selective mutism as opposed to stopping the cycle.”
And parents can play a big role in treatment. “A focus on parenting strategies that will promote positive communication behaviors in addition to other aspects such as building consistent reward systems are often an integral part of treatment," says Dr. Kovac.
"These children need to be supported and need guidance to help them achieve their communication goals," says Dr. Laptook.
If you or someone you know is seeking help for mental health concerns, visit the National Alliance on Mental Illness (NAMI) website, or call 1-800-950-NAMI(6264). For confidential treatment referrals, visit the Substance Abuse and Mental Health Services Administration (SAMHSA) website, or call the National Helpline at 1-800-662-HELP(4357). In an emergency, contact the National Suicide Prevention Lifeline at 1-800-273-TALK(8255) or call 911.
Dr. Lisa Kovac, Ph.D., BCBASMA, Board Certified Behavior Analyst and School Psychologist, Selective Mutism Association Executive Director, selectivemutism.org
Dr. Becca Laptook, Licensed Clinical Child Psychologist, Selective Mutism Association Board of Directors, selectivemutism.org