Insights into Psychology

What Is… Selective Mutism

selective mutism negative reinforcement cycle

In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is selective mutism.

Selective mutism (SM) is a rare disorder that begins in childhood and is characterized by an inability to speak in select social contexts (hence the “selective” part of the name). It used to be called elective mutism, but perhaps the DSM folks realized that sounded a bit too blame-y.

Selective mutism symptoms

In the DSM-5, SM is classified as an anxiety disorder. Symptoms include:

  • consistent failure to speak in specific social situations where speaking is expected, despite being able to speak in other situations
  • the speech disturbance interferes with achievement at school or with social communication
  • the duration is at least 1 month, although it can’t only occur in the first month of school
  • the disturbance in speech isn’t related to language comprehension issues or lack of knowledge
  • it doesn’t occur solely on the context of autism spectrum disorder or a psychotic disorder (someone can have both selective mutism and autism diagnoses if they appear to manifest independently, but not if seem to be two sides of the same coin)

There may also be behaviours associated with social anxiety, such as decreased eye contact, freezing, and hiding. Avoidance behaviours can include avoiding public toilets (which happens in another form of social phobia known as paruresis or shy bladder syndrome). Physical symptoms of anxiety may also occur.

Assessment before making the diagnosis involves ruling out physical or cognitive deficits, hearing loss, or tics that may be impairing speech.

Risk factors

There is an increased risk for SM when there’s a family history of either SM or other anxiety disorders (social anxiety in particular). Children who develop SM tend to have shy, inhibited temperaments, and may have overactive threat detection going on in the amygdala (something that occurs in other disorders, including OCD).

There appears to be a higher risk among immigrant and language-minority children. This may be related to a fear being ridiculed or ignored based on their speech, e.g. mispronunciation of words, which is also a contributing factor to SM.

Some of the theories around the development of SM are:

  • behavioural: negatively reinforced learning (avoidance by the child and subsequent rescue by a parent) leads to behavioural inhibition (i.e. mutism) as an adaptive response to anxiety
  • Freudian/psychodynamic: children became fixated in the oral or anal stage of development, and SM is a way of displaying anger and punishing the parents
  • family systems: the disorder arises when there is extreme interdependency in attachments and distrust of the outside world
  • SM is a form of social phobia
  • SM can be an attempt to cope with trauma (traumatic mutism may also occur, but that would tend to occur across all contexts, unlike SM)

Other characteristics

SM occurs most often in children, and the average age of onset is between age 3 and 6. The prevalence is less than 1%. It appears to be slightly more common in females than males. It begins in childhood but can persist into adulthood.

A variety of other conditions have been observed to co-occur with selective mutism, including bedwetting, sensory processing disorder, OCD, depression, dissociative disorders, and autism spectrum disorder. Most children with SM have social phobia (90% according to one source).

Some children may outgrow SM on their own, although social phobia may persist. The disorder can be self-reinforcing, i.e. the longer you go without speaking in certain contexts, the more difficult it becomes.

Treatment

Treatments include psychodynamic therapy (in the form of play therapy), family therapy, behavioural therapy, cognitive behavioural therapy (in teens or adults) or medication, which typically involves antidepressants. There are also various speech language pathology interventions that can be used.

Behavioural treatments can include:

  • stimulus fading: have the child start talking one-on-one with a trusted individual, and then gradually bring others into the room
  • shaping: facilitate communication. by starting with strategies like gestures or whispering
  • self-modelling: record the child communicating effectively in a comfortable setting, and then have them watch the recording to boost self-confidence

Most of what I came across was focused on children, since that’s when it develops, but it does occur in adults, especially if they didn’t receive any treatment as children. In the DSM-IV, SM fell under the hodgepodge category of disorders that begin in childhood, but in the DSM-5, it was shifted over to the anxiety disorders category. To me, at least, it makes a great deal of sense that this would be a way for social anxiety to manifest itself.

Had you heard of selective mutism before?

Sources

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40 thoughts on “What Is… Selective Mutism”

  1. Wow, that’s so interesting. I think I’ve heard of it, but I’d forgotten about it. I can definitely envision how it would become harder and harder to talk once you quit talking in a certain setting. It would become difficult to come back from it. It makes me sad to think of kids who are afraid to speak or who lack confidence!!

  2. I have it! Still! I’m nearly 60 and it’s a pain. I’m not sure it had been ‘invented’ when I was a child. My childhood was painful and the anxiety has continued into adulthood. The character of Raj in Big Bang theory introduced me to the condition as an adult and when I learnt about it, it really helped me to understand some of my behaviours! I had layers of avoidance because I didn’t want the people I could talk to, to know there were people I couldn’t. I’m much better than I used to be after therapy but am reconciled to the fact that this is something I just need to live with now. Interestingly, I was born in the US and returned to UK aged 3. My parents left me with my Grandma who hated my American accent so maybe that’s where it started for. My Mum had a cousin who didn’t speak so maybe there is a genetic component too.

  3. I had symptoms of SM as a teen, but they were thought of as willful behavior. Eek, those behavioral interventions sound like they’d scare me even more, particularly self-modeling.

  4. Yes, I’ve heard of it. My question is: can they NOT speak, even if they wanted to? Does the anxiety affect their physical ability to speak? Or is it a psychological barrier?

    1. It sounds a lot like shy bladder syndrome in that the physical ability is there, but the psychological barrier is significant enough that wanting isn’t enough to overcome it.

  5. Thank you so much for this post. I have a good friend whose daughter has Selective Mutism. It is very much a struggle. Thank you as always for keeping us all informed. I hope the education will deter some from the stigma. It is so heart-breaking to watch a child go through these symptoms.

  6. I have one experience of it, with my cousin’s son. He was about three and told him Mom he didn’t like his preschool and didn’t want to go. She listened but didn’t change the school. He got mad, and he stopped speaking, but at home, not at preschool. Isn’t that surprising? It doesn’t seem like social anxiety as much as trying to punish his mom. It last well over a year. He’s 12 now, seems to be a healthy though highly sensitive and observant boy.

    1. Oh that’s an interesting dynamic. It sounds like a better fit with what psychoanalytic theory talks about than the social anxiety angle.

  7. A couple years ago I watched a documentary on this with my Mum, and I realised that one of my classmates at school might have had it, although no one has called it this way specifically. Looking back at that, people weren’t really very supportive for him. Most teachers and kids accepted it over time as a sort of peculiar thing, but none of us really understood it and he was often pressured by teachers in a not very helpful way, to speak, like publicly in class. His carer had apparently told the school that he speaks no problem at home, and very loudly, which peeved some teachers. I hadn’t really paid much attention to that at school, but I do recall observing that it went sort of in waves, there would be a period when he’d speak, and then a period where he wouldn’t at all or very little. Now as I’m thinking of it it kind of strikes me that, if it was really selective mutism, no one had seemed to address it properly at a school where, after all, loads of people had some additional special needs.
    Must be a difficult thing to live with.
    I myself had a weird experience which I suppose is kind of similar to selective mutism, but which I don’t really know what it classifies as, if anything at all. 😀 Basically, as a teenager, there was something that scared me, the strange thing is that I don’t even really remember the details now, except that it was something very sudden and where it happened, and then I went almost entirely speechless for like a week I guess. That was proper creepy because it wasn’t that I was so shy that I didn’t want to speak, it was like something deeper inside me wouldn’t let it happen, it kind of required a lot of willful, mental effort, I don’t even know how to explain it. I like to think that no one paid much attention to it or even noticed, because I was still able to sometimes say single words or hmm and the like, and I would avoid situations that had to do with speaking as much as I could, and a lot of people had an idea that I was “quiet” so I guess they figured I’m “quieter” than usual, and no one commented on it except one teacher who said I was really inactive at her lessons and my roommate, but the whole thing freaked me out. I wouldn’t call my Mum for this entire time, and as I usually called her every day, sometimes multiple times, she was rather worried, but I only told her about that incident years later. Soon after that thing happened to me we had a school break so I went home and from that point my speech went gradually back to normal. Since that was so sudden and unexpected, and I don’t really know why that happened except I must have been in a fair bit of a shock or something, I’m sometimes still scared that it’s gonna happen again. Sofi once asked me if I weren’t blind, but had to be disabled, what kind of disability I’d pick, and I said that I think I could cope reasonably well with being mute, which is not to diminish the struggles of people who deal with this, but simply to say that I think that for me personally, this disability would be the easiest to bear because I prefer to express myself in writing anyway. But, in my mini experience, things can get really tricky when you go speechless suddenly like that, plus on top of an already existing disability.
    My Mum recently talked to a woman who has an adult son somewhere on the autism spectrum, and how it’s been a lot more of a struggle ever since he’s become an adult because everyone, including professionals, seem to have an unspoken assumption that autism is only a childhood thing. So it really sucks with disorders like selective mutism, and autism and probably loads of others, that they are so neglected in adults.

  8. That’s really interesting. I wonder if the periods of not being able to speak had any connection to the AVPD. The mind is such a fascinating thing.

    The approach the teachers used with your classmates sounds like exactly the wrong way to deal with selective mutism, and probably just made it worse.

  9. I haven’t heard of this before. As I was reading it, I kept thinking about a young man I know with Asberger’s – how he seems unable to speak in certain situations, but not in others. But then I read that it’s not necessarily related to autism spectrum. It does seem fascinating, and I think I’ve known some other people (mostly very quiet musicians) who might have this condition.

    1. From what I read, it sounds like only speaking in selected situations can be a symptom on the autism spectrum, but it can happen alongside but separately from autism.

  10. Huh, that’s an interesting idea with the AVPD, wouldn’t have thought about that although it certainly makes sense that there could be some connection.
    Yeah seriously, even though I wasn’t really aware at the time what was going on with my classmate, or even thinking much about it at all, the teachers’ approach made even me cringe, so I can imagine must have been all the more so with him.

  11. Met an adult who got treated extensively with therapy since his SM started at age 6 or so. In his case, his mother basically rescues him, all the way to adulthood. Talks for him and all that.

    I remember feeling envious and then really ashamed of my envy, but my T did help me recognise why I felt so envious. These days I wonder if he’ll ever become an independent adult, especially after his mother can’t literally go everywhere with him to speak for him.

    1. There needs to be a course on how to be an effective, boundaried, non-abusive parent, and the IUD needs to stay in until that course is passed with flying colours.

      1. Yeeeeppppp!

        I never thought coddling could be bad but last I heard (from C, who met him recently an event she was part of), the guy isn’t better. Can’t function in every day life without his mum and people around him encouraging him tons so he can speak 1 sentence, then praising him and clapping afterwards. Just how is he going to ever live an independent life if he can’t even order food for himself? Or work in a regular job, not the special one his (well connected) mother set up for him? He has grown siblings and they’re going to be saddled with him after their mum dies.

  12. I used to have the chance to talk to this retired educational psychologist on a regular basis and he once brought it up as a case whilst he told me about how the different fields became more distant with each other as the years went by. It’s nice to get the opportunity to know more about it once again. Thanks for that!

  13. This was such an interesting read – I only really knew about the term selective mutism more than anything else so it was really fascinating to find out more about it!

  14. As a speech and language therapist I have come across selective mutism a fair bit. Such a challenging thing to manage and change. Really debilitating for the child and family too. Nice post Ashley 😊

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