Selective Mutism: Symptoms, Signs & Treatments

What Are the Symptoms of SM? 

According to the DSM-5, diagnostic criteria, diagnostic features, and associated features follow:

• Consistent failure to speak in social situations where there is an expectation to speak, despite speaking in other situations (such as home)
• Does not initiate speech or reciprocally respond
• May grunt, point, or write to communicate
• Fear of social embarrassment
• Social isolation, withdrawal, cessation of play
• Clinging, shrinking, averting eye contact
• Compulsive traits
• Struggles to eat in front of others (not due to an eating disorder)
• Struggles to use a public restroom
• Negative affect
• Temper tantrums
• Mild oppositional behavior (due to anxiety, not an oppositional disorder)
• Symptoms interfere with educational, occupational, or social success
• Symptoms must last for 1 consecutive month
• Symptoms aren’t due to a lack of knowledge of the language

When people with SM feel expected to speak, they become terrified. Their level of anxiety significantly increases, but by remaining silent or motionless, their anxiety level slightly decreases, obtaining temporary relief for themselves. This is an ineffective coping strategy to maintain a baseline level of homeostasis. Their relief is only temporary because longitudinally, these people become more anxious and suffer in silence if not treated effectively.

People with SM usually speak at home, but symptoms can be so severe that they may not even be verbal in their own home with their parents or siblings (aka: “comfortable people”) if guests stop by the house, even if the guests are in another room.

People with SM may also struggle to speak to their “comfortable people” in community settings, such as at a restaurant, even if they’re in a more secluded booth far away from other families.

These people fail to initiate speech or reciprocate verbally in environments where speaking is expected, such as ordering at a fast-food restaurant or asking a store clerk how much something costs.

This struggle to speak is despite the fact that they can speak and want to be able to speak with others. Wanting to speak, but being unable to speak, does not equate to defiant, oppositional, manipulative, or controlling behavior; it is anxiety. 

To conceptualize the experience of selective mutism, there is an analogy to help clarify: When some people go to the eye doctor to complete the glaucoma screening with the “puff of air test,” a person with anxiety about this will have their eyes involuntarily close. These people physically know howto open their eyes, and they actually want to keep their eyes open and comply with the procedure. But, their fear causes an inability to keep them open. These people are not trying to be defiant, oppositional, manipulative, or controlling. It’s the same with SM.

Ironically, some people with SM actually are eager to engage in social situations in nonverbal manners, such as:

• Obtaining a non-speaking role in the school musical
• Playing a nonverbal card game with peers during indoor recess
• Pushing a peer on the swing at recess

These particular people with SM are much more able to communicate nonverbally by pointing, nodding, shaking their head, and writing than people who are more frozen.

When Does SM Onset? Can It Be “Outgrown?”

According to the DSM-5, SM affects .03-1% of the general population, and the onset is usually prior to age 5, although many times these children are not identified until much later. Unfortunately, this is because a person’s SM can be misinterpreted as “normative shyness,” delaying treatment.

Can SM be outgrown without treatment? The DSM-5 confirms that as people with SM age, they don’t always end up meeting the full criteria of SM anymore. However, they usually still meet the criteria for social anxiety disorder, which is still clinically significant and can still negatively impact their lives in social, academic, and occupational settings.

Differential Diagnosis Between SM and Shyness: What Is the Difference?

SM is far from normative shyness. “Shyness (i.e., social reticence) is a common personality trait and is not by itself pathological.¹” Only a small percentage of normative shy individuals (12%) even meet the diagnostic criteria for social anxiety disorder. Therefore, it’s fairly acceptable to be shy, but it’s rare to have a “shy person” also have social anxiety disorder, and it’s even more rare for that shy person to have SM.

As children begin exploring their communities, they may clam up with heightened expectations. As “normative shy” children gain more social experiences, the intensity and frequency of these types of extreme shy episodes (such as hiding behind a caregiver’s leg at a park) tend to diminish. SM is much more intense, frequent, and chronic than being shy, and their symptoms don’t tend to simply diminish.

Shy children usually “warm up” after a while in a given social situation. Children with SM do not (not without treatment and coping strategies).

Shy children may struggle to initiate conversation, but they usually respond, even if with just a couple of words, whereas SM usually will not. Shy children will not have such a frozen affect with their nonverbal behavior as a child with SM.

Selective Mutism Example

If you are still confused of the difference between SM and shyness, here is an example of what SM looks like from a parent perspective when visiting their child in the school environment:

Hailey’s father walked into her preschool classroom, waved to her and said, “Hi!” but she looked at him like a deer in headlights. He took her over to her favorite area of the classroom, the dramatic play area, to help her feel comfortable. Nobody else was around, and he tried again- whispered this time, “Hi, Hailey.” Instead of acknowledging him, she looked blank, expressionless, and dead on the inside. He wanted to let her know it was him, and let her know that she was safe. 

A few minutes later, the children sat down for circle time. Hailey was seated in the circle next to the teacher’s left side. The teacher started the “circle-time” question on the right side, so as an intervention, Hailey would go last and could mimic something she heard. 

“What animal do you like best?” was the question. Every child answered the question. When it was Hailey’s turn, her body shrunk down, she averted eye contact and looked at the ground. Her dad couldn’t even tell if she was breathing. “Dogs,” he thought. “You like dogs. Just say it. It’s safe here. Dogs. Please,” he pleaded in his mind.

The teacher gave ample wait-time and then offered a forced-choice question: “Hailey, do you like cats or dogs better?” Instead of taking this chance, she nodded while still looking at the ground. Her dad let out his breath he didn’t even know he was holding. This is selective mutism and not shyness.

What Causes SM?

The multifaceted origination of anxiety disorders and/or maintenance of anxiety disorders comes from a combination of:

• Genetics affecting brain chemicals/brain structure
• Personality/temperament
• Environmental factors
• Learned behavior
• Cognitions

Evidence shows that genes influence brain chemicals and alter brain structure, which then can lead to anxiety disorders. In addition, chronic and excessive anxiety actually changes the structure of different sections of the brain, perpetuating more anxiety.

Because all of these issues above are intertwined, they can all have an effect on each other, which makes SM so complicated.

Genetics and the Brain

At this time, there is still much more unknown than is actually known about the genetics of anxiety disorders. Some genes and alleles do affect the neurotransmitter systems that contribute to a person’s negative affect symptoms. If the person is not producing enough neurotransmitters, transporting them efficiently, retaining enough, or balancing each other out, anxiety disorders can occur.

These neurotransmitters are:

• Serotonin
• Noradrenaline/norepinephrine
• Glutamate and gaba

The University of Chicago documented that there was research funded by grants from the National Institute of Mental Health: When the serotonin receptor gene is shorter than it’s supposed to be, this is associated with the development of chronic stress.² More research is being done to help clarify anxiety disorders.

Structurally, the limbic system in the forebrain is most affected by anxiety disorders because it plays a central role in processing all anxiety-related information.

The limbic system structures are:

• Hippocampus
• Amygdala
• Hypothalamus

These structures are of particular importance in anxiety due to the “fight, flight, freeze” mechanism, which is an instinctual, physiological response to fear. SM is the “freeze” portion and an overlearned physiological response.

In Taylor Clark’s book,Nerve: Poise Under Pressure, Serenity Under Stress, and the Brave New Science of Fear and Cool, he states that when a person freezes from this autonomic nervous system response, they become an alarmed-looking human statue. He writes:

In the wild, many predators react to movement, but if you abruptly go rigid, there’s a chance that the tiger that you just spotted won’t notice you.  Think of freezing as a state of defensive preparation.  The body gets the same jolt of adrenaline that readies it for fighting or fleeing, but the brain has calculated that at least for that moment, your best odds of survival come with no action at all.³

In the wild, this autonomic freeze reaction may have been valuable, beneficial, and saved lives, but in cases of SM, it makes lives worse.

The reputable psychiatrist on anxiety disorders, Aaron T. Beck, M.D., states, “It has been said that evolution favors anxious genes.” This is because “it is better to have “false positives” (false alarms) than “false negatives” (which miss the danger).”⁴ Because evolution favors anxious genes, this may be why so many anxiety disorders are rampant today.

It is very important to note that if a person with SM has no other family members with SM (which is likely the case), it doesn’t mean that it is not genetically based for that person.

There are many different anxiety disorders, and they can be passed down genetically without being the same exact anxiety disorder. The National Institute of Mental Health (NIMH) states, “vulnerability markers are now conceptualized as tied to families of anxiety disorders, as opposed to specific conditions.”⁵

In the family of anxiety, some disorders are:

• Separation anxiety disorder
• Social anxiety disorder
• Specific phobias, such as agoraphobia (the fear of leaving one’s house)
• Generalized anxiety disorder (GAD)
• Obsessive compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Panic disorder

Personality/Temperament

According to the DSM-5, there actually are specific temperamental and personality characteristics that are linked to a higher risk for developing anxiety.

It is well documented that this includes:

• Concepts such as negative affectivity
• Harm avoidance
• Behavioral inhibition

Environmental Factors

According to the DSM-5, there are some environmental factors to take into consideration with SM. These include but are not limited to:

• Medical issues the first year of life
• Speech delays and/or hearing impairment
• English as a second language
• Parenting behaviors and styles

Learned Behavior

The DSM-V states that both SM and social reticence (being reserved) can also originate from learned behavior:

• Parents modeling social inhibition
• Overprotective parenting styles

From these environmental factors and/or learned behavior, a child may learn to be fearful or overly cautious of novel experiences from observing a parent’s response to these types of situations. However, this is actually a rare cause of SM, but in combination with other factors, it is something to consider in leading to SM or maintaining existing SM.

It is important to note that not every child who has a speech delay or a hearing impairment, etc., is going to develop SM. For instance, most children with a speech delay will not develop SM: About 7-8% of US kindergartners are diagnosed with a language impairment, but of those, only 0.015-0.5% have a SM.

Cognition

Because cognitive behavioral therapy (CBT) is an evidenced-based treatment for anxiety disorders, some wonder if ineffective cognitions (thoughts) can cause anxiety disorders.

CBT was developed in the 1960’s by psychiatrist and leading professor for the University of Pennsylvania School of Medicine, Aaron T. Beck, M.D. In his book, Anxiety Disorders and Phobias: A Cognitive Perspective, he states the primary pathology of an anxiety disorder resides in the cognitive apparatus.

However, Dr. Beck claims that cognitions are “far from being a cause of anxiety disorders.” This means cognitions don’t cause anxiety disorders but they contribute to them and help maintain them, so altering cognitions can lead to anxiety symptom reduction.

What Is the Treatment for SM? 

How can people with a severe fear response better self-manage so that they can more effectively function at school, work, and during social situations in the community? There are many treatment modalities that, when used in combination, can have great success (but cannot guarantee the absence of symptoms).

Parent-Child Interaction Therapy (PCIT)

There needs to be antecedent management to adjust the environment and the triggers to the person’s anxiety to help lessen their anxiety. Antecedent management can be accomplished using concepts from Dr. Sheila Eyberg’s parent-child interaction therapy (PCIT), which is research-informed for SM.

Dr. Eyberg created PCIT back in the 1970’s at the University of Florida, and it was built from multiple theories of development including attachment, parenting styles, and social learning. PCIT incorporates her concepts of child-directed interaction (CDI) and PRIDE skills (labeled praise, reflect, imitate, describe, and enjoyment), both at school and in community settings. Just because the word “parent” is in the title, doesn’t mean this can’t and shouldn’t be used in a variety of settings.

PCIT is meant to help a person feel:

• Valued
• Accepted
• Appreciated
• Worthy
• Confident

If a person with an anxiety disorder feels those positive feelings above, those alone can help reduce anxiety, and they will be more likely to speak.

Operant Conditioning

B.F. Skinner, Ph.D. was Professor of Psychology at Harvard University and was the father of behaviorism and operant conditioning. His theory is that people will continue behaviors that have desirable consequences (and reduce behaviors that have undesirable consequences). He believes that one’s environment plays a large role in controlling behavior.

Obviously, with SM, the person’s brain chemicals and brain structure also contribute to behavior. Therefore, it is important to remember that operant conditioning is effective only when the environmental expectations of the child match the skills the child is capable of. If a person does not possess the skills being reinforced, adding an incentive will not accomplish the goal. However, with proper treatment, children with SM seem to be able to be very responsive to this type of behavioristic model.

Operant conditioning involves gradual exposure to the feared stimuli (in this case, speaking), to shape behaviors, with successive approximations, to habituate and desensitize to anxiety. People with SM are challenged with small challenges first, then positively reinforced for meeting those challenges. Then their challenges are gradually increased, which helps their brain continue to habituate and desensitize to anxiety.

Cognitive Behavior Therapy (CBT)

CBT is based on a cognitive theory of psychopathology in which people’s thoughts or perceptions regarding situations in their lives can positively or negatively influence their emotional, physiological, and behavioral reactions. Dr. Beck’s CBT is evidenced-based for anxiety disorders.

In terms of SM, people experience:

• Thought distortions
• Automatic negative thoughts (ANTS)
• Invalid rules and assumptions
• Exaggeration of the threat of danger
• Ignoring information that can contradict inaccurate beliefs
• Overgeneralization of situations
• Schema-driven behavior
• Catastrophizing
• Perseverating thoughts

These ineffective thought patterns that maintain anxiety needed to be challenged in CBT therapy, which is most effective for people ages 7 and older, due to the abstract nature of CBT.

Mindfulness

Mindfulness is an ancient Zen technique, popularized by the development of dialectical behavior therapy (DBT) by Marsha Linehan, Ph.D., APBB., Professor of Psychology and adjunct Professor of Psychiatry and Behavioral Sciences at the University of Washington.

It has been researched that a person with anxiety experiences a hypertrophy (an increase) in the volume of neurons in the amygdala, heightening fear responses that are disproportionate to the event (anxiety) and causing an overactive amygdala to keep perpetuating the anxiety.

Mindfulness is a specific therapeutic technique that can physically alter the amygdala in a beneficial manner, leading to less severe stress responses: According to the Oxford University Press, MRI research results show that improving a person’s subjective experience of stress through this technique can actually decrease grey matter density in the amygdala:

“This finding is particularly interesting as it suggests that an active re-learning of emotional responses to stress can lead to beneficial changes in neural structure and well-being, even when there is presumably no change in the person’s external environment.”⁶

This means that a person’s external stressors may remain the same, but the person does not feel as stressed-out by the stressors. When the brain physically changes, anxiety seems less.

Mindfulness combines:

• Deep breathing
• Sensory input
• Acceptance and serenity while in the present moment (otherwise known as the “here and now”)
• Non-judgmental awareness of present experiences

Intensive Treatment

Many times, a foundation of intensive treatment for SM is beneficial in getting a “head-start.” Intensive treatment is typically 30 hours in 1 week with clinicians specializing in selective mutism. The skills practiced during the 30 hours of intensive treatment seem to hold their gains better than they do when practiced 1 hour per week in traditional therapy.

Imagine gaining a 29-week “head-start” and saving 29 weeks of a person’s life. Multiple intensive treatment centers exist across the country, many of which are based on a “day camp” model running roughly six hours per day for one week at a time. The child is typically placed with a group of children based on age level, and each child has a one-on-one clinician. Some of these are located in Illinois, New York, Michigan, Florida, Pennsylvania, Massachusetts, and Canada.

Once the foundation of these skills has been built in an intensive program, the skills can be generalized into the child’s school environment and social situations within the community.

Handover/Takeover™ Exercises

Dr. Shipon-Blum is an expert in SM, owns the Selective Mutism Anxiety and Treatment Center in Pennsylvania, and she coined the term, handover/takeover.™ These are exercises to practice appropriate nonverbal socialization and eye contact, but without directly letting the child know that is what is being practiced. Handover/takeover™ involves handing items to others and receiving items from others.⁷ Dr. Shipon-Blum gives an example of having a play-date over and doing a guided cooking project:

The parent of the child with SM can facilitate handover/takeover™ with a baking activity like this at a play-date: “Brayden, please pass Mikey the cinnamon.” A few seconds later, “Next is the vanilla. Mikey, the vanilla is near you. Please pass Brayden the vanilla so he can add it to his bowl.”

With SM, the goal is first to practice looking toward someone, rather than practicing actual eye contact, but do not say, “Let’s practice looking toward Brayden,” since that will likely increase anxiety in a child with SM. Rather, prompt the handover/takeover™ exercises, and then looking toward someone will naturally come in time.

Reproducible Tasks

A “reproducible task” is a concept Dr. Shipon-Blum talks about frequently. These are tasks that are the same over and over again. How do these benefit a child with SM? When a child both enjoys an activity, plus feels competent with it, the thoughts and feelings that are produced regarding this activity boost the child’s confidence level.⁷ When a child’s confidence is up, their anxiety level is down. When a child’s anxiety level is down, their speech output is up.

Forced Choice Questions, Behavioral Descriptions, and Reflection

At the start of treatment for a person with SM, one should never ask them an open-ended question. Rather, they have a better chance at being successful with forced-choice questions. A forced-choice question offers 2 or 3 choices.

For example: “Do you want to play outside or inside?” The person with SM may point outside. The other person responds with a behavioral description: “I see you pointing outside. Thank you for letting me know…Do you want to ride bikes, draw with chalk, or do something different?” The person with SM may point to the basketball. The other person responds with a behavioral description: “I see you pointing to the basketball. Thank you for letting me know. Let’s play basketball!”

If the person with SM is farther along in treatment, it may look something like this:

“Do you want to play outside or inside?” The person with SM responds, “Outside.” The other person responds by PCIT’s reflection technique: “Outside. Thank you for telling me…Do you want to ride bikes, draw with chalk, or do something different?” The person with SM responds, “Something different, basketball.” The other person responds by reflecting, “Something different. Let’s play basketball. Thank you for telling me.”

School Services

Most children with SM will remain in their general education environment with typically developing peers, which is usually for the best. However, they can still obtain special-education services to help them succeed, such as counseling/social work, in addition to resource services and accommodations and antecedent management in the classroom to help reduce their anxiety and increase verbal output.

Therefore, it’s recommended to solidify special-education services for a child with SM under a 504 Plan or with an Individualized Education Plan (IEP) under the “other health impairment” (OHI) or “emotional disorder” (ED) category.

Many parents have a stigma with the terminology of “special-education,” but these services are provided under the Individuals with Disabilities Education Act, more commonly known as the IDEA law, which is regulated by the federal government. The goal is to “level the playing field” for a child, so the child is able to be more successful at school, both socially and academically, with legalized accommodations to help the child succeed.

Some of these accommodations for SM follow:

• PCIT with CDI and PRIDE
• Process time/wait time
• Forced-choice questions
• Coping activities during transitional periods
• Pointing/hand signals as acceptable on assessments
• Successive approximations to shape behavior
• Preferential seating near comfortable peers
• Behavioral descriptions
• Frequent breaks
• Movement breaks
• Handover/Takeover™ exercises
• Reproducible tasks
• Fidget manipulatives
• Proprioceptive and vestibular input opportunities
• Teacher to read presentations aloud for the student (that the student wrote)
• Assign the student non-speaking classroom oriented chores to help them feel important, needed, and successful
• Token economy system
• Private feedback on academic performance
• Bathroom card

Medication

Currently, there are no FDA approved medications specifically for SM, but there are plenty approved for anxiety disorders. From the CAMS study, a combination of CBT psychotherapy and medication (SSRI) shows the best outcomes for a variety of anxiety disorders. There are several SSRI medications to choose from, and Prozac seems to be the most commonly prescribed for SM.

According to the Mayo Clinic, SSRIs are among the safest drugs because they are not habit forming and have low risk for side effects. “All SSRIs work in a similar way and generally cause similar side effects. However, each SSRI has a different chemical makeup, so one may affect you a little differently than another.”⁸

Conclusions

SM is one of the most misunderstood mental health conditions. It is important that the sooner a person with SM is recognized correctly, the sooner they can get treatment, and the sooner they get treatment, the quality of their life can improve.