It’s like the default switch of silence goes off and she cannot speak to strangers. At home, Rena, whose name has been changed upon request, is a bright spark. She loves to talk and giggle, her eyes twinkling with mischief. At school, the five-year-old’s eyes dim with fear; it’s paralytic to her vocal chords. Rena, says her mum, has selective mutism (SM).
Mandeep Jassal, Behavioural Therapist at Priory Wellbeing Centre, Dubai and Abu Dhabi, explains: “Selective mutism is typically diagnosed around the age of five years and is a severe anxiety disorder. According to the DSM-5 [Diagnostic and Statistical Manual of Mental Disorders], individuals with this disorder fail to speak when spoken to when expected to in social situations e.g. at school or with relatives they do not see very often. This failure to speak typically lasts for at least a month.”
The diagnosis criteria, explains the American Speech-Language-Hearing Association (Asha), are:
- The child shows consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school), despite speaking in other situations.
- The disturbance interferes with educational or occupational achievement or with social communication.
- The duration of the disturbance is at least one month (not limited to the first month of school).
- The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
- The disturbance is not better explained by a communication disorder (e.g., child-onset fluency disorder, or stammering) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.
Individuals with selective mutism fail to speak when spoken to when expected to in social situations e.g. at school or with relatives they do not see very often.
How can the disorder manifest?
- Lack of eye contact
- Clinging to parents
- Hiding
- Running away
- Crying
- Freezing
- An outburst if asked to speak publicly
- Avoidance of eating in public
- Anxious when having picture or video taken
- Anxious to use public restrooms
Parental protection might be making things worse
A parent’s natural urge is to shield their child, so when put in a situation where a child is behaving like a ‘deer in the headlights’ and asking to be rescued, it’s only natural that they would come to their aid. However, this reinforces the behaviour of the child, ultimately making things worse. Website Anxiety Canada explains the vicious cycle as
Is my child an introvert or suffering from selective mutism?
Stella Antoniou, child and family therapist and parent coach at Stellantoniou.com, explains: “Being selectively mute is a disorder, a developmental difficulty. Being an introvert meanwhile is a personality trait. It has nothing to do with a disorder, anxiety, trauma or anything else that has to do with your life.”
Jassal adds: “Introverts are not unable to speak and become ‘frozen’ with anxiety, which is what happens with selective mutism.”
Being selectively mute is a disorder, a developmental difficulty. Being an introvert meanwhile is a personality trait.
Busting myths about selective mutism
US-based Selective Mutism Association (SMA) debunks common misnomers
Myth 1: Selective mutism (SM) is extremely rare
SMA explains that while studies point to at least 7.1 out of every 1,000 kids having the condition, it’s often misdiagnosed as the child may be called ‘shy’ or ‘autistic’. The number of cases is likely to be falsely low, it says.
Myth 2: Kids with SM are traumatized
While trauma may feed the anxiety, it’s not a given that it’s in play. It’s just that children may be more on edge because of the anxiety.
Myth 3: Silence is a form of passive aggressive behaviour
SMA explains that this is far from the truth. “Despite looking oppositional, selective mutism is more often the result of anxiety, avoidance behaviour, and well-learned patterns of removing themselves (or being rescued) from speaking situations to decrease this anxiety,” it says.
Myth 4: Selective mutism is extremely difficult to treat
Cognitive behavioural therapy and play therapy are known to help children suffering from SM.
Myth 5: Selective mutism is really just severe shyness
“Shyness is marked by a tendency to withdraw from people, particularly unfamiliar people, but shy kids are able to function adequately in society,” says SMA. “Rather, selective mutism is characterised by extreme inhibition and an inability to adapt to social situations that interferes with a person’s daily functioning and communication with others.”
Myth 6: Selective mutism is on the autism spectrum
While symptoms may seem similar when looking from afar, they are far from it? But if you are wondering which one your child has, says SMA, “One of the best ways for clinicians to rule out autism is to observe video of the child in his or her comfortable environment (usually in the home) to determine the extent of the lack of speech and a thorough understanding of the child’s true language abilities (recognising that more broad mutism may be more directly linked to language deficits and autism).”
Myth 7: All children with SM have social anxiety
While some do contend with social anxiety, you will also find kids with SM who will laugh and engage with their peers – they’ll just be non-verbal while they do it.
Myth 8: Children with SM tend to be below average in intelligence
How do you evaluate a child who will not respond to an answer in the conventional verbal method? It’s difficult and feeds this myth. “Alternative testing methods and use of accommodations such as recordings usually allow for a more accurate assessment for these children,” explains the association.
Treatment for SM
Jassal’s top tips for parents are:
- Forgo pressure tactics: Remove pressure on the child to speak, which in turn will help to reduce the anxiety, help them to feel more relaxed at school or home. This is to help them begin to feel comfortable enough to say a few words or sentences.
- Baby steps are okay: Let your child know that you understand their difficulty and tell them they can take small steps when they feel ready.
- All communication is fine: Reassure your child that non-verbal communication e.g. smiling or waving are great steps on the way to verbal communication. This and love, support and patience will help.
Antoniou calls for acknowledging their children’s feelings. “They should validate the way the kids’ feel and not push the child to talk. Because selective mutism has nothing to do with speech. It all has to do with social anxiety.”
However, this doesn’t mean a vacuum when it comes to educating them. “Let the children be the way they are without pushing them and also make sure they are having discussions, reading stories, playing different activities based on their anxieties,” she adds.
Antoniou explains that the role of the teacher is paramount in helping kids with SM. They can, she suggests:
- Use flashcards or visual cards that the kids can use for communication.
- They can do therapeutic storytelling in the class.
- They can set up a little kit that the child can have that they can use if they feel anxious, like sensory balls.
- They can take them to the school counsellor.
Does a multi-lingual approach cause selective mutism?
On the information-sharing platform Reddit, user @kitobich explained that their son has SM. “When he was a toddler in kindergarten he would not reply at all to any of the adults working there, at first also not the children. At school it also kept happening mainly with the adults, with kids it got better. He has been going to therapy for a year now and it's getting better. One big factor might be in our case, aside from him being very shy and somewhat socially anxious, that he is growing up trilingual and the language of the adults in kindergarten and school was not one spoken at home with either parent. Anyways having a therapist acknowledge it is SM helped a lot for the teachers to stop pushing him or putting him on the spot because that only makes it worse,” they wrote.
According to US-based Child Mind Institute, SM is more common among children who speak a second language, but bilingualism isn’t the cause of it. “For kids who already have an anxious temperament, being expected to use a language they are less comfortable with can put them at additional risk,” it explains.
Priyanka Dang, Clinical Psychologist at Open Minds Psychiatry Counselling and Neuroscience Centre, Dubai, explains: “Children typically progress though the stages of second language acquisition:
- Prolonged silence,
- Repeating words,
- Starting the process of quietly and non-communicatively practicing words and phrases in the second language, and
- ‘Going public’ with the new language. Children with the typical nonverbal period (phase one) move smoothly through the phases, but those with actual SM show no progression. Because of anxiety, they might become ‘stuck’ in phases one through three, never speaking confidently in circumstances that call for ‘going public’.”
Dang says that a child’s ability to move through these phases depends on personality. “Behavioural inhibition to the unfamiliar is one of these personality factors with significant potential impact on multilingualism. Children who are timid, frightened, and/or inhibited and who are expected to operate in a second, foreign language may be more likely to exhibit mutism as a response to this trait,” she adds.
Behavioural inhibition to the unfamiliar is one of these personality factors with significant potential impact on multilingualism. Children who are timid, frightened, and/or inhibited and who are expected to operate in a second, foreign language may be more likely to exhibit mutism as a response to this trait
Play therapy and its impact
Antoniou, who uses play therapy to help children with SM, integrates art, music and even doll houses in her sessions to connect with kids, analyse their fears and rehabilitate them. She recalls a little girl who she treated after a bemused mum brought her to her practice. She explains: “I had a little girl who was completely mute at school and very, very loud at home. And the mother was depressed, because she was like, ‘She doesn’t communicate her needs at school, won’t say she needs the toilet’.
“So what I did in play therapy was I used creative visualisation – so what this is a technique through which a child using various transcripts that I have visualizes a world where they have no anxiety, they speak, they talk, and then after they’ve visualised it, they put it down on paper (drawing, painting). This helped her a lot. Gradually, she put herself in a situation where she talked, she visualised it. It was a long journey but it worked.”
The silent switch went off – she could talk again.
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