When A Child Is Silent

by Darline Turner Lee, Physician Assistant, ACSM Exercise Specialist
Article Last Reviewed: Sept. 9, 2006

One of my best friends has a six-year old son. When I last saw him (our second meeting), after a brief period of distant evaluation he energetically showed me his loft bed at the hotel in Animal Kingdom where the family was staying on vacation. We looked at the animals outside his window and discussed the merits of gummy bears in the lounge. “He really seems to like you.” My friend stated. “He rarely interacts with strangers so willingly.” What I took as a simple interaction with my friend’s son I now know was a major accomplishment for him. My friend’s son has Selective Mutism, a pediatric form of social anxiety disorder.

When my friend first told me about this disorder and that she believed her son suffered from it, I made the classic mistake of trying to talk her out of it. “C’mon, give the little guy a break. Not all kids are immediately outgoing. So he’s a little shy. Is that so wrong?”

Certainly, shyness isn’t wrong. But when it becomes incapacitating, inhibiting the individual’s ability to interact with others and to function at one’s job (school) or other social situations, then it must be addressed.

Selective Mutism is a form of social anxiety disorder that affects less than one percent of children. Yes, it’s rare. The Diagnostic and Statistical Manual of Mental Disorders-Fourth edition, provides the following criteria for diagnosis:

• Consistent failure to speak in specific social situations (in which there is an expectation for speaking) despite speaking in other situations.
• The disturbance interferes with educational or occupational achievement or with social communication.
• The disturbance must last for at least one –month (not limited to the first month of school).
• The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
• The disturbance is not accounted for by a Communication disorder (e.g. stuttering) and does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia or other Psychotic disorder.

Kussmaul, a German physician, first described Aphasia Voluntaria, voluntary mutism, in 1877. Elective Mutism was the English translation given by Tramer in 1934. Physicians and psychologists now know that the mutism is not elective. Affected children really do want to speak but are unable to due to the overwhelming anxiety. Some describe the disorder as having the sensation of wanting to speak, but not being able to form the words. Others say they open their mouths and begin speaking but no sound comes forth. These experiences only further heighten the embarrassment and anxiety, causing the child to retreat even further into mutism.

Children with Selective Mutism are not autistic nor do they typically have learning disabilities. They are usually very bright and perceptive. They possess the language skills to speak but it is the anxiety and fear that inhibits them. They are not mute due to a traumatic event, abuse or neglect.

So what causes selective mutism? There is a genetic predisposition. Children with Selective Mutism usually have a first degree or other very close relative that has or had an anxiety disorder. Research indicates that many of these children have a more inhibited personality and tend to be more fearful in new situations. As infants they may have been more excitable, cried more easily, were moody and clingy to parents. As they mature and begin encountering social situations, their anxiety is heightened and they often freeze where they are, stare blankly, nod or gesture or, in extreme cases, hide.

If a parent or other caregiver suspects that a child has Selective Mutism the child should be evaluated by a pediatrician. A physiologic disorder such as a hearing deficit, developmental disorder, physical trauma or other psychological disorder must be ruled out. If the physical assessment is normal the child should have an evaluation by a child psychologist. Nancy Nussbaum, Ph.D of the Austin Neurological Center does psychological assessments of children for Selective Mutism.

“I consult with the parents first without the child present. I ask about the temperament during infancy and the child’s reactions to new situations and stimuli. I also inquire about family history since there tends to be a genetic correlation. I counsel the parents how to interact with the child. It is so important not to label the child and to avoid trying to push the child to speak in situations when clearly there is overwhelming anxiety.”

Selective Mutism can be seen with other disorders but there is not always a definitive association.

“Kids with Selective Mutism just seem to be more reactive. Their nervous systems are just more sensitive to stimuli.” according to Nussbaum.

Treatment for Selective Mutism consists of cognitive behavioral therapy and in extreme cases medication. Therapy aims to desensitize the child to the anxiety. Using positive reinforcement, modeling and role-playing, therapists help children overcome anxiety by sharing specific skills the children can use in social situations. Parents are also taught how to use positive reinforcement and ego building to help their child.

Some children will require medication to manage their symptoms. Selective Serotonin Reuptake Inhibitors are effective in helping allay a child’s anxiety so that the skills from cognitive behavioral therapy can be implemented. Michele Hauser, M.D. is a child psychologist who evaluates and prescribes medication for children when necessary.

“When a child is suffering from selective mutism, their fear and anxiety is just like that of an adult’s anxiety attack. Children’s pain is further compounded by the immature verbal skills needed to express that fear and anxiety. Many adults report they become extremely depressed and even suicidal because of their anxiety disorders. These same feelings are bottled up in a child without the ability to express them. Medications can have dramatic positive results and should not be delayed.”

Hauser states that she typically evaluates and prescribes medication and then refers the child back to the psychologist for cognitive behavioral therapy. “The best treatment is a combination of the two.” Medications are often used on a short-term basis. As the child develops skills and success in social situations, the medications can be tapered off.

Selective Mutism doesn’t just go away nor will a child “grow out of it.” Left untreated the child becomes further inhibited and can suffer academically and socially. Children respond very well to therapy and go on to live very normal lives.

Selective Mutism Resources

Cat’s Got Your Tongue? A Story for Children Afraid to Speak. By Charles E. Schafer, Ph.D. Illustrated by Judith Friedman.

A Highly Sensitive Person. Elaine Aron, Ph.D. This topic is extensively researched by Dr. Aron and she shares her findings in this book as well as in A Highly Sensitive Child. For more information, visit her website www.hsperson.com.

The Selective Mutism Group-Childhood Anxiety Network www.selectivemutism.org. Join the experts in the field for the Family Retreat on July 8-11, 2004 in Baltimore, MD. See the website for details.

The NYU Child Study Center http://www.aboutourkids.org/aboutour/disorders/mutism.html.

The Silence Within: A Teacher/Parent Guide to Helping Selectively Mute and Shy Children. By Gail Goetze Kervatt, M.Ed. Additional information at http://www.selective-mutism.com/index.html.

The Selective Mutism Foundation. http://www.selectivemutismfoundation.org

UCLA Child & Adolescent OCD, Anxiety and Tic Disorders Program
http://www.npi.ucla.edu/caap/Default.htm.