Differentiating the symptoms of Selective Mutism (SM) from “shyness” and other anxiety conditions can be challenging for the general public as well as many professionals. As a result, many individuals with SM are mislabeled and/or diagnosis is significantly delayed. Common misdiagnoses include Social Anxiety Disorder, Separation Anxiety Disorder, Unspecified Anxiety Disorder, Autism Spectrum Disorder, and Oppositional Defiant Disorder. It is important to note, however, that having the symptoms of SM does not mean you cannot also have the symptoms of these other conditions, and there are those who meet diagnostic criteria for two or more of these conditions. Recognizing SM can be hard when most professionals are only able to see the child in specific, often anxiety-provoking, settings such as the school or an office, so common symptoms of SM such as freezing, poor eye contact, making noises instead of verbalizing, and/or apparent “refusal” to speak can be easily misinterpreted. The core diagnostic criterion of SM is lack of speech in certain situations (such as school or out in the community) despite the ability to speak and comfortable demonstration of speech in other settings (such as the home environment). Thus, careful consideration to the who, what, when, where, and how the individual speaks is important to distinguishing Selective Mutism from other conditions.
Despite the inherent challenges, coming to the right diagnosis as early as possible is important because it may significantly impact the way the child receives treatment. Cognitive Behavioral Therapy (CBT) is a highly regarded intervention package for children and adults with a variety of anxiety disorders. How CBT is applied, however, may vary depending on the specific diagnosis and symptoms, and there are a number of interventions to select from under the umbrella of CBT. Strategies such as deep breathing, muscle relaxation, problem solving, and cognitive restructuring (i.e., challenging anxious thoughts) are all components of CBT that may be effective for many conditions, but may have limited effectiveness (at least early on into treatment) with an individual with SM due to difficulties inherent to the diagnosis. For instance, a child with SM would likely be unable to verbalize the content of their anxious thoughts in order to be able to learn techniques to challenge the thoughts; some may be so overwhelmed by anxiety that they are unable to do deep breathing or engage in physical movements in front of a clinician. Moreover, since SM is usually first apparent during the preschool and early elementary school years, interventions must be selected that are developmentally appropriate, and young children often do not have the cognitive awareness and skill to be able to recall and implement techniques learned in a therapy office once back in their school or a community setting. Such intervention approaches may be appropriate later in treatment once the child is verbal with the therapist and/or when the child is slightly older.
Exposure to anxiety-provoking situations is another key component in CBT for anxiety conditions, and many SM experts would describe it as the key approach for treating Selective Mutism. By encountering situations that elicit anxiety (e.g., talking to their teacher alone in a classroom) in a systematic and planful way, the person participating in the intervention is able to learn through the experience that their anxiety is manageable, and they are able to build confidence to tackle increasingly challenging tasks (e.g., talking to their teacher when a classmate or two are nearby). In order to create appropriate exposure tasks, the treating provider must correctly identify the type of anxiety and organize exposure tasks in a hierarchal fashion. Asking an individual with SM to raise their hand to participate in class (as a therapist might assign in a case of social anxiety) would likely be too lofty a goal in the early stages of treatment for SM. Reinforcing the child for separating from their parent to go to school without tears (as may be appropriate in a case of separation anxiety) would not likely lead to increased speech while at school. Introducing an alternate method of communication such as a Picture Exchange Communication System (PECS; as a therapist may introduce in a case where a child has Autism Spectrum Disorder and is nonverbal) would certainly not encourage the child to overcome anxiety surrounding speaking while at school. Thus, selecting the appropriate exposures and interventions depends on an appropriate diagnosis. For a person with SM, appropriate exposures may vary significantly; here are a few examples:
- Responding with one word to the treating professional
- Giving their ice cream order to the employee when given the options of chocolate or vanilla
- Asking for help locating an item in a store
- Speaking to the school interventionist alone in their office
- Responding to a classmate’s question
- Reading aloud in a small group
- Raising their hand to respond in class
Parents, teachers, or health care providers who suspect that a child may be exhibiting signs of Selective Mutism should consider seeking a thorough assessment with a clinician well-versed in SM. Common assessment methods include completing paper-and-pencil questionnaires such as the Selective Mutism Questionnaire (SMQ), the School Speech Questionnaire (SSQ) and the Screen for Child Anxiety Related Disorders (SCARED), direct observations of the child in the school and/or in the clinic setting with familiar and unfamiliar communication partners, a review of videos of the child’s interaction in the school or community setting, and mapping out to whom and under what conditions the child may speak. Of course, the clinician would also need to gather information from those who know the child best (i.e., their parents, teachers, other common caregivers) who can shed light onto the symptoms and provide information about the child’s biopsychosocial health history in order to confirm the appropriate diagnosis or diagnoses.
Treatment for SM is often based on the CBT technique of exposure, and clinicians may incorporate a number of strategies to facilitate exposures. One such approach is “fading in” wherein the individual with SM is first asked to speak to someone comfortable such as a parent while the new person (such as the therapist, teacher, or extended family member) very slowly joins the interaction-first overhearing the individual speaking for a while before asking direct questions. Another approach is using specific questions to encourage speech. For instance, many people with SM find it easier to answer forced choice questions (e.g., “Do you want to play a board game or color or do something else next?”) than it would be to answer an open-ended question (e.g., “What should we do next?”). Family and school education are also an important component to getting the right help so that parents, siblings, teachers, and school administrators all feel confident in their role in supporting intervention efforts. By contrast, other approaches, such as play therapy, do not have robust research support to suggest that they are effective in treating this condition.
The Selective Mutism Association maintains a list (Find a Treating Professional) of treating professionals who work with individuals with SM and are professional members of our organization.
Katelyn Reed,MS, LLP
SMA Board of Directors