In psychiatry, selective mutism (SM) is an anxiety disorder in which a person who is otherwise capable of speech becomes emotionally overwhelmed and does not speak when exposed to specific situations, specific places, or to specific people, one or multiple of which serve as triggers. This kind of mutism usually co-exists with social anxiety disorder. People with selective mutism may stay silent even when the consequences of their silence include shame, social ostracism, or punishment. In some cases, the affected person wants to speak, but feel like they can not get the words out.
Signs and symptoms The DSM-5 describes selective mutism as a persistent difficulty with speaking in specific social settings where speech is expected, such as in school, despite an ability to speak in other situations. The symptoms should not be too temporary and they must affect the person's ability to perform in a certain situation. Consideration should be given to possible other diagnoses.American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. p. 195. .
Children and adults with selective mutism are fully capable of speech and understanding language but may be completely unable to speak in certain situations, even if speech is expected of them. This behaviour may be perceived as shyness for some or rudeness by others. A child with selective mutism may be completely silent at school for years but speak quite freely or even excessively at home. There is a hierarchical variation among people with this disorder: some people participate fully in activities and appear social but do not speak, others will speak only to peers but not to adults, others will speak to adults when asked questions requiring short answers but never to peers, and still others speak to no one and participate in few, if any, activities presented to them. In a severe form known as "progressive mutism", the disorder progresses until the person with this condition no longer speaks to anyone in any situation, even close family members.
Selective mutism is strongly associated with other anxiety disorders, particularly social anxiety disorder. In fact, the majority of children diagnosed with selective mutism have comorbid social anxiety disorder (100% of participants in two studies and 97% in another). Selective mutism is sometimes conflated with autism, particularly among young children; this happens most frequently when a child acts particularly withdrawn around their diagnostician, and can lead to misdiagnosis and ineffective treatment. Although many autistic people are also selectively mute, they often display other behaviors—stimming, repetitive behaviors, social isolation even among family members (not always answering to name, for example)—that set them apart from a child with selective mutism alone. Some autistic people may be selectively mute due to anxiety in unfamiliar social situations. If mutism is entirely due to autism spectrum disorder, it cannot be diagnosed as selective mutism as stated in the last item on the list above.
The former name elective mutism indicates a widespread misconception among psychologists that selectively mute people choose to be silent in certain situations, while the truth is that they often wish to speak but are unable to do so. To reflect the involuntary nature of this disorder, the name was changed to selective mutism in 1994, although this name remains controversial. The name situational mutism was first suggested by Alice Sluckin, and has been used by some activists and autism researchers such as Damian Milton, arguing that the current name still carries the implication that people with the condition are choosing to be mute.
The incidence of selective mutism is not certain. Due to the poor understanding of this condition by the general public, many cases are likely undiagnosed. Based on the number of reported cases, the figure is commonly estimated to be 1 in 1000, 0.1%. However, a 2002 study in The Journal of the American Academy of Child and Adolescent Psychiatry estimated the incidence to be 0.71%.
Other symptoms In addition to reduced speech, people with selective mutism may display other associated behaviours and characteristics.
Shyness, social anxiety, fear of social embarrassment, or social withdrawal Difficulty maintaining eye contact Reduced facial expression or difficulty smiling Difficulty expressing feelings, including to family members A tendency to worry Sensitivity to noise or crowds
Causes
Selective mutism (SM) is an umbrella term for the condition of otherwise well-developed children or adults who cannot speak or communicate under certain settings. Selective mutism could be caused due to a combination of genetic, environmental, and developmental factors. Key causes include inherited anxious temperament, high social anxiety, family history of anxiety, sensory processing issues, and language delays. Many people are not diagnosed until late in childhood only because they do not speak at school and therefore fail to accomplish assignments requiring public speaking. Their involuntary silence makes the condition harder to understand or test. Parents often are unaware of the condition since the children may be functioning well at home. Teachers and pediatricians also sometimes mistake it for severe shyness or common stage fright.
Most children and adults with selective mutism are hypothesized to have an inherited predisposition to anxiety. They often have inhibited temperaments, which is hypothesized to be the result of over-excitability of the area of the brain called the amygdala. This area receives indications of possible threats and sets off the fight-or-flight response. Behavioral inhibitions, or inhibited temperaments, encompass feelings of emotional distress and social withdrawals. In a 2016 study, the relationship between behavioral inhibition and selective mutism was investigated. Children between the ages of three and 19 with lifetime selective mutism, social phobia, internalizing behavior, and healthy controls were assessed using the parent-rated Retrospective Infant Behavioral Inhibition (RIBI) questionnaire, consisting of 20 questions that addressed shyness and fear, as well as other subscales. The results indicated behavioral inhibition does indeed predispose selective mutism. Corresponding with the researchers' hypothesis, children diagnosed with long-term selective mutism had a higher behavioral inhibition score as an infant. This is indicative of the positive correlation between behavioral inhibition and selective mutism.
Given the very high incidence of social anxiety disorder within selective mutism (as high as 100% in some studies), it is possible that social anxiety disorder causes selective mutism. Some children or adults with selective mutism may have trouble processing sensory information. This could cause anxiety and a sense of being overwhelmed in unfamiliar situations, which may cause the child or adult to "shut down" and not be able to speak (something that some autistic people also experience). Many children or adults with selective mutism have some auditory processing difficulties. Many children or adults who have selective mutism almost always speak confidently in some situations.
About 20–30% of children or adults with selective mutism have speech or language disorders that add stress to situations in which the child is expected to speak. In the DSM-4, the term "elective mutism" was changed to "selective mutism". This name change intended to deemphasize this refusal and oppositional aspect of the disorder. Instead, it highlighted that in select environments, the child is unable to speak rather than choosing not to. In fact, children with selective mutism have a lower rate of oppositional behavior than their peers in a school setting. Some previous studies on the subject of selective mutism have been dismissed as containing serious flaws in their design.
Some have suggested a connection between selective mutism and the freeze response. According to the unsafe world model of selective mutism, selective mutism is a stress reaction to situations erroneously experienced via cognition without awareness as unsafe. It assumes a high sensitivity to unsafety, whereby the nervous system triggers dissociation or freeze mode at relatively low thresholds. Various factors could influence the process of distinguishing safe from unsafe contexts. Environmental influences (family dysfunction, traumatic or stressful life events, parental control, negative experiences at school, and immigrant status) have shown some involvement in the origins of selective mutism, however research and the evidence for the contribution of these factors is limited. According to a systematic study it is believed that children or adults who have selective mutism are not more likely than other children or adults to have a history of early trauma or stressful life events. This could be because abuse is only one of several risk factors for selective mutism.
Prevalence Estimates of the prevalence of selective mutism (the fraction of the population experiencing it at any given time) face methodological challenges, and vary between 0.2% and 1.6%. Studies disagree as to whether prevalence is higher among males, females or neither. Prevalence is slightly higher among children who have immigrated to a different country, speak a minority language, or have speech or language delays.
Treatment Contrary to popular belief, people with selective mutism do not necessarily improve with age. Effective treatment is necessary for a child to develop properly. Without treatment, selective mutism can contribute to chronic depression, further anxiety, and other social and emotional problems.Selective Mutism Group: Ask the Doc archives: When do I need to seek professional help for my child?
Consequently, treatment at an early age is important. If not addressed, selective mutism tends to be self-reinforcing. Others may eventually expect an affected child to not speak and therefore stop attempting to initiate verbal contact. Alternatively, they may pressure the child to talk, increasing their anxiety levels in situations where speech is expected. Due to these problems, a change of environment may be a viable consideration. However, changing school is worth considering only if the alternative environment is highly supportive, otherwise a whole new environment could also be a social shock for the individual or deprive them of any friends or support they have currently. Regardless of the cause, increasing awareness and ensuring an accommodating, supportive environment are the first steps towards effective treatment. Most often affected children do not have to change schools or classes and have no difficulty keeping up except on the communication and social front. Treatment in teenage or adult years can be more difficult because the affected individual has become accustomed to being mute, and lacks social skills to respond to social cues.
The exact treatment depends on the person's age, any comorbid mental illnesses, and a number of other factors. For instance, stimulus fading is typically used with younger children because older children and teenagers recognize the situation as an attempt to make them speak, and older people with this condition and people with depression are more likely to need medication.