Journal of Psychosocial Nursing and Mental Health Services

Youth in Mind 

Unable to Speak: Selective Mutism in Youth

Heather L. Smith-Schrandt, PhD; Erin Ellington, DNP, APRN, PMHNP-BC

Abstract

It is important for psychiatric nurses to be familiar with the clinical presentation and recommended treatment for selective mutism (SM), as it is a childhood anxiety disorder that is not commonly studied. This article provides a brief overview of its diagnostic criteria, prevalence, assessment, and history. Special attention is given to misconceptions regarding the disorder and differentiation of trauma and oppositional disorders. Two vignettes illustrate varied presentations of SM, with and without comorbid social phobia. Empirically supported behavioral and psychopharmacological treatment is outlined, and considerations for nursing are provided. [Journal of Psychosocial Nursing and Mental Health Services, 56(2), 14–18.]

Abstract

It is important for psychiatric nurses to be familiar with the clinical presentation and recommended treatment for selective mutism (SM), as it is a childhood anxiety disorder that is not commonly studied. This article provides a brief overview of its diagnostic criteria, prevalence, assessment, and history. Special attention is given to misconceptions regarding the disorder and differentiation of trauma and oppositional disorders. Two vignettes illustrate varied presentations of SM, with and without comorbid social phobia. Empirically supported behavioral and psychopharmacological treatment is outlined, and considerations for nursing are provided. [Journal of Psychosocial Nursing and Mental Health Services, 56(2), 14–18.]

Addressing psychiatric and psychosocial issues related to children and adolescents

Selective mutism (SM) is a disorder in which individuals speak in some situations or contexts, but not in others where speech is expected. To be diagnosed, symptoms must be present for at least 1 month, excluding month of school entry. Absence of speech must have a negative impact on daily living and should not be better accounted for by developmental, communication, or psychotic disorders, or lack of fluency in the primary language of the setting (American Psychiatric Association, 2013). Associated characteristics can include behavioral inhibition (e.g., distress and reluctance to novel stimuli), negative emotionality (e.g., frequent or intensive negative emotions), clinginess, stubbornness, temper tantrums, and social withdrawal (Ford, Sladeczek, Carlson, & Kratochwill, 1998; Muris, Hendriks, & Bot, 2016).

History and Myths

SM was first identified in 1877 as aphasia voluntaria” and appeared in the Diagnostic and Statistical Manual of Mental Disorders as “elective mutism” in 1980 (Smith-Schrandt & Storch, 2017a). Terminology was changed to “selective mutism” in 1990, and SM was reclassified as an anxiety disorder in 2013 (Smith-Schrandt & Storch, 2017a). Failure to speak was previously attributed to trauma, family dysfunction, or willful deviance. Although the belief that poor parenting causes SM has been largely rejected, myths regarding the role of trauma and opposition are dissipating more slowly (Smith-Schrandt & Storch, 2017a). Most children with SM have not experienced trauma, although some report negative experiences such as having been teased about speech or berated by a teacher (Schwartz, Freed, & Sheridan, 2006). Normative social communication that has been stunted following trauma is better conceptualized as a posttraumatic or acute stress disorder. Adults may perceive children to be oppositional as they refuse to comply with speech or participation requests, but this is due to anxiety, not willfulness (Ford et al., 1998). Children with SM want to play with friends, share their ideas, and interact, but they are unable due to debilitating anxiety.

Clinical Picture

There are no large epidemiological studies of SM providing comprehensive data regarding prevalence, phenomenology, and course. SM is typically diagnosed in early school years, affecting less than 1% of children and a slightly higher number of girls than boys (Bergman, Piacentini, & McCraken, 2002; Viana, Beidel, & Rabian, 2009). Most children will not meet full criteria for SM by young adulthood even without treatment; however, symptoms of social anxiety and avoidance usually persist (Steinhausen, Wachter, Laimböck, & Metzke, 2006).

Children with SM typically speak comfortably, and even loudly, enthusiastically, or excessively, at home. They may simply be viewed as shy before starting school, but in most cases, signs and symptoms of SM are present in preschool or before (Bergman et al., 2002). Many parents describe a freezing response, or “deer in headlights” look when speech is requested. If parents have concerns, professionals often suggest “shyness” will be outgrown. In one study, 70% of children with SM were never diagnosed or referred by their primary care provider, and only 27% of parents thought of their pediatrician as a helpful resource (Schwartz et al., 2006).

Impairment associated with SM often appears at school entry, with 51% of children in one study demonstrating serious socialization or school difficulties (Schwartz et al., 2006). For example, children may have wetting or soiling accidents due to inability to communicate need for the restroom (Kristensen, 2000). Teachers may be unable to assess academic functioning, particularly reading and speech. Parents might worry when they observe their child playing alone on the playground. Over time, impairment can increase. Social skills can lag without opportunity to practice. Learning can suffer if a child is unable to communicate questions, needs, and confusion. Depressive symptoms can develop from the burden of anxiety, isolation, or peer rejection. Symptoms of SM in adolescent years may not be as ubiquitous. Adolescents may talk to a few friends but only outside of school, or may respond minimally, quietly, and slowly to teachers' questions, but may not volunteer information or ask questions (Viana et al., 2009).

Children with SM have shown increased rates of oppositional behavior, communication or speech deficits, and other anxiety diagnoses (Gensthaler et al., 2016). Although SM is rooted in anxiety, oppositional defiance can be comorbid if noncompliance occurs outside of speaking situations. Early speech difficulties can contribute to SM, especially in those predisposed to anxiety, but most children with SM do not have speech problems (Schwartz et al., 2006). The most commonly co-occurring diagnosis is social phobia (50% to 95%), and children with SM often have relatives with social phobia (33%), SM (12%), or avoidant personality disorder (17%) (Chavira, Shipon-Blum, Hitchcock, Cohan, & Stein, 2007; Schwartz et al., 2006). In fact, SM can be conceptualized as an early or extreme variant of social phobia, as children with SM may be less socially skilled than children with social phobia (Young, Bunnell, & Beidel, 2012). Silence is an avoidant coping strategy that decreases social anxiety short-term, but over time intensifies anxiety to clinical impairment (Young et al., 2012). However, not all children with SM also meet criteria for social phobia. Consider the below vignettes, the first with and the second without comorbid social phobia at the time of evaluation.

Case Vignettes

Eloise, Age 16, Female

Eloise speaks rarely at school. She will talk to certain teachers in a one-on-one environment, but only provides short responses. Eloise is a fraternal twin and speaks to her sister at school when alone. Eloise speaks freely to only one peer, who is a long-time friend of the twins. Eloise is reliant on her twin for her communication needs outside the home. She does not order her own food, leave the house without a family member, or display any emotional or facial expression in public. Over time, her twin has become more resentful of her accommodating role, which was the impetus, along with increased school absence and declining grades, for Eloise to seek treatment. Eloise requested her twin attend the evaluation, and their mother agreed it was necessary.

Eloise has long hair that hangs in her face, wears baggy plain clothes and no makeup, slouches, and does not make eye contact or otherwise communicate in the lobby. In the office, Eloise responded non-verbally and with quiet, short responses, and looked to her twin before responding as if for approval, encouragement, or guidance. Her twin wanted Eloise to respond independently but was quick to jump in with more information and to ask Eloise if she wanted her to answer. When Eloise was speaking directly to her twin, she was more animated (smiling and laughing) and verbose. Eventually, Eloise described a physical feeling of being unable to “get the words out,” along with accompanying feelings of social anxiety, such as worrying she wasn't saying the “right” thing, and not retrieving a fallen pencil for fear of attention movement might bring.

Nate, Age 6, Male

Nate and his infant brother live in a bilingual household with their father, a first-generation Hispanic American, and Nate's American-born Caucasian mother. Nate's parents report that he is fluent in English, and they have noted no speech abnormalities. Nate is in first grade and was diagnosed with SM in preschool. He speaks to only a few friends but interacts with all classmates and is well liked by teachers and students. He readily communicates with teachers non-verbally and will whisper responses to a friend who will share his answer. He will raise his hand, tap on shoulders, or even tug on sleeves to indicate he has something to communicate. During his evaluation, Nate bounced around the lobby with energy and smiles and easily engaged with the provider, seeming to enjoy the attention. He demonstrated vibrant, creative, and intricate non-verbal communication and noises, as if he were playing charades. In the provider's office, Nate eventually responded verbally to the provider but with a distorted voice. Nate typically used a “monster” or “baby” voice when first communicating with someone.

Treatment

Early diagnosis leads to more timely intervention and prevents long-term effects of SM. Diagnosis is typically made based on interview and observation, and standardized measures such as the Selective Mutism Questionnaire (Bergman, Keller, Piacentini, & Bergman, 2008). Behavioral treatment, as well as pharmacotherapy, should be considered once the diagnosis is made.

Behavioral Treatment

Treatment for SM is not often studied, with only two randomized controlled trials performed on SM (Bergman, Gonzalez, Piacentini, & Keller, 2013; Oerbeck, Stein, Wentzel-Larson, Langsrud, & Kristensen, 2014). However, cognitive-behavioral therapy has been proven effective as first-line treatment (Klein, Armstrong, Skira, & Gordon, 2016; Smith-Schrandt & Storch, 2017b). Two evidence-based approaches are integrated behavioral therapy (Bergman, 2013) and social communication anxiety treatment (S-CAT) (Klein et al., 2016).

Treatment should include: (a) gradual and systematic exposure to feared situations, and (b) significant involvement and coaching of family members and school personnel. Historically, treatment could take months to years (Jackson, Allen, Boothe, Nava, & Coates, 2005), but recent behavioral approaches attempt to shorten length of treatment. Intensive group-based delivery of behavioral treatment and “camp” type frameworks are becoming available, which include the benefit of peer interaction and are ideal in areas with a dearth of properly trained clinicians (Sharkey, McNicholas, Barry, Begley, & Ahern, 2008). Examples of this type of program are Brave Buddies (Child Mind Institute, 2016) (access https://childmind.org/center/brave-buddies), and Mighty Mouth Kids and WeSpeak (access https://www.selectivemutism.org/professional/kurtz-pyschology-consulting-pc).

Relaxation and coping strategies can be helpful early in treatment, but ultimately children should be encouraged to engage in activities that elicit anxiety. Exposure and experience of tolerating anxiety results in habituation and corrective learning (Farmer & Chapman, 2016). For example, each time children order at restaurants, ordering becomes easier and produces less anxiety (habituation). In addition, children learn that anxiety is uncomfortable but not dangerous, and their anxiety subsides over time. Children find that feared outcomes do not happen (e.g., they did not answer wrong) or are not as terrible as anticipated (e.g., no one laughs at their incorrect response).

Exposure must be gradual so children can experience success and do not shut down. Individualized hierarchies should be developed (Table). Communication exists on a spectrum from non-verbal responses to verbal initiation, and hierarchies can include steps such as communicating non-verbally, making eye contact, mouthing words, whispering, and using increasingly audible speech (Kearney, 2010). Individual functional factors that increase likelihood of speech are identified and integrated as steps in the hierarchy (Ale, Mann, Menzel, Storch, & Lewin, 2013). Typically, speech is easier in quiet settings with fewer people, a nonchalant approach, diverted eye contact, and focus on a shared activity. Multiple-choice questions, which require predictable and short responses (e.g., “What is your favorite subject?”), are effective early in treatment. Binary questions (with yes or no answers) will likely be met with only non-verbal responses, whereas open-ended questions (e.g., “Why do you think that is?”) may produce too much anxiety. Contingency management and rewards for exposure completion increase motivation and willingness. Technology and play (e.g., puppets, guessing games, televideo, talking animal “apps”) can be incorporated to facilitate communication and build rapport (Bunnell & Beidel, 2013).

Example Hierarchy for Systematic Gradual Exposure to Feared Speaking Situations

Table:

Example Hierarchy for Systematic Gradual Exposure to Feared Speaking Situations

Other behavioral components that have proven helpful include shaping, “fading in,” and social skill building (Smith-Schrandt & Storch, 2017b). Shaping refers to gradually approximating speech. Initial exercises might include mouthing a response without audible vocalization, or starting with easy-to-pronounce phonemes (Klein et al., 2016). “Fading in” is a procedure in which speech is gradually transferred from a “safe” person to an unfamiliar person (Zakszeski & DuPaul, 2017). For example, a teacher may sit in the back of the classroom and gradually move closer to a parent–child conversation, ultimately joining in while the parent fades out of the classroom. Children with SM often lag in social skills, and may benefit from direct coaching such as role play, education about body language, or a list of conversation starters.

Any treatment of SM should include family coaching (e.g., Transfer of Control in S-CAT) to generalize treatment gains and reduce accommodation of avoidance (Khanna & Kendall, 2009; Klein et al., 2016). It is difficult for parents to see children in distress, and instinct is to rescue. It can be especially hard for anxious parents to tolerate their distress and their children's distress (Rudy, Storch, & Lewin, 2015). Parents benefit from psychoeducation on the exacerbating role of accommodation and coaching to reduce accommodation (e.g., counting to 10 before assuming non-response). Parents should also increase opportunities for children's exposure and allow for natural consequences. For example, parents may replace “Would you like a red lollipop?” with “If you want a lollipop, tell them which color you prefer,” and may refuse children the lollipop without speech. Parents are not the only ones who accommodate; siblings sometimes take on the “communicator” role, and children with SM will often befriend outgoing peers who are happy to do most of the talking. Siblings and friends can be coached to gradually reduce accommodation and “bridge the gap.” For example, a child with SM might be more likely to speak to new peers when a friend they already converse with is also at the playdate.

Importantly, school-based cooperation can speed improvement and facilitate generalization. Alternative methods of assessment (e.g., videotaped presentations, parents as test administrators) and other accommodations (e.g., bathroom pass, preferential seating by a friend or in the back of the classroom) may be initially necessary. Teachers can also benefit from learning factors that influence likelihood of speech (Child Mind Institute, 2016). For example, teachers can be warned against large reactions to vocalization because excessive attention, even if positive, can increase anxiety.

Psychopharmacology

Behavioral intervention is considered first-line treatment, but some children may need medication as well. Currently, there are no published practice parameters for clinicians regarding medication management of SM. However, a recent systematic review of literature found fluoxetine to be the most studied medication, followed by sertraline, citalopram/escitalopram, other selective serotonin reuptake inhibitors and phenelzine, and a monoamine oxidase inhibitor. All studies showed symptomatic improvement (Manassis, Oerbeck, & Overgaard, 2016). Despite positive results, only three of the studies reviewed had unmedicated comparison groups, and only two were double-blinded. Limited evidence requires a careful risk–benefit analysis by a prescribing clinician, and medication should be reserved for children with persisting symptoms, severe impairment, or older age. In addition, clinical judgment is required when determining dosage, titration, and duration of medication treatment (Manassis et al., 2016).

Conclusion

Although SM is not the most common anxiety disorder, it can be impairing emotionally, socially, and academically. Untreated SM can result in continued impairment and increases the risk for other psychiatric disorders. The understanding of SM has been plagued by myths and slowed by lack of research attention. The field of clinical psychology has started to develop standardized measures and identify empirically supported treatments. Psychiatric nurses and advanced practice nurses can impact the SM course for children and their families in different ways. Roles may include increasing awareness, identifying SM early, providing psychoeducation, and treating SM properly, including provision of or referral for psychopharmacology and appropriate behavioral treatment. Nurses can be part of the team that helps silent children find their voices.

References

  • Ale, C.M., Mann, A., Menzel, J., Storch, E.A. & Lewin, A.B. (2013). Two cases of early childhood selective mutism: Variations and treatment complexities. Clinical Case Studies, 12, 278–290. doi:10.1177/1534650113482358 [CrossRef]
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
  • Bergman, R.L. (2013). Treatment for children with selective mutism: An integrative behavioral approach. New York, NY: Oxford University.
  • Bergman, R.L., Gonzalez, A., Piacentini, J. & Keller, M.L. (2013). Integrated behavior therapy for selective mutism: A randomized controlled pilot study. Behaviour Research and Therapy, 51, 680–689. doi:10.1016/j.brat.2013.07.003 [CrossRef]
  • Bergman, R.L., Keller, M.L., Piacentini, J. & Bergman, A.J. (2008). The development and psychometric properties of the selective mutism questionnaire. Journal of Clinical Child and Adolescent Psychology, 37, 456–464. doi:10.1080/15374410801955805 [CrossRef]
  • Bergman, R.L., Piacentini, J. & McCracken, J.T. (2002). Prevalence and description of selective mutism in a school-based sample. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 938–946. doi:10.1097/00004583-200208000-00012 [CrossRef]
  • Bunnell, B.E. & Beidel, D.C. (2013). Incorporating technology into the treatment of a 17-year old female with selective mutism. Clinical Case Studies, 12, 291–306. doi:10.1177/1534650113483357 [CrossRef]
  • Chavira, D.A., Shipon-Blum, E., Hitchcock, C., Cohan, S. & Stein, M.B. (2007). Selective mutism and social anxiety disorder: All in the family?Journal of the American Academy of Child & Adolescent Psychiatry, 46, 1464–1472. doi:10.1097/chi.0b013e318149366a [CrossRef]
  • Child Mind Institute. (2016). Teachers guide to selective mutism. Retrieved from https://childmind.org/downloads/Teachers-Guide-to-SM-v1.pdf
  • Farmer, R.F. & Chapman, A.L. (2016). Exposure-based interventions. In Behavioral interventions in cognitive behavior therapy: Practical guidance for putting theory into action (2nd ed., pp. 269–299). Washington, DC: American Psychological Association.
  • Ford, M.A., Sladeczek, I.E., Carlson, J. & Kratochwill, T.R. (1998). Selective mutism: Phenomenological characteristics. School Psychology Quarterly, 13, 192–227. doi:10.1037/h0088982 [CrossRef]
  • Gensthaler, A., Maichrowitz, V., Kaess, M., Ligges, M., Freitag, C.M. & Schwenck, C. (2016). Selective mutism: The fraternal twin of childhood social phobia. Psychopathology, 49, 95–107. doi:10.1159/000444882 [CrossRef]
  • Jackson, M.F., Allen, R.S., Boothe, A.B., Nava, M.L. & Coates, A. (2005). Innovative analyses and interventions in the treatment of selective mutism. Clinical Case Studies, 4, 81–112. doi:10.1177/1534650103259676 [CrossRef]
  • Kearney, C.A. (2010). Helping children with selective mutism and their parents: A guide for school-based professionals. New York, NY: Oxford University. doi:10.1093/med:psych/9780195394542.001.0001 [CrossRef]
  • Khanna, M.S. & Kendall, P.C. (2009). Exploring the role of parent training in the treatment of childhood anxiety. Journal of Consulting and Clinical Psychology, 77, 981–986. doi:10.1037/a0016920 [CrossRef]
  • Klein, E.R., Armstrong, S.L., Skira, K. & Gordon, J. (2016). Social communication anxiety treatment (S-CAT) for children and families with selective mutism: A pilot study. Clinical Child Psychology and Psychiatry, 22, 90–108. doi:10.1177/1359104516633497 [CrossRef]
  • Kristensen, H. (2000). Selective mutism and comorbidity with developmental disorder/delay, anxiety disorder, and elimination disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 249–256. doi:10.1097/00004583-200002000-00026 [CrossRef]
  • Manassis, K., Oerbeck, B. & Overgaard, K.R. (2016). The use of medication in selective mutism: A systematic review. European Child and Adolescent Psychiatry, 25, 571–578. doi:10.1007/s00787-015-0794-1 [CrossRef]
  • Muris, P., Hendriks, E. & Bot, S. (2016). Children of few words: Relations among selective mutism, behavioral inhibition, and (social) anxiety symptoms in 3- to 6-year-olds. Child Psychiatry and Human Development, 47, 94–101. doi:10.1007/s10578-015-0547-x [CrossRef]
  • Oerbeck, B., Stein, M.B., Wentzel-Larsen, T., Langsrud, Ø. & Kristensen, H. (2014). A randomized controlled trial of a home and school-based intervention for selective mutism—Defocused communication and behavioural techniques. Child and Adolescent Mental Health, 19, 192–198. doi:10.1111/camh.12045 [CrossRef]
  • Rudy, B.M., Storch, E.A. & Lewin, A.B. (2015). When families won't play ball: A case example of the effect of family accommodation on anxiety symptoms and treatment. Journal of Child and Family Studies, 24, 2070–2078. doi:10.1007/s10826-014-0008-3 [CrossRef]
  • Schwartz, R.H., Freedy, A.S. & Sheridan, M.J. (2006). Selective mutism: Are primary care physicians missing the silence?Clinical Pediatrics, 45, 43–48. doi:10.1177/000992280604500107 [CrossRef]
  • Sharkey, L., McNicholas, F., Barry, E., Begley, M. & Ahern, S. (2008). Group therapy for selective mutism—A parents' and children's treatment group. Journal of Behavior Therapy and Experimental Psychiatry, 39, 538–545. doi:10.1016/j.jbtep.2007.12.002 [CrossRef]
  • Smith-Schrandt, H. & Storch, E.A. (2017a). Selective mutism. In Wenzel, A.E. (Ed.), The Sage encyclopedia of abnormal and clinical psychology. Washington, DC: Sage.
  • Smith-Schrandt, H. & Storch, E.A. (2017b). Selective mutism: Treatment. In Wenzel, A.E. (Ed.), The Sage encyclopedia of abnormal and clinical psychology. Washington, DC: Sage.
  • Steinhausen, H.C., Wachter, M., Laimböck, K. & Metzke, C.W. (2006). A long-term outcome study of selective mutism in childhood. Journal of Child Psychology and Psychiatry, 47, 751–756. doi:10.1111/j.1469-7610.2005.01560.x [CrossRef]
  • Viana, A.G., Beidel, D.C. & Rabian, B. (2009). Selective mutism: A review and integration of the last 15 years. Clinical Psychology Review, 29, 57–67. doi:10.1016/j.cpr.2008.09.009 [CrossRef]
  • Young, B.J., Bunnell, B.E. & Beidel, D.C. (2012). Evaluation of children with selective mutism and social phobia: A comparison of psychological and psychophysiological arousal. Behavior Modification, 36, 525–544. doi:10.1177/0145445512443980 [CrossRef]
  • Zakszeski, B.N. & DuPaul, G.J. (2017). Reinforce, shape, expose, and fade: A review of treatments for selective mutism (2005–2015). School Mental Health, 9, 1–15. doi:10.1007/s12310-016-9198-8 [CrossRef]

Example Hierarchy for Systematic Gradual Exposure to Feared Speaking Situations

Exposure TaskSubjective Units of Distressa
Raise hand in class to answer question10
Answer one-word question when called on10
Answer one-word question one-on-one with teacher9
Say “hi” to teacher with eye contact9
Talk to mom with teacher at table8
Say “bye” to teacher when leaving8
Talk to mom with teacher in back of room7
Watch video with teacher6
Record video for teacher to watch5
Record message for teacher to hear4
Do math problem on chalkboard4
Shake hands with teacher3
Talk to mom alone in classroom3
Authors

Dr. Smith-Schrandt is Associate Staff Psychologist, Kansas City Center for Anxiety Treatment, P.A., Overland Park, Kansas; and Dr. Ellington is Clinical Assistant Professor, University of Missouri Kansas City, School of Nursing and Health Studies, Kansas City, Missouri.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Erin Ellington, DNP, APRN, PMHNP-BC, Clinical Assistant Professor, University of Missouri Kansas City, School of Nursing and Health Studies, 2464 Charlotte, Kansas City, MO 64108; e-mail: ellingtone@umkc.edu.

10.3928/02793695-20180122-04

Sign up to receive

Journal E-contents