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“She won't speak to anyone…”

Fatima is a 7 year old girl who plays soccer with her brothers and talks excitedly about her favorite World Cup team. Yet, at recess time, she stands alone watching the other kids play soccer and doesn’t speak when her classmates ask her if she wants to play. And despite the school year being half over, she has not spoken a single word in her classroom.

Fatima's parents have tried everything to get her to talk. They've tried talking to her about her feelings, and asking if she's been bullied. They've tried positive consequences such as rewards for being able to speak. They've tried punishing her for not talking. But nothing seems to work! What would you recommend?

Introduction

It is normal for many people to feel anxious in social situations from time to time. In fact, having just enough anxiety and shyness can be helpful because it can protect us from doing things that may be embarrassing or awkward. In some people however, that anxiety is to such an extreme that it prevents people from being able to communicate to others in public.

What is Selective Mutism?

Selective mutism is an anxiety disorder where:

• On one hand, when the person is with safe people (typically mother or father) or safe places (typically home), the person is able to talk normally. With safe people and safe places, one might not even suspect that the person has any issues.
• On the other hand, when outside the home (typically at school or public places such as stores or restaurants), or with people outside of the immediate family, the person is unable to speak. They may:
  • Be unable to talk with other relatives outside the immediate family;
  • Be unable to talk at school with teachers, classmates;
  • Be unable to talk in public such as with store clerks or restaurant staff;
  • Avoid situations that make them anxious, e.g. refuse to go out with family for shopping or other activities;
  • Have physical symptoms of anxiety such as stomach aches or headaches.
  • Appear rude, because they avoid eye contact, or are unable to say hi or goodbye to people.

Hence the name "selective mutism", whereby they are mute in a selection of places, and with a selection of people.

Selective mutism is NOT...

• ... the person being mute ‘on purpose’
• ... the person trying to control or manipulate a situation on purpose.

The distinction is important. 

It helps explain why strategies which help the child feel safe and calmer will help, whereas strategies that increase stress do not.

What Causes Selective Mutism?

Selective mutism is due to severe anxiety outside of the person's control. It is due to the brain being so overwhelmed, that the person is unable to speak. Our brains have a hard-wired ‘fear system’. This ‘turns on’ when we feel we are in danger. It allows us to be ready to ‘fight’ or flee danger. People with selective mutism appear to have a hypersensitive alarm system, which becomes trigger by day to day social situations outside of the immediate family.

Have you ever been paralyzed by anxiety and unable to speak? Imagine having this type of anxiety in common, everyday situations in public.

Factors that contribute to a sensitive alarm include:

• Genetics and family history: Through no fault of their own, their brains may simply be wired to be more sensitive. There is often a family history of anxiety traits, with other family members having had anxiety problems.
• Life stressors: Experiencing stressful life situations (e.g. divorce, separation, bullying, family medical or mental health issues, etc) may contribute to their buildup of stresses.
  

Getting Help and Support is Important

When left untreated, or unsupported, selective mutism can lead to serious problems as they get older such as:

• Social isolation, as well as increased risk of being teased or bullied.
• Learning problems. Your child won’t be able to ask questions or ask for help. Teachers can find it hard to assess your child’s learning needs. Your child will not be able to take part in group work or learn important presentation skills.
• Depression, substance use and other mental health issues.
• Underachievement with school, work and relationships.

For this reason, it is essential that children with selective mutism receive help and support from caring adults.

Self-Help: How can I help my child?

The good news is that there are many things that parents can do that can be helpful.

Do’s (and Dont’s)

Do help your child’s nervous system feel safer by staying calm yourself. Children with selective mutism need the help of adults to help them stay calm and safe.

• Do take a break if you notice yourself getting stressed out -- we often say not so helpful things when we are upset or angry.
• Do try to keep a calm environment, or at least give the child a calm place to go when needed at home, e.g. their bedroom.
• Don’t have an overstimulating environment with too much noise, visual clutter, or emotional stress (e.g. people yelling or fighting).
• Don’t do things which worsen anxiety as they will backfire in the long run, for example:
  • Don’t get angry or frustrated at the child for not speaking.
  • Don’t pressure or force your child to speak or make the child feel guilty for not speaking. Even giving rewards for speaking is a form of pressure.
  • Don’t blame your child for being ‘manipulative’.
  • Don’t punish your child for not speaking.

Do express gratitude (rather than praise).

• Has your child done something positive?
• Express gratitude
  • E.g. “Thank you for letting the server know what you wanted, sharing with your sister, etc.”
  • E.g. Use “I” statements such as “I feel so proud when ___” “I am so happy when you…”
• Note that many parents are tempted to use praise, such as saying, “Good job!”, however many children with selective mutism are sensitive to praise. The problem with praise, is that although it is positive judgment, it is still judgment. And deep down, sensitive children, don’t want to be judged, they just want to be accepted.

Do use acceptance, validation and empathy.

• Do ask about feelings, e.g. “How did you feel about ___.”
  • Does your child have trouble expressing feelings?
    • Do help your child with naming feelings (“I can see how that might have made you frustrated / stressed / upset / worried / etc. Is that how you felt?”)
• Don’t invalidate your child. For example, don’t say things like “Why can’t you even talk?” “You shouldn’t feel this way” “Its not such a big deal” etc.

Do spend daily quality 1:1 time with your child

• Try to set aside some special time each day where your child gets to be themself with you.
• Choose activities that promote interaction, whether non-verbal or verbal. Board games, throwing a ball around, baking, crafts or Lego will give you lots of chances for your child to talk about feelings and emotions. Video games are not the best choice, as they don’t give the same chances for eye contact and communication.

Do use PRIDE skills when you interact with your child.

• PRIDE is a mnemonic for ways to build a deeper connection with your child, from parent child interaction therapy (PCIT), a type of treatment used for selective mutism.

Do make a talking map.

• This is a map that shows the different people and different places that your child is able to talk in. It gives you a quick way of seeing where to focus your efforts on helping your child, with which people and which places.

Example of a Talking Map

Do practice communication skills to help your child climb the "Communication Ladder".

• The Communication Ladder is your child's ability to communicate.
• Easiest steps are at the bottom, and harder steps at the top. Like climbing a ladder, we help the child start at the bottom, and work their way up step-by-step.
• For example:
  • Using gestures
    • E.g. a parent could help encourage the child: "It would be really nice to wave hi to Jennifer! Let’s wave to her!"
  • Whispering to a trusted adult
  • Whispering to a trusted adult, in front of a teacher
  • Whisper to a teacher
  • Talk out loud to a teacher one on one

When To Get Professional Help?

Are you finding that your child’s selective mutism is not getting better on its own?

• Parents may hear that their child is just shy and will outgrow the selective mutism. But there are serious consequences for a child who can’t communicate or speak to others.
• Do get help earlier than later. It is easiest to treat earlier than later.

Where to find help?

• Your primary care provider: It is always best to start by seeing your primary care provider, who can help ensure that there aren’t any medical conditions that are contributing, and who can recommend next steps, which may include:
  • Psychologists
  • Occupational therapists (OT), who can help your child with strategies to calm their nervous system
  • Speech/language therapists (SLP)

There may also be issues that need to be addressed such as:

• Other anxiety disorders such as separation anxiety (difficulty being away from parents), social anxiety disorder (9 out of 10 children with selective mutism meet criteria for social anxiety disorder). 
• Sensory processing differences
• Learning issues
• Attentional issues
• Speech or language problems
• Daytime wetting or bed wetting (enuresis)

How is Selective Mutism Treated?

Professionals may use therapies such as cognitive behavioural therapy (CBT), parent-child interaction therapy (PCIT) and many others. They may use some of the strategies already mentioned in the Self-Help section, as well as:

Self-regulation

• Self-regulation is about teaching child how to recognize their different states of regulation, and how to return themselves to feeling calm. This is important with selective mutism, as people with selective mutism become easily triggered and then become unable to speak. 
• Making accommodations and modifications to the environment, in order to help your child’s nervous system feel calmer.

For more information about self-regulation

• Do use self-regulation strategies from commonly used programs used in schools such as:
  • “Zones of Regulation” (www.zonesofregulation.com)
  • Shanker Self-Regulation https://self-reg.ca/parents)

Setting Communication Goals Step-By-Step

After a child has some self-regulation skills, the next step is to challenge the child’s nervous system step-by-step to accomplish communication goals such as:

• Goal: Being able to order in a restaurant
  • Communication steps:
    • Child whispers want they want to parent
    • Child gestures to the server on the menu what they want
    • Child whispers to the parent, in front of the server
    • Child whispers to the server what they want
  • Has the child made a positive step?
    • Find a calm, quiet time and place to use calm, positive reinforcement such as expressing gratitude, e.g. "Thank you for _____" 
    • Don't make too big a deal, especially not in front of other people, as the person may be too self-conscious.
• Goal: Having a conversation with a peer
  • Communication steps
    • Be around the another person without talking, e.g. playing Lego beside the teacher, or listening to the teacher talk
    • Whispering to teacher or classmates
      
    • Using a ‘regular’ voice and giving yes/no answers (e.g. to closed ended questions like “Did you have a fun time last night?”)
    • Using a ‘regular’ voice and giving longer, more complex answers to open ended questions like “What did you do last night?”

The idea is to go step-by-step towards the eventual goal. If a child struggles with a step, then one can find a simpler, lower step to go back to.

Frequently Asked Questions

Q. What about well-meaning but unhelpful family and friends?

A. Sometimes there will be other well-meaning adults that try to pressure your child. Perhaps grandma wants to reward your child with chocolate for speaking. Or perhaps there is an uncle that pressures your child to speak.

Validate your well-meaning relative by saying: “Thank you for wanting to help my child with being able to speak. The professionals have recommended that in this case, the best way to help him speak is to keep things calm, relaxed and chill. It takes time, but it is the best in the long run. Thanks again for your concern - that means a lot to me.”

Working with the School

The school is likely already aware that your child struggles with talking at school. They may not realize however, the nature of the problem. It will be helpful to educate teachers about how they can meet your child’s needs to feel safe. It is helpful for them to know about what doesn’t help. Sometimes well intentioned educators may use not so helpful strategies such as using shaming, comparisons, or guilt, etc.

Consider doing the following:

1. Have a meeting with parents and educators (e.g. teacher) WITHOUT the child.

See if there can be a meeting with the teacher first. This gives parents a chance to know the teacher.

Other school staff who may also help include:

• Principals or vice-principals:
• School psychologists: If available, a school psychologist plays a key role in coming up with a plan.
• Occupational therapy (OT): Can be very helpful for helping with self-regulation, especially if a student has sensory processing issues.
• Speech-language pathologists (SLP): Some SLPs can help with selective mutism.
• Guidance counselors
• Behaviour therapists
• Social workers

Do’s for the School

• Do help the child understand that selective mutism is a type of severe anxiety disorder, and not due to defiance or stubbornness. It is due to the child’s sensitive system becoming stressed or overwhelmed, i.e. getting into the “yellow” or “red” zone.
• Do understand that the child may be triggered by situations that might not trigger other children, e.g. social situations and sensory triggers.
• Do understand that the student will communicate better when they are feeling calm and less anxious..
• Do focus on helping the child’s nervous system feel calmer, i.e. “in the green zone” to use self-regulation language.
• Do ensure that the child feels safe and connected with key educators. In the short-run, we feel connected when we feel accepted by others, as opposed to judged and criticized.
• Do validate, empathize and accept how the child is.
• Do find common interests with which to connect to the child., e.g. talking about hobbies, interests, pets, music, popular culture, etc.

Don’ts for the School

• Don’t use blame, teasing, humiliation and coercion to motivate the child to speak.
• Don’t try to use logic and reason, e.g. “if you don’t talk, then (consequence will happen).” Even using positive reward systems might not be the best option.
• Don’t make the child the focus of attention, even if it is positive attention. Thus, don’t praise the child in front of others for speaking, i.e. don’t say “Good job!” You might however, quietly express gratitude instead, e.g. “Thanks for all the effort you are making with (getting to school, communicating, etc.) I appreciate it!”

After the parents meet the teacher, parents can meet with their child at home and explain that the adults have a plan.

• Parents can say things such as "We had a very nice meeting with your teacher. You know what? She's really into dogs, just like you. In fact, she has a dog of her own. I think she's really nice, and I think you're going to get along with her."

3. Meeting with parents, teacher and the child.

The next step is to have a meeting with the child and the adults. At this meeting, the child can be introduced to the key people who will support the child at school. Or if the child has already met those people, the child will get to know them in more depth, including what the plans will be at school.

You might say, “I know you’ve already met your teacher. And we’ll having a meeting so that we can get to know your teacher more, and your teacher will learn more about what helps and doesn’t help you feel calm and safe at school.”

Medications

Is your child still struggling with selective mutism, despite trying other approaches?

• If so, medications may be helpful.
• Advantages of medications
  • They can reduce the body’s alarm, thus making it easier to talk.
  • Antidepressants known as SSRIs (selective serotonin reuptake inhibitors) have the most evidence for helping children and youth with anxiety conditions.
  • Medications can be prescribed by a family physician, pediatrician or psychiatrist.
• Medications can have side effects, and for this reason, are not used unless other strategies have already been tried.

Authors

Written by members of the Mental Health Information Committee at the Children’s Hospital of Eastern Ontario (CHEO). Special thanks to the Selective Mutism Group (Aimee Kotrba, Ph.D. & Lisa Kovac, Ed.S.) with help with earlier versions of this article.

For More Information

Dr. Elisa Shipon-Blum: Understanding Selective Mutism: A Guide to Helping Our Teachers Understand. Retrieved Aug 15, 2005 from http://www.selectivemutism.org

SelectiveMutism.org is a great website overall and has a great free Caregiver Toolkit
https://www.selectivemutism.org/wp-content/uploads/2023/06/SMA_Caregiver_ToolKit_SinglePages2023.pdf

References

Black B, Uhde TW. Treatment of elective mutism with fluoxetine: a double-blind, placebo-controlled study. J Am Acad Child Adolesc Psychiatry. 1994 Sep;33(7):1000-6.

Coloroso, Barbara. Kids are Worth it! Harper-Collins, 2002. 

Kumpulainen K. Phenomenology and treatment of selective mutism. CNS Drugs. 2002;16(3):175-80.

Neufeld, G. Holding On to Your Kids, 2002. Discusses the concept of attachment in depth, and how parents can attach with their children.

Creative Commons License. 

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Disclaimer

Information in this fact sheet may or may not apply to your situation. Your health care provider is the best source of information about your situation.