Selective Mutism – A Comprehensive Overview
BY DR. ELISA SHIPON-BLUM

Selective Mutism is a complex childhood anxiety disorder characterized by a child’s inability to speak and communicate effectively in select social settings, such as school. These children are able to speak and communicate in settings where they are comfortable, secure, and relaxed.

More than 90% of children with Selective Mutism also have social phobia or social anxiety. This disorder is quite debilitating and painful to the child. Children and adolescents with Selective Mutism have an actual FEAR of speaking and of social interactions where there is an expectation to speak and communicate. Many children with Selective Mutism have great difficulty responding or initiating communication in a nonverbal manner; therefore, social engagement may be compromised in many children when confronted by others or in an overwhelming setting where they sense a feeling of expectation.

Not all children manifest their anxiety in the same way. Some may be completely mute and unable to speak or communicate to anyone in a social setting, others may be able to speak to a select few or perhaps whisper. Some children may stand motionless with fear as they are confronted with specific social settings. They may freeze, be expressionless, unemotional and may be socially isolated. Less severely affected children may look relaxed and carefree, and are able to socialize with one or a few children but are unable to speak and effectively communicate to teachers or most/all peers.

When compared to the typically shy and timid child, most children with Selective Mutism are at the extreme end of the spectrum for timidity and shyness.

Why does a child develop Selective Mutism?
The majority of children with Selective Mutism have a genetic predisposition to anxiety. In other words, they have inherited a tendency to be anxious from one or more family members. Very often, these children show signs of severe anxiety, such as separation anxiety, frequent tantrums and crying, moodiness, inflexibility, sleep problems, and extreme shyness from infancy on.

Children with Selective Mutism often have severely inhibited temperaments. Studies show that individuals with inhibited temperaments are more prone to anxiety than those without shy temperaments. Most, if not all, of the distinctive behavioral characteristics that children with Selective Mutism portray can be explained by the studied hypothesis that children with inhibited temperaments have a decreased threshold of excitability in the almond-shaped area of the brain called the amygdala. When confronted with a fearful scenario, the amygdala receives signals of potential danger (from the sympathetic nervous system) and begins to set off a series of reactions that will help individuals protect themselves. In the case of children with Selective Mutism, the fearful scenarios are social settings such as birthday parties, school, family gatherings, routine errands, etc.

Some children with Selective Mutism have Sensory Processing Disorder (DSI) which means they have trouble processing specific sensory information. They may be sensitive to sounds, lights, touch, taste and smells. Some children have difficulty modulating sensory input which may affect their emotional responses. DSI may cause a child to misinterpret environmental and social cues. This can lead to inflexibility, frustration and anxiety. The anxiety experienced may cause a child to shut down, avoid and withdraw from a situation, or it may cause him/her to act out, have tantrums and manifest negative behaviors.

Some children (20-30%) with Selective Mutism have subtle speech and/or language abnormalities such as receptive and/or expressive language abnormalities and language delays. Others may have subtle learning disabilities including auditory processing disorder. In most of these cases, the children have inhibited temperaments (prone to shyness and anxiety). The added stress of the speech/language disorder, learning disability, or processing disorder may cause the child to feel that much more anxious and insecure or uncomfortable in situations where there is an expectation to speak.

More studies are necessary to fully assess speech/language abnormalities and Selective Mutism as well as processing disorders and Selective Mutism. It is important to note that there are many children with Selective Mutism who are early speakers without any speech delays/disorders or processing disorders.

Research at the Selective Mutism Anxiety Research and Treatment Center (SMart Center) indicates that there is a proportion of children with Selective Mutism who come from bilingual/multilingual families, have spent time in a foreign country, and/or have been exposed to another language during their formative language development (ages 2-4 years old). These children are usually temperamentally inhibited by nature, but the additional stress of speaking another language and being insecure with their skills is enough to cause an increased anxiety level and mutism.

A small percentage of children with Selective Mutism do not seem to be the least bit shy. Many of these children perform and do whatever they can to get others attention and are described as professional mimes! Reasons for mutism in these children are not proven, but preliminary research from the SMart Center indicates that these children may have other reasons for mutism. For example, years of living mute and therefore have ingrained mute behavior despite their lack of social anxiety symptoms or other developmental/speech problems. These children are literally stuck in the nonverbal stage of communication. Selective Mutism is therefore a symptom. Children are rarely “just mute.” Emphasis needs to be on causes of the mutism and propagating factors of mutism.

Studies have shown no evidence that the cause of Selective Mutism is related to abuse, neglect or trauma.

What is the difference between Selective Mutism and traumatic mutism?
Children who suffer from Selective Mutism speak in at least one setting and are rarely mute in all settings. Most have inhibited temperaments and manifest social anxiety. For children with Selective Mutism, their mutism is a means of avoiding the anxious feelings elicited by expectations and social encounters.

Children with traumatic mutism usually develop mutism suddenly in all situations. An example would be a child who witnesses the death of a grandparent or other traumatic event, is unable to process the event, and becomes mute in all settings.

It is important to understand that some children with Selective Mutism may start out with mutism in school and other social settings. Due to negative reinforcement of their mutism, misunderstandings from those around them, and perhaps heightened stress within their environment, they may develop mutism in all settings. These children have progressive mutism and are mute in/out of the home with all people, including parents and siblings.

What behavior characteristics does a child with Selective Mutism portray in social settings?
It is important to realize that the majority of children with Selective Mutism are as normal and as socially appropriate as any other child when in a comfortable environment. Parents will often comment how boisterous, social, funny, inquisitive, extremely verbal, and even bossy and stubborn these children are at home! What differentiates most children with Selective Mutism is their severe behavioral inhibition and inability to speak and communicate comfortably in most social settings. Some children with Selective Mutism feel as though they are on stage every minute of the day! This can be quite heart-wrenching for both the child and parents involved. Often, these children show signs of anxiety before and during most social events. Physical symptoms and negative behaviors are common before school or social outings.

It is important for parents and teachers to understand that the physical and behavioral symptoms are due to anxiety and treatment needs to focus on helping the child learn the coping skills to combat anxious feelings.

It is common for many children with Selective Mutism to have a blank facial expression and never seem to smile. Many have stiff or awkward body language when in a social setting and seem very uncomfortable or unhappy. Some will turn their heads, chew or twirl their hair, avoid eye contact, or withdraw into a corner or away from the group seemingly more interested in playing alone.

Others are less avoidant and do not seem as uncomfortable. They may play with one or a few children and be very participatory in groups. These children will still be mute or barely communicate with most classmates and teachers.

As social relationships are built, and a child develops one or a few friendships, he/she may interact and even whisper or speak to a few children in school or other settings but seem to be disinterested or ignore other classroom peers. Over time, these children learn to cope and participate in certain social settings. They usually perform nonverbally or by talking quietly to a select few. Social relationships become very difficult as children with Selective Mutism grow older. As peers begin dating and socializing more, children with Selective Mutism may remain more aloof, isolated, and alone.

Children with Selective Mutism often have tremendous difficulty initiating and may hesitate to respond even nonverbally. This can be quite frustrating to the child as time goes by. The child’s nonverbal communication may go on for many years, becoming more ingrained and reinforced unless the child is properly diagnosed and treated. Ingrained behavior often manifests itself by a child looking and acting normally but communicating nonverbally. This particular child cannot just start speaking. Treatment needs to center on methods to help the child unlearn the present mute behavior.

What are the most common characteristics of children with Selective Mutism?
Most, if not all, of the characteristics of children with Selective Mutism can be attributed to anxiety.

1. Temperamental Inhibition: Timid, cautious in new and unfamiliar situations, restrained, usually evident from infancy on. Separation anxiety as a young child.
2. Social Anxiety Symptoms: Over 90% of children with Selective Mutism have social anxiety. Uncomfortable being introduced to people, teased or criticized, being the center of attention, bringing attention to himself/herself, perfectionist (afraid to make a mistake), shy bladder syndrome (Paruresis), eating issues (embarrassed to eat in front of others).
3. Social Being: The majority of children/teens with SM have age appropriate social skills and are on target developmentally, although some do not.  Most children on the autism spectrum struggle with speech/language skills, social skills and have developmental challenges.
4. Physical Symptoms: MUTISM, tummy ache, nausea, vomiting, joint pains, headaches, chest pain, shortness of breath, diarrhea, nervous feelings, scared feelings.
5. Appearance: Many children with Selective Mutism have a frozen-looking, blank, expressionless face and stiff, awkward body language with lack of eye contact when feeling anxious. This is especially true for younger children in the beginning of the school year or then suddenly approached by an unfamiliar person. They often appear like an animal in the wild when they stand motionless with fear! The older the child, the less likely he/she is to exhibit stiff, frozen body language. Also, the more comfortable a child is in a setting, the less likely a child will look anxious. For example, the young child who is comfortable and adjusted in school, yet is mute, may seem relaxed, but mutism is still present. One hypothesis is that heightened sympathetic response causes muscle tension and vocal cord paralysis.
6. Emotional: When the child is young, he/she may not seem upset about mutism since peers are more accepting. As children age, inner turmoil often develops and they may develop the negative ramifications of untreated anxiety (see below).
7. Developmental Delays: A proportion of children with Selective Mutism have developmental delays. Some have multiple delays and have the diagnosis of an autistic spectrum disorder, such as Pervasive Developmental Disorder, Aspergers, or Autism. Delays include motor, communication and/or social development.
8. Sensory Integration Dysfunction (DSI) symptoms, Processing Difficulties/Delays: For many children with SM, sensory processing difficulties are the underlying reason for being ‘shut down’ and their mutism. In larger, more crowded environments where multiple stimuli are present (such as the classroom setting), where the child feels an expectation, sensory modulation specifically, sensory defensiveness exists. Anxiety is created causing a ‘freeze’ mode to take place. The ultimate ‘freeze mode’ is MUTISM.
9. Common symptoms: Picky eater, bowel and bladder issues, sensitive to crowds, lights (hands over eyes, avoids bright lights), sounds (dislikes loud sounds, hands over ears, comments that it seems loud), touch (being bumped by others, hair brushing, tags, socks, etc), and heightened senses, i.e., perceptive, sensitive, Self-regulation difficulties (act outing, defiant, disobedient, easily frustrated, stubborn, inflexible, etc).
10. Common symptoms within a classroom environment: Withdrawal, playing alone or not playing at all, hesitation in responding (even nonverbally), distractibility, difficulty following a series of directions or staying on task, difficulty completing tasks. Experience at the Smart Center dictates that sensory processing difficulties may or may not cause learning or academic difficulties. Many children, especially, highly intelligent children can compensate academically and actually do quite well. MANY focus on their academic skills, often leaving behind ‘the social interaction’ within school. This tends to be more obvious as the child ages. What is crucial to understand is that many of these symptoms may NOT exist in a comfortable and predictable setting, such as at home. In some children, there are processing problems, such as auditory processing disorder, that cause learning issues as well as heightened stress.
11. Behavioral: Children with Selective Mutism are often inflexible and stubborn, moody, bossy, assertive and domineering at home. They may also exhibit dramatic mood swings, crying spells, withdrawal, avoidance, denial, and procrastination. These children have a need for inner control, order and structure, and may resist change or have difficulty with transitions. Some children may act silly or act out negatively in school, parties, in front of family and friends. WHY? These children have developed maladaptive coping mechanisms to combat their anxiety.
12. Co-Morbid Anxieties: Separation anxiety, Obsessive Compulsive Disorder (OCD), hoarding, Trichotillomania (hair pulling, skin picking), Generalized Anxiety Disorder, Specific phobias, Panic Disorder.
13. Communication Difficulties: Some children may have difficulty responding nonverbally to others, i.e., cannot point/nod in response to a teachers question, or indicate thank you by mouthing words. For many, waving hello/goodbye is extremely difficult. However, this is situational. This same child can not only respond nonverbally when comfortable, but can chatter nonstop! Some children may have difficulty initiating nonverbally when anxious, i.e., have difficulty or are unable to initiate play with peers or go up to a teacher to indicate need or want.
14. Social Engagement Difficulties: When one truly examines the characteristics of a child with Selective Mutism, it is obvious that many are unable to socially engage properly. When confronted by a stranger or less familiar individual, a child may withdraw, avoid eye contact, and ‘shut down,’ not only leaving a child speechless but preventing him/her from engaging with another individual. Greeting others, initiating needs and wants, etc., are often impossible for many children. Many shadow their parents in social environments often avoiding any social interaction at all. The common example given is; ‘A child in grocery story can sing, laugh and talk loudly, but as soon as someone confronts him/her, the child freezes, avoids and withdraws from social interaction.’ As the child ages, freezing and shutting down rarely exist, but the child remains either noncommunicative or will respond nonverbally after an indeterminate amount of warm up time.

MUTISM is just one of the many characteristics that children with Selective Mutism portray.

When are most children diagnosed as having Selective Mutism?
Most children are diagnosed between 3 and 8 years old. In retrospect, it is often noted that these children were temperamentally inhibited and severely anxious in social settings as infants and toddlers, but adults thought they were just very shy. Most children have a history of separation anxiety and being slow to warm up. Often it is not until children enter school and there is an expectation to perform, interact and speak, that Selective Mutism becomes more obvious. What often happens is teachers tell parents the child is not talking or interacting with the other children. In other situations, parents will notice, early on, that their child is not speaking to most individuals outside the home.

If mutism persists for more than a month, a parent should bring this to the attention of their child’s physician.

Why do so few teachers, therapists and physicians understand Selective Mutism?
Studies of Selective Mutism are scarce. Most research results are based on subjective findings based on a limited number of children. In addition, textbook descriptions are often nonexistent, or information is limited, and in many situations, the information is inaccurate and misleading. As a result, few people truly understand Selective Mutism. Professionals and teachers will often tell a parent, the child is just shy, or they will outgrow their silence. Others interpret the mutism as a means of being oppositional and defiant, manipulative or controlling. Some professionals erroneously view Selective Mutism as a variant of autism or an indication of severe learning disabilities. For most children who are truly affected by Selective Mutism, this is completely wrong and inappropriate!

Research at the SMart Center indicates that children who seem oppositional in nature often have parents, teachers, and/or treating professionals who have pressured them to speak for months, perhaps years. Mutism not only persists in these children, but is negatively reinforced. These children may develop oppositional behaviors out of a combination of frustration, their own inability to make sense of their mutism, and others pressuring them to speak.

As a result of the scarcity and often inaccuracy of information in the published literature, children with Selective Mutism may be misdiagnosed and mismanaged. In many circumstances, parents will wait and hope their child outgrows their mutism (and may even by advised to do so by well-meaning, but uninformed professionals). However, without proper recognition and treatment, most of these children do NOT outgrow Selective Mutism and end up going through years without speaking, interacting normally, or developing appropriate social skills. In fact, many individuals who suffer from Selective Mutism and social anxiety who do not get proper treatment to develop necessary coping skills may develop the negative ramifications of untreated anxiety (see below).

Why is it so important to have my child diagnosed when he/she is so young?
Our findings indicate that the earlier a child is treated for Selective Mutism, the quicker the response to treatment, and the better the overall prognosis. If a child remains mute for many years, his/her behavior can become a conditioned response where the child literally gets used to non-verbalizing. In other words, Selective Mutism can become a difficult habit to break!

Because Selective Mutism is an anxiety disorder, if left untreated, it can have negative consequences throughout the child’s life and, unfortunately, pave the way for an array of academic, social and emotional repercussions such as:

• Worsening anxiety
• Depression and manifestations of other anxiety disorders
• Social isolation and withdrawal
• Poor self-esteem and self-confidence
• School refusal, poor academic performance, and the possibility of quitting school
• Underachievement academically and in the work place
• Self-medication with drugs and/or alcohol
• Suicidal thoughts and possible suicide

Anxiety disorders are the most common mental illnesses among children and adolescents. Our main objective is to diagnose children early, so they can receive proper treatment at an early age, develop proper coping skills, and overcome their anxiety. According to the US Surgeon General, our country is in a state of emergency as far as children’s mental health is concerned. 10% of children suffer from mental disorders, but less than 5% of these children are actually receiving treatment.

If parents suspect their child has Selective Mutism, what should they do?
Parents should initially remove all pressure and expectations for the child to speak, conveying to their child that they understand he/she is scared and it is hard to get the words out and that they will help their child through this difficult time. Praise the child’s efforts and accomplishments, support and acknowledge the difficulties and frustrations.

Parents should speak with their family physician or pediatrician and/or seek out a psychiatrist or a therapist who has experience with Selective Mutism. However, please note that having experience with Selective Mutism does not guarantee that the treatment approach and understanding is correct. In fact, a clinician with less experience, yet who has an excellent understanding of Selective Mutism may be an ideal choice for your child.

What are the key questions to ask a potential therapist or physician?
Do your homework! You will have a much better idea what to look for if you understand Selective Mutism. Educate yourself as much as possible before seeing any professional. Parents should read as much information as they can about Selective Mutism. The Selective Mutism Association website has countless pages of information and it is updated on a regular basis.

Key questions to ask include:

• What are your areas of expertise?
• Have you ever treated a child with Selective Mutism? If so, how many and what are your success rates?
• What are your views on Selective Mutism? In other words, what are some of the reasons a child manifests mutism?
• What is your treatment approach to Selective Mutism?
• What will be my role as a parent? What is the teacher’s role?
• What is your opinion on medication in treating Selective Mutism and when do you consider medication?
• Can you supply me with references of families you have worked with?
• How will you work with my child to help him/her progress communicatively?*

*Children do not progress communicatively without learning coping skills. Simply lowering anxiety is NOT enough to enable the child to begin engaging socially, learn to progress to verbal communication and feel comfortable in an environment. Skills must be taught.

Caution: When speaking to potential treating professionals, please be cautious of those who see Selective Mutism as a controlling/manipulative behavior. Treatment approaches based on discipline and forcing a child to speak are inappropriate and will only heighten anxiety and negatively reinforce mute behavior.

How is a child evaluated for Selective Mutism?
Social Communication Anxiety Treatment® or S-CAT® is an evidenced-based program created by Dr. Elisa Shipon-Blum and implemented at the Selective Mutism Anxiety Research and Treatment Center (SMart Center). Presently, the SMart Center is the ONLY Center in the world that implements S-CAT®.

Dr. Elisa Shipon-Blum’s S-CAT® Program is based on the concept that Selective Mutism (SM) is a social communication anxiety disorder that is more than just not speaking.  Families in the S-CAT® Program are provided with structured, individualized, step-by-step treatment.

Dr. Shipon-Blum has created the SM-Stages of Social Communication Comfort Scale© that describes the various stages of social communication possible for a child suffering from Selective Mutism. Children suffering from Selective Mutism (SM) change their level of social communication based on the setting as well as the expectations from others within a setting. As a result, social comfort and communication will change from setting to setting and person to person.  The Social Communication Bridge® illustrates this concept in a visual form.

For example, a child may be “chatting up a storm” with their friend or family member in one setting, yet meet that same person in another setting (such as at school or perhaps at a family function) and the child may have difficulty socially engaging, communicating nonverbally and perhaps the child cannot communicate at all!

For some children, they appear very comfortable and mutism is the most noted symptom. This usually means they are able to engage nonverbally with others via astute nonverbal skills (professional mimes!) in most, if not all settings. These children are stuck in the nonverbal stage of communication (Stage 1) and suffer from a subtype of SM called Speech Phobia.

Although mutism is the most noted symptom of SM, the inability to speak merely touches on the surface of our children.  A complete understanding of the child is necessary to develop an appropriate treatment plan for home and in the real world, as well as in school by developing accommodations and interventions, e.g. IEP or 504 Plan.

According to Dr. Shipon-Blum’s work, after a complete evaluation consisting of parent and teacher assessment forms such as the Selective Mutism Comprehensive Diagnostic Questionnaire (SM-CDQ)© and the SM School Evaluation Form©, and parent and child interviews, treatment needs to address three key questions:

1. Why did this child develop (including influencing, precipitating and maintaining factors)?
2. Why does Selective Mutism persist despite past treatment and/or parent/teacher awareness?
3. What can be done at home, in school, and in the real world to help the child build the coping skills needed to overcome his/her social communication challenges?

To help a child suffering in silence, an understanding of which stage the child is in during particular social encounters must be developed. The Social Communication Anxiety Inventory (SCAI©) can be used to determine the stage of social communication on the  Social Communication Bridge®. Treatment is then developed via the whole child approach under the direction of the treatment professional, the child, parents, and school personnel working together.

Dr. Shipon-Blum emphasizes that although anxiety lowering is key, it is often not enough, especially as children age. Over time, many children with Selective Mutism no longer feel anxious, but their mutism and lack of proper social engagement continue to exist in select settings.

Children with SM need strategies and interventions to progress from nonverbal to spoken communication. This is the Transitional Stage of Communication, an aspect missing from most treatment plans. In other words, how do you help a child progress from nonverbal to verbal communication?

Strategies and interventions are developed based on where the child is on the Social Communication Bridge in a particular setting and are meant to be a desensitizing method as well as a vehicle to unlearn conditioned behavior. Time in the therapy office is simply not enough. The office setting is used to help prepare the child for the school and real world environments by developing strategies to help the child unlearn his or her conditioned behavior. Then, in the real world and within the school setting, the strategies and interventions are implemented.

The S-CAT® Program incorporates anxiety lowering techniques, methods to build self-esteem, and strategies and interventions to help with social comfort and communication progression. This may include bridging from shut down to nonverbal communication and then transitioning into spoken communication via the Verbal Intermediary®, Ritual Sound Approach®, and possibly the use of augmentative devices.

Children with SM need to understand, feel in control, and have choice in their treatment (age dependent). These are critical components of Social Communication Anxiety Treatment® strategies, which provide the child with choices and help to transfer the child’s need for control into the strategies and interventions.

S-CAT® games and goals (based on age and where the child is on the Social Communication Bridge®) are used to help develop social comfort and ultimately progress into speech via the use of ritualistic and controlled methods. Strategy charts are used to help develop social comfort and progress into speech. Silent goals (environmental changes) and active goals (child directed goals based on choice and control) are some of the other tools used within the S-CAT® Program.

Every child is different and therefore an individualized treatment plan needs to be developed to incorporate home (parent education, environmental changes), the child’s unique needs, and school modifications (teacher education, accommodations and interventions). By lowering anxiety, increasing self-esteem, and increasing communication and social confidence within a variety of real world settings, the child suffering in silence will develop necessary coping skills to enable for proper social, emotional, and academic functioning.

A trained professional familiar with Selective Mutism will have a parental interview. Emphasis will be on social interaction and developmental history, other manifestations of anxiety, behavioral characteristics (shy temperament), home life description (family stress, divorce, death, etc.) and medical history. From the results of the initial interview, the professional will often see the child. Children with Selective Mutism may or may not speak to the diagnosing professional. Whether or not a child speaks to the evaluating physician does not really matter. An astute professional should be able to assess interpersonal communication skills and build rapport quite easily and, if given at least one session and possibly viewing videotapes from home, can rule in or out Selective Mutism as a diagnosis.

Because 20-30% of children with Selective Mutism have an abnormality with speech and language, a thorough speech and language evaluation is often ordered. If motor/sensory issues exist an occupational therapy evaluation is also recommended. A complete physical exam (including hearing), standardized testing, psycho-educational testing as well as a thorough developmental screening are often recommended if the diagnosis is not clear.

What are the diagnostic criteria for Selective Mutism?
DSM-V-TR (2018) defines Selective Mutism as follows:

1. Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.
2. The disturbance interferes with educational or occupational achievement or with social communication.
3. The duration of the disturbance is at least 1 month (not limited to the first month of school).
4. The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
5. The disturbance is not better accounted for by a Communication Disorder (e.g., stuttering) and does not occur exclusively during a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder.

Associated features of Selective Mutism may include excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling or oppositional behavior, particularly at home. There may be severe impairment in social and school functioning. Teasing or goading by peers is common. Although children with this disorder generally have normal language skills, there may occasionally be an associated Communication Disorder (e.g., Phonological Disorder, Expressive Language Disorder, or Mixed Receptive- Expressive Language Disorder) or a general medical condition that causes abnormalities of articulation. Intellectual disabilities, hospitalization or extreme psychosocial stressors may be associated with the disorder. In addition, in clinical settings children with Selective Mutism are almost always given an additional diagnosis of Anxiety Disorder, especially Social Phobia is common. (DSM-V-TR) (APA, 2018)

Authors note: The above criteria are quite vague/nonspecific and should not be used alone to rule in or rule out the diagnosis of Selective Mutism. As mentioned earlier, children with Selective Mutism manifest many behavioral characteristics other than mutism. In addition, since children with Selective Mutism often have difficulty responding and/or initiating nonverbally, Selective Mutism can be viewed as a communication disorder. In addition, children with autism, PDD-NOS, Aspergers and other developmental disorders can manifest mutism that is selective in location.

How is Selective Mutism treated?
The main goals of treatment should be to lower anxiety, increase self-esteem and increase social confidence and communication. Emphasis should never be on getting a child to talk. All expectations for verbalization should be removed. With lowered anxiety, confidence, and the use of appropriate tactics/techniques, communication will increase as the child progresses from nonverbal to verbal communication. Treatment approaches should be individualized, but the majority of children are treated using a combination of:

1. Social Communication Anxiety Therapy® (S-CAT®): This is the philosophy of treatment implemented at the Selective Mutism, Anxiety, and Related Disorders Treatment Center (SMart Center). This treatment includes development of an individualized treatment plan that focuses on the whole child and incorporates a TEAM approach involving the child, parent, school personnel, and treating professional. Recommended therapeutic tactics and techniques are implemented to build social comfort and progression of communication comfort (nonverbal and verbal) in various social settings (in and out of school). Because anxiety levels change from situation to situation, and often from one person to the next, methods often change from one social situation to another. Therefore, by lowering anxiety, increasing self-esteem, as well as increasing communication and social confidence within a variety of REAL WORLD settings, the child suffering in silence will develop necessary coping skills to enable for proper social, emotional, developmental, and academic functioning.
2. Behavioral Therapy: Positive Reinforcement and Desensitization techniques are the primary behavior treatments for Selective Mutism, as well as removing all pressure to speak. Emphasis should be on understanding the child and acknowledging their anxiety. Introducing the child to social environments in subtle and non-threatening ways is an excellent way to help the child feel more comfortable, i.e., Parents can take the child into school when few people are around to get the child to practice speaking. Eventually, bring a friend or two to school and allow the children to play when other children are not present. Small groups with only a small number of children are helpful, as well as allowing parents to spend time with the child within the class. After the child is speaking quite normally, the teacher, and then the students are gradually introduced into the group setting. Positive reinforcement for verbalization should be introduced when, and only when, anxiety is lowered and the child feels comfortable and is obviously ready for some subtle encouragement.
3. Play Therapy, Psychotherapy, and other psychological approaches: These can be effective if all pressure for verbalization is removed and emphasis is on helping the child relax and open up. Confronting mutism in a non-threatening way is important. These children are SCARED, and the focus should be to help them identify their level of being scared’ in a particular situation. Helping them to realize that you understand and are there to help them relieves tremendous pressure.
4. Cognitive Behavioral Therapy: CBT trained therapists help children modify their behavior by helping them redirect their fears and worries into positive thoughts. CBT needs to incorporate awareness and acknowledgement of anxiety and mutism. Most children with Selective Mutism worry about others hearing their voice, asking them questions about why they do not talk and trying to force them to speak. The focus should be on emphasizing the childs positive attributes, building confidence in social settings, and lowering overall anxiety and worries.
5. Medication: Studies indicate that the most effective approach to treatment is a combination of behavioral techniques and medication. Often behavioral techniques are used for an indeterminate amount of time prior to the addition of medication. If children are not making enough progress with behavioral therapy alone, medication may be recommended to reduce the anxiety level. Serotonin reuptake inhibitors (SSRIs) such as Prozac, Paxil, Celexa, Luvox, and Zoloft are very effective in the treatment of anxiety disorders. Similar to the SSRIs, there are other drugs that affect one or more neurotransmitters such as serotonin, norepinephrine, GABA, and dopamine, etc. which are also proving to be affective. Examples are Effexor XR and Buspar. Both classes of drugs work well in children who have a true biochemical imbalance. This seems to be the case in the majority of children with Selective Mutism. Very often, we have seen positive effects in as little as a week! Medication is used as a jump start with the hope that, as we lower anxiety via medication, we can implement behavioral techniques more easily and successfully! Goals for the duration of treatment with medication are usually 9-12 months.
6. Self-esteem boosters: Parents should emphasize their childs positive attributes. For example, if your child is artistic, then by all means show off the artwork! Have a special wall to display your childs masterpieces; perhaps you can even have a special exhibition! Have them explain their artwork to family members and close friends. This promotes more verbalization practice, as well as helps with confidence!
7. Frequent socialization: Encourage as much socialization as possible without pushing your child. Arrange frequent play dates with classmates or even small group interactions with individuals the child knows well. The goals is for your child to feel comfortable enough with the classmates so that verbalization will occur. Most children with Selective Mutism will talk to friends in their own home. As the child gets increasingly comfortable speaking to one child, invite another child over, and then have two or three children at a time! Transfer speaking into the school via set tactics/techniques. For some children, Social Skills therapy is necessary and often helpful in accomplishing increased communication.
8. School involvement: Parents need to educate teachers and school personnel about Selective Mutism! You must be an advocate for your child. The school needs to understand that children with Selective Mutism are not being defiant or stubborn by not speaking, that they truly CANNOT speak. Explain to the teacher that a child needs to feel that it is alright for them not to speak. Nonverbal communication is acceptable in the beginning. As the child progresses with treatment, the teacher should be involved in the treatment plan with verbalization being encouraged in subtle, non-threatening ways. An Individualized Educational Plan (IEP) or 504 Plan may be necessary to help accommodate your childs inability to communicate verbally and to help the child progress communicatively as well as build social comfort.
9. Family involvement and parental acceptance: Family members must be involved in the entire treatment process! Very often changes in parenting styles and expectations are necessary to accommodate the needs of the child. Remember, never pressure or force your child to speak this will only cause more anxiety. Convey to your child that you are there for them. Spend one on one time, especially at night, when all pressure is off and engage your child in discussions about their feelings. Allowing your child to open up helps relieve stress. A parents acceptance and understanding is crucial for the child!

It is important to realize that with proper diagnosis and treatment, the prognosis for overcoming Selective Mutism is excellent!

Author: Dr. Elisa Shipon-Blum is President and Director of the Selective Mutism, Anxiety, & Related Disorders Treatment Center (SMart Center). She created CommuniCamp™, an intensive group treatment program for Selective Mutism, and is also Founder and Director Emeritus of the Selective Mutism Association and a Clinical Assistant Professor of Psychology and Family Medicine PCOM. Dr. Shipon-Blum’s initial interest in Selective Mutism was personal. Her experience trying to find help for her daughter made the need for research, development of appropriate/effective treatment strategies, and dissemination of information about this social-communication disorder abundantly clear. Many of these findings are based on research from treatment at the SMart Center of hundreds of children with Selective Mutism.

Contributors: Christine Stanley, Lori Dabney, Laurie Gorski