Mutism is a rare childhood condition characterized by a consistent failure
to speak in situations where talking is expected.
In mutism, the child has the ability to converse normally and does so, for
example, in the home, but consistently fails to speak in specific
situations such as at school or with strangers. The condition is also
called selective mutism, to differentiate it from children who are
physically unable to speak. Experts believe that this selective problem is
in social situations such as in school or in the company of adults. It
is, therefore, often considered a type of social phobia. This is not a
communication disorder because the affected children can converse normally
in some situations. It is not a developmental disorder because their
ability to talk, when they choose to do so, is appropriate for their age
level. This problem has been linked to anxiety, and one of the major ways
in which both children and adults attempt to cope with anxiety is by
avoiding whatever provokes the anxiety. Affected children are typically
shy and are especially so in the presence of strangers and unfamiliar
surroundings or situations. However, the behaviors of children with this
condition go beyond
These children understand language and are able to talk normally in
settings where they are comfortable, secure and relaxed. Over 90 percent
of children with mutism also have social phobia or social anxiety, and
some experts view mutism as a symptom of social anxiety. Others view it as
a separate, but related, disorder. It is not yet understood why some
individuals develop typical symptoms of social anxiety, like reluctance to
speak in front of a group of people or feeling embarrassed easily, while
others experience the inability to speak that characterizes mutism. What
is clear is that children and adolescents with mutism have an actual fear
of speaking and of social interactions where there is an expectation to
talk. They may also be unable to communicate nonverbally, may be unable to
make eye contact, and may stand motionless with fear as they are
confronted with specific social settings. This can be quite heart
wrenching to watch and is often very debilitating for the child as well as
frustrating for parents and teachers.
A child meets the criteria for mutism if the following are true:
It is estimated that one in every 1,000 school-age children are affected
Causes and symptoms
Mutism is believed to arise from anxiety experienced in social situations
where the child may be called upon to speak. Refusing to speak or speaking
in a whisper spares the child from the possible humiliation or
embarrassment of saying the "wrong" thing. When asked a
direct question by teachers, for example, the affected child may act as if
they are unable to answer. Some children may communicate via gestures,
nodding, or very brief utterances. Additional features may include
excessive shyness, oppositional behavior, and impaired learning at school.
The majority of children with mutism have a genetic predisposition to
anxiety. In other words, they have inherited the tendency to be anxious
members and may be vulnerable to the development of an anxiety disorder.
Very often, these children show signs of anxiety, such as difficulty
separating from parents, moodiness, clinging behavior, inflexibility,
and crying, and extreme shyness starting in infancy. When they reach the
age when they begin to interact socially outside the family environment,
their persistent fear of speaking or communicating begins to manifest in
symptoms like freezing, lack of response, stiff posture, blank facial
expression, lack of smiling, and mutism. Studies have shown that some
children are born with inhibited temperaments, which means that even as
infants, they are more likely to be fearful and wary of new situations.
There is reason to believe that many or most children with mutism were
born with this inhibited personality type.
Research has also shown that these behaviorally inhibited children have a
decreased threshold of
excitability in the area of the brain called the amygdala. The normal
function of the amygdala is to receive and process signals of potential
danger and set off a series of reactions that will help individuals
protect themselves, such as the fight-or-flight response. In anxious
individuals, the amygdala seems to overreact and set off these responses
even when the individual is not really in danger. In the case of
selectively mute children, the anxiety responses are triggered by social
interactions in settings such as school, the playground, or social
gatherings. Over time, a child with selective mutism becomes mute because
of an inability to cope with fearful feelings that occur when he or she is
expected to speak. When the child does not respond, the pressure is
usually removed and the child feels relief from fear.
Besides genetics and biological factors, researchers believe that other
factors may contribute to the development of selective mutism. A
significant number of children with mutism also have expressive
, and a fairly large number come from a bilingual environment, which may
add to a child's vulnerability to mutism. Anxiety is still the root
cause of the mutism, and it is theorized that these language difficulties
may make the child more self-conscious about his or her speaking skills
and thus may increase the fear of being judged by others. These risk
factors are probably additive; in other words, if a child has genetic risk
of anxiety, plus a bilingual environment or a speech disorder, the
likelihood of that child developing selective mutism becomes higher with
each added factor.
If selective mutism persists for more than a month, parents should discuss
this pattern with their child's teachers, family physician, or
pediatrician. The doctor may refer the child to a speech therapist,
psychiatrist or psychologist.
The diagnosis of mutism is fairly easy to make because the signs and
symptoms are clear-cut and easily observable. However, other social
disorders effecting social speech, such as autism or
, must be considered in the diagnosis. The average age of diagnosis is
between three and eight years of age; however, in retrospect many parents
will say that their child displayed signs of excessive shyness and
inhibition since infancy. It is not until children enter school, where
there is an expectation to perform, interact, and speak, that mutism
becomes more apparent. Often a parent suspects during the
years that there is a problem, but lack of knowledge about selective
mutism makes it difficult to find help. It is all too common for parents
to question their child's pediatrician about the child's
inability to speak in public and be told that the child is just shy and
will outgrow the behavior. Once a child enters school, though, teachers
often point out the severity of the problem to the parents. Some parents
are also reluctant to have their child evaluated and treated.
Since selective mutism is an anxiety disorder, successful treatment
focuses on methods to lower anxiety, increase
, and increase confidence and communication in social settings. The
emphasis should never be on "getting a child to talk," nor
should the goal of treatment be for the child to speak to the therapist.
Progress outside the clinic or doctor's office is much more
important than whether the child speaks during the therapy session.
Initially, all expectations for verbalization should be removed. As the
child's anxiety is lowered and confidence increases, verbalization
usually follows. If it does not occur spontaneously, techniques can later
be added to help encourage progress. A professional should devise an
individualized treatment plan for each child and allow the child, family,
and school to have a great deal of input into the treatment process.
Therapy usually involves some combination of behavioral therapy, cognitive
, or psychoanalytic therapy, medication, and in some cases,
The primary types of behavioral therapy used for selective mutism are
desensitization, fading, and positive reinforcement techniques.
Desensitization means exposing a child to something that is feared in a
gradual way, in order to help the child overcome the fear. Fading therapy
is a type of desensitization that creates a series of events or exposures
that starts with a situation that is comfortable for the child, such as
being alone in the classroom with a parent and playing a board game. New
variables that are progressively more difficult are gradually added. For
example, having the teacher walk past the room and overhear the child
speaking to the parent, and then having the teacher enter the room, and
eventually have the child interacting with the teacher in the classroom.
Positive reinforcement, or the use of rewards for changes in behavior,
should only be introduced after anxiety is lowered and the child is ready
to begin working on goals. It is also important to realize that there are
many intermediate steps between being mute and being verbal. During the
early stages of treatment, nonverbal communication such as pointing,
nodding, and use of pictures to express needs, can be encouraged and
rewarded. Though some may fear that allowing nonverbal communication will
enable the mutism to continue, many therapists believe it is a necessary
step for most children with mutism to overcome their communication anxiety
in a step-by-step manner.
Cognitive behavioral therapy (CBT) helps children change their thoughts
(the cognitive part) and their actions (the behavioral part). CBT
therapists recognize that anxious children tend to exaggerate the
frightening aspects of certain situations, so they help the children gain
a more realistic perspective in order to decrease anxiety. They also know
that anxious children avoid situations they fear or (in the case of
selectively mute children) avoid speech in anxiety-provoking situations.
Avoidance makes anxiety worse. Therefore, CBT helps the child overcome
avoidance by gradually facing what is feared with lots of praise and
positive reinforcement for doing so. Parents, teachers, and other adults
around the child can be very helpful in this process. Cognitive strategies
for the selectively mute child aim to reduce the social anxiety that is
often part of the disorder. Cognitive strategies help the child challenge
negative expectations and replace them with more realistic ones. This
process is combined with behavioral strategies that focus on helping the
selectively mute child to talk in increasingly challenging situations. The
therapist carefully collects information on where and with whom the child
already speaks and then helps the child choose a goal to work on in a
situation that is just slightly more challenging.
Play therapy is an adaptation of psychoanalytic therapy, which is a
psychological treatment based on helping people understand their
unconscious thoughts. This field of psychology includes Freudian theories
but also many other modern theories about how our minds work. Play therapy
refers to the use of play as communication; therapists who are trained in
these techniques observe and participate in play activities with the child
and interpret the child's actions as a form of subconscious
communication. There is not a lot of evidence for play therapy being
effective in the treatment of mutism; however, a well trained play
therapist might be able to help a child with mutism better understand and
express emotions and may be a part of an overall treatment plan. It may be
especially useful when a stressful event or environment is a factor. For
some children there may be contributing factors such as the death of a
parent or other loved one, a
, or a move. Play therapists may be able to help a child to express and
better understand the emotions that they are experiencing in these
Since there is no evidence of family pathology being the cause of most
cases of mutism, this type of therapy is not necessary in most cases.
However, if there are unusual circumstances or a highly stressful family
environment, then it may be advisable for families to participate in more
intensive family therapy.
The prognosis for mutism is good. Sometimes it disappears suddenly on its
own. The negative impact on learning and school activities may, however,
persist into adult life.
Mutism cannot be prevented because the cause is not known. However, family
conflict or problems at school contribute to the seriousness of the
—An almond-shaped brain structure in the limbic system that is
activated in stressful situations to trigger the emotion of fear. It is
thought that the emotional overreactions in Alzheimer's patients
are related to the destruction of neurons in the amygdala.
—A developmental disability that appears early in life, in which
normal brain development is disrupted and social and communication
skills are retarded, sometimes severely.
—A form of therapy that uses rewards to reinforce desired
behavior. An example would be to give a child a piece of chocolate for
—A type of psychotherapy in which people learn to recognize and
change negative and self-defeating patterns of thinking and behavior.
—A type of therapy in which the entire immediate family
—A type of psychotherapy for young children involving the use of
toys and games to build a therapeutic relationship and encourage the
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Anxiety Disorders Association of America.
8730 Georgia Avenue, Suite 600, Silver Spring, MD 20910. Web site:
National Academy of Child & Adolescent Psychiatry.
3615 Wisconsin Ave. NW, Washington, DC 20016. Web site:
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