Thursday, February 9, 2017

Selective Mutism: not just a form of shyness

Selective mutism is the inability to speak in certain situations. It usually occurs in children less than five years old; however, it is not usually noticed until a child starts school. It is often mistaken for shyness. For fans of The Big Bang Theory, selective mutism isn’t a new term. One of the main characters, Raj Koothrappali (played by Kunal Nayyar), suffered from selective mutism until he was able to overcome it at the end of season 6. My interest in selective mutism is much more personal than a character from a favorite TV show. My five year old daughter often won’t speak in social situations in which she is unfamiliar, is the center of attention or speak with adults whom are not active members of her life (i.e. my husband’s work acquaintances). So I’m curious if my daughter suffers from selective mutism and if so, what I can do to help her overcome this problem. In the course of my research, I see that selective mutism is rate. It affects less than one percent of individuals seen in mental health setting.

Causes of selective mutism can stem from an anxiety disorder, self-esteem issues or problems with speech, language and hearing. The symptoms of selective mutism includes a consistent failure to speak in specific social situations where there is an expectations for speaking. The failure to speak interferes with school, work or with social communication. The lack of speech lasts at least a month and the failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation. For example, a non-Spanish speaker not speaking in a situation in which Spanish is being spoken is not selective mutism. The failure to speak is also not due to a communication disorder (i.e. stuttering) and does not occur exclusively during the course of autism spectrum disorders, schizophrenia or other psychotic disorders. According to the Diagnostic and Statistical Manual of Mental Disorders: Fifth (DSM-V, 2013), children with selective mutism may show anxiety disorders (i.e. social phobia), excessive shyness, fear of social embarrassment and social isolation and withdrawal. Children with selective mutism may also show signs of separation anxiety, frequent tantrums, moodiness, inflexibility, slow to warm up and sleep problems.

If selective mutism is suspected, parents are advised to first, remove all pressure and expectations for the child to speak. Pressuring a child to speak when they won’t, will only add to the anxiety the child is feeling. Second, convey to the child that the parents understand he or she is scared and it is hard to get the words out but Mommy and Daddy are there to help. Third, praise the child’s efforts and accomplishments when a child speaks when they normally wouldn’t. Also support and acknowledge the difficulties and frustrations when a child refuses to speak again. Fourth, if parents are really concerned, they need to speak with their family physician or pediatrician. Beware of doctors and “experts” who see selective mutism as controlling or manipulative behavior or the result of overprotective parents. This is not the case and seek out help from those who truly understand selective mutism.

The diagnosis of selective mutism is very detail and in depth. First, the child is examined by a Speech-Language Pathologist (SLP) as well as the child’s pediatrician and a psychologist or psychiatrist. A complete background is gathered starting with the child’s educational history. The educational history includes academic reports, parent/teacher comments, and any previous testing. A hearing screening is performed to rule out any hearing inability or a middle ear infection. An oral-motor examination is performed in which the coordination and strength of the muscles in the lips, jaws and tongue is tested. The parents/caregivers are interviewed for any suspected problems, environmental factors (i.e. language stimulation), and information about the child’s amount and location of verbal expression. A family history of psychiatric, personality and or physical problems could be attributed to the child’s selective mutism. The child’s speech and language development is examined to see how well the child express himself and understands others. Lastly, a speech and language evaluation will be done to determine the child’s expressive language. This is usually done with the SLP; however, if the child will not speak, a home video of the child speaking is acceptable. A language comprehension is taken in the form of standardized test as well as verbal and non-verbal communication (i.e. pretend play or artistic expressions).

If a child is diagnosed with selective mutism, what is the course of treatment? The SLP will create a behavioral treatment program which will focus on specific speech and language problems or social anxiety issues. First, stimulus fading involves the child in a relaxed situation with someone they talk to freely and a new person is gradually introduced into the room until the child is comfortable talking in front of and with each person. Second, shaping is a structured approach to reinforce all efforts by the child to communicate until audible speech is achieved. These efforts could include gestures, mouthing, or whispers. Third, self-modeling techniques have the child watch videos of himself or herself performing the desired behavior. Self-modeling is used to facilitate self-confidence and carry over behaviors into settings in which the mutism occurs.

I realize that my daughter may not have selective mutism and I have plenty I can do myself to help build her confidence to speak to those she may not be familiar with. I realize that my daughter is a chatterbox at home and in public with people within earshot but the moment she is the center of attention, she clams up. And it’s completely normal. I also realize that shyness is hereditary as I remember being unable to speak freely with people I did not know or even family members I saw often. The fear of saying the wrong thing or even saying it incorrectly, kept me from speaking. Selective mutism is a form of an anxiety disorder and with behavioral treatments, a child can overcome it. It is important to remember to not to pressure a child to speak when they are anxious.  Encourage but do not force. Help build the child’s confidence and he or she may surprise you and speak freely. If in doubt, speak with your child’s doctor for further help.

American Speech Language Hearing Association:

Selective Mutism Center: