AN INTERVIEW with Angela McHolm, author of Helping Your Child with Selective Mutism

New Harbinger Publications: What is selective mutism, and at what age does it usually develop?Angela McHolm: Selective mutism (SM) is a condition in which children fail to speak in certain situations, despite speaking comfortably in others. While children with selective mutism typically speak at home, they often do not talk to teachers or classmates at school. Depending on its pervasiveness, some children with SM also feel uncomfortable speaking to children or adults in the community (e.g., the swimming instructor; grocery store clerk). Those in the field understand the condition to be, in most cases, an anxiety-based disorder. As described in the book, my co-authors and I view selective mutism as a specific phobia of being heard and/or seen speaking in certain situations. Research suggests that selective mutism typically appears during the preschool years, at a time when children first enter daycare or a school setting.

NHP: How can a parent differentiate between selective mutism and ordinary shyness?

AM: This is a very important issue and one that can often make the difference in terms of the early identification of children with selective mutism. Parents are often assured by well-intended family members, educators, or health care providers that their children are “just shy” and that they will “grow out” of their difficulties. Although research formally studying the differences is not yet available, it is our view that shyness is often one contributing factor of selective mutism. Children with SM are often characterized as shy, but the vast majority of shy children do not develop SM. Shy children and children with SM likely share a temperamental trait called “behavioral inhibition” which leads to cautiousness in unfamiliar situations. However, the majority of intensely shy children are able to speak to others once they become comfortable in a setting. Despite familiarity with classmates and school personnel, the child with SM typically remains uncomfortable and inhibited by his or her speaking anxiety long after shy children make the adjustment.

NHP: Is selective mutism a new condition?

Despite a relatively recent increase in the public’s awareness, SM is not a new condition. Scientists and mental health professionals have been describing children who speak in some but not other situations for over a century. As far back as 1877, a German physician by the name of Clifton Kussmaul first described a disorder called aphasia voluntaria, in which people did not speak in certain settings despite being fully capable of talking. Nearly sixty years later, in 1934, a Swiss psychiatrist named Moritz Tramer coined the first term to describe this behavior in children: elective mutism.

NHP: You talk about the differences in treating selective mutism in older and younger children. Can you tell us a little about how treatment differs in these two groups and how this disorder manifests itself differently in the two?

In general, older children with selective mutism require more time and more intensive supports to work through their difficulties. In addition to the fact that the mutism has persisted longer, a child’s cognitive maturity will inevitably lead to new challenges. As the child matures, he or she will become more aware of his or her difficulties and how they set him apart from others. The older child also may, either consciously or unconsciously, start to use more sophisticated avoidance strategies when faced with anxiety-provoking, speaking situations. Treatment of older children with selective mutism is typically most effective when it combines behavioral techniques (e.g., gradual exposure to feared speaking situations) with cognitive therapy. This form of treatment, called cognitive-behavior therapy (CBT), helps the child learn to alter anxiety-inducing thinking patterns while gradually facing anxiety-provoking, speaking situations.

NHP: What is the “conversational ladder?”

As is the case when working through most fears or phobias, exposure to the feared situation is a highly effective way of overcoming associated anxiety. Instead of avoiding fearful experiences, a person can gradually expose him or herself to anxiety-provoking situations and with practice, those situations typically become less anxiety-provoking over time. For children with selective mutism, a “conversational ladder” of speaking-related situations can be built that allows for gradual exposure to feared speaking situations. A conversational ladder can be built for any setting in which a child experiences anxiety conversing or speaking to others (e.g., at school; during play dates). With the help of school personnel and other professionals involved, parents can identify steps on the conversational ladder ranging from situations in which the child already talks comfortably, to those in which the child talks less frequently, and finally those in which the child does not speak at all. Each step or speaking situation on the ladder is small enough that the child will experience only a slight increase in anxiety and will continue to speak in the new situation. Our book explains to parents and others how to build a conversational ladder tailored to the individual child.

NHP: In your book you cite research that indicates that this condition occurs about one and half to two times more in girls than in boys. Why do you think this is the case?

Of the research available to date, it does seem that more girls than boys develop this condition. Although the field has yet to examine possible reasons for this, it would appear that selective mutism follows the same gender patterns found among other childhood anxiety disorders. Girls, in general, appear to be more likely to develop a variety of anxiety-based conditions including separation anxiety, specific phobias, and generalized anxiety.

NHP: You talk about some other difficulties that are associated with selective mutism. Can you tell us about a few of the most common problems that tend to coincide with it?

Children with selective mutism have their own unique qualities but they do tend to have some things in common, too. In addition to their fear of speaking, children with selective mutism may be prone to other types of difficulties. For example, research has shown that most children with SM could be diagnosed with at least one other anxiety-related condition. The most common include social anxiety or phobia, separation anxiety, and perfectionistic tendencies. Social anxiety is particularly common among children with SM and is reflected in social inhibition beyond speaking. These children may be uncomfortable interacting with peers (even when they do not have to speak), feel nervous eating in front of others, or even avoid using public bathrooms. It is important for parents to realize that a child’s anxious tendencies may be limited to a fear of speaking or she may struggle with other anxiety-related difficulties.

NHP: What does the latest research tell us about what causes and what doesn’t cause selective mutism?

As is the case for research examining most children’s mental health issues, we don’t yet have the definitive answer on what causes SM. Based on clinical experience and the descriptive studies available in the literature, we do believe that certain contributing factors are often involved. Parents, for example, often describe children with SM as having a shy or anxious temperament. As slow-to-warm to new people or experiences, these children may be more prone to develop a fear of speaking when they first enter a daycare or school setting. Other contributing factors include a family history of shyness or anxiety, early speech and language difficulties, adjustment to a new culture (among immigrant children), and limited opportunities to socialize with schoolmates away from the school setting. As we learn more about these children, it has also become clear that in most cases early trauma or family problems do not cause SM. Early writers in the field had thought otherwise but there is no research evidence to support this.

NHP: Is medication ever used to treat this condition and if so, what are a few things parents should consider when weighing this option?

Some physicians have suggested to parents that medication may be an effective way to treat selective mutism. A particular class of drugs called serotonin reuptake inhibitors (SRIs), used in the treatment of social phobia and other anxiety conditions, has been suggested to be helpful. Although interest in this treatment approach has increased in the past decade, large scale, controlled studies have yet to examine its effectiveness for these children. As a result, it is important for parents to be advised that the risks and benefits to their child are not yet fully understood. Parents should also be aware that, although medication may help to reduce a child’s general reactivity to anxious situations, it is unlikely to cure SM. Children with SM have developed a behavioral pattern of avoidance in certain speaking situations that will need to be directly addressed. If medication is used, another treatment approach (such as graded exposure through the “conversational ladder”) would likely remain necessary to help the child replace avoidance behaviors with comfortable speaking.

NHP: You talk about establishing a “management team” to help a child overcome selective mutism. Who should be on this team and how can a parent go about setting in up?

Helping a child overcome selective mutism requires the efforts of many adults including parents, school staff, and other professionals. The “management team” is a group of individuals who collaborate to help the child climb his or her conversational ladder and successfully work through his or her fear of speaking, particularly at school. Depending on staffing at the child’s school and the availability of supporting professionals, the composition of the team will be unique to each child. Inside our book we provide the parent with some suggestions of good candidates and tips on how to facilitate the set up of a management team at the school. Helping a child work through selective mutism takes time and patience. Through regular meetings of the management team, the child’s progress can be monitored both in and outside of school and next steps on the conversational ladder can be effectively planned.