This is one of the most commonly asked questions by parents and teachers. Unfortunately, the answer is not a straightforward one. Over the years, different theories have emerged concerning possible causes for selective mutism. In the past, many investigators were concerned about the possibility of abnormal family relationships. They suggested that the selectively mute child had too close a relationship with the mother (what experts termed enmeshed) and a distant and uninvolved father. Even more frightening were the suggestions that the child was mute as a result of abuse (and since most selectively mute children were girls, sexual abuse). It is interesting that large studies of selectively mute children have consistently refuted this claim. The original term of elective mutism (SM was first used in 1992) suggested that a child elected not to speak and was voluntarily doing so. Treatment by some consisted of trying to force the child to speak. I remember a senior colleague related how she watched a selectively mute child being kept in a clinic until the child spoke! A large study of selectively mute children in 1980 by Hayden suggested that selective mutism is not homogenous but made up of different subgroups including children who were "speech phobic" as opposed to those with "passive aggressive" This marked a change in the thinking prevalent at that time, that the many children were defiant or controlling. It brought about the idea that such children were actually fearful or anxious. By the 1990s, this was the prevalent idea and a number of important scientific papers reinforced the notion. Today, North American psychiatrists believe that anxiety, particularly social anxiety is a major factor in the development of selective mutism. In fact, some psychiatrists suggest that selective mutism is not an entity by itself but merely a severe form of social phobia. However, in our own exploratory study, we do not find social anxiety as being any higher compared to social phobics who are not SM. During the 80s, a number of papers suggest a developmental basis for selective mutism. An important paper from Newcastle by Drs Kolvin and Fundudis mentioned the presence of developmental problems such as enuresis, speech delay and language difficulties. This area continue to be mentioned in a studies throughout the 90s and recently from Norway as well. I believe that selective mutism is indeed a heterogenous condition with several possible causes. To use an analogy, we can view it like an ant studying the elephant, it depends on where you are (and how you are looking at selective mutism). The main causes of selective mutism are listed below: - The child's innate temperament - The family interactions may play a role in some children - The developmental difficulties the child has, particularly in language development - The anxiety, particularly social anxiety the child has |
What can parents do if they have a child who is selectively mute? Step 1: Make sure that the problem is identified. Your child is not just shy. If your child's teacher is worried, you should be too. Step 2: Get a professional assessment. A complete assessment includes language assessment, psychoeducational assessment, Behaviour analysis of the child at home(with the family), in school (with teachers) and by observing the child. Often a referral to a speech language pathologist, a psychologist or a psychiatrist is necessary. Read about guidelines for schools: Step 3: Identify resources. Find out what kind of help is available at the school and community level. Approach private services if necessary. Step 4: You can help your child too! There are many useful ways that parents can help a child who is selectively mute. Look here. REMEMBER that your child needs your support so don't give up on them! |
After almost 150 years of research, there is no gold standard of treatment in such children. Treatments have been described in many case reports but there has been few systematic studies of treatment procedures. This is not surprising because selectively mute children are often difficult to enroll in treatment (much less involve themselves in research). They often do not seek treatment and feel threatened when approached with the idea. In order to help such children, a multipronged approach may be required. Once again it depends on a few factors: 1. The child's willingness to participate. If the child/teenager sees the problem as it is and is willing to be helped, prognosis is good. The child's willingness to participate often depends on the parents' view of the situation. 2. The family situation and willingness to help. We have met several families in which one parent is deeply involved but another chooses to take a "back seat" This is common in Singapore, where the mother is often the only parent that is actively involved. What the parents expect also determine what kinds of treatments are available. For example, one parent felt that medications are a fast and easy way out and asked for that right upon seeing the doctor. On the other hand, some families expect family therapy to work out the problems at home. 3. The school's involvement in the problem. Schools that have specialised personal helping children are best equipped to help a selectively mute child. Some school boards have a psychologist or speech and language pathologist who can work closely with the teacher and develop a treatment plan. 4. The available resources. Selectively mute children require intensive work and this is best in the context of early schooling rather than when the problem becomes chronic. As such, early recognition and referral to appropriate professionals is crucial. Some areas are underserved and lack such services. The treatments currently popular in treating such children include: A combination of all these is often labelled as multimodal treatment. |
A number of conditions may mimic selective mutism and needs to be looked for when we suspect that a child may have selective mutism. These include: 1. Other forms of mutism. Mutism can be the result of physical or psychological conditions. Medical conditions that result in the loss of the ability to speak is manifold and includes brain disease as well specific injuries to the brain. If a child becomes mute when he/she was previously able to speak, there is a need to make sure that no physical malady has struck. We have seen a 13 year old with epilepsy presenting as mutism. It was the result of a rare form of mutism associated with epilepsy. Sometimes mutism can be the result of a psychological trauma as well. A child seen at the Child Guidance Clinic was mute after he witnessed his father murdering his mother. All these forms of mutism are often pervasive and not in particular situations. 2. Language disorders. Stuttering is common articulation problem and children with this difficulty may choose to minimise their speech for fear of teasing. This, of itself, should not lead to a diagnosis of selective mutism. We are aware that a number of studies have pointed to the fact that selectively mute children often have a number of language related problems and we are trying to study this understudied area. 3. Pervasive Developmental Disorders (PDD). Many children with PDD may be selective in their speech. However, they have far more problematic lives because they may have language disabilities, learning disabilities, socialisation problems as well as odd behaviours. If a child has PDD, he should not be diagnosed as selective mutism as his problem is more than just not speaking in specific situations. There is obviously some overlap in this area. But at this point in time, research is still not sufficient to determine the relationship between selective mutism and the autism spectrum disorders. 4. Not speaking the language of instruction in school. This is by far the most common reason why young children do not speak in school. In Singapore, most children speak their mother tongue at home and when they start school, the transition to English may be difficult for some. This should not be considered selective mutism. In Toronto, many children come from immigrant families where English is not the medium of communication at home. If such children start school and do not speak, it would be important to distinguish the inability of the child to speak the language with the inability to speak in that particular situation. |
The diagnosis of Selective Mutism is made by a professional dealing with children. However, everyone should be aware of the common presentation. We use the Diagnostic Statistical Manual (4th Edition) which is the diagnostic criteria established by the American Psychiatric Association as a guide: 1. The child is able to speak. This ability has been demonstrated before (most commonly at home). 2. The child does not speak in some situations. It is important to recognise that the muteness occurs in some and not all situations. The child's muteness is thus selective. This also distinguishes the selectively mute child from one who is completely mute because of physical or psychological reasons. 3. The selective mutism has a duration longer than 1 month as long as it is not the first month of school. The duration criteria is meant for research purposes and should not be regarded as binding. After all a child who started school and doesn't speak in the first 1 month and 2 days would not automatically be regarded as selectively mute. We should also consider other factors such as an extremely strict teacher who may prefer that children are seen and not heard. 4. The mutism is not a result of being unfamiliar with a language. Thus children coming from "English as a second language" background, where they speak another language at home compared to English in school, should not be labelled selectively mute. It is important to note that a number of selectively mute children do come from ESL (or different languages other than the one spoken in school) backgrounds. These children can speak English but remain mute in school. The most common age in which children with selective mutism present is invariably between 5 and 7 years of age. In our experience, we have seen much older children and teens presenting mainly because the parents and teachers were not aware that this was a problem that needed intervention. |
Selective Mutism is a rare childhood problem that occur in about 0.1% of children. These children are able to speak in some situations but do not speak in others. In most cases, the children speak at home but become quiet and reticent in less familiar situations. Frequently, the parents are surprised by this as the child is speaking normally at home. In fact, some parents actually report that the child is quite a chatterbox at home. The problem is often missed initially when a child is merely labelled as shy. Most children with selective mutism presents for help at school going age (or when they enter playschool or kindergarten). The teacher notices that the child is way too quiet even for a shy child and informs the parents. Sadly, many teachers and parents know little about the problem and continue to label the child as just being very shy. Initally, well meaning adults merely shrug and allow the quiet child "space" hoping that he/she will open up. This doesn't work and the kind encouragement becomes anger and even rage. One teacher was so frustrated at a teen's reticence at grade 8 that she literally flipped (the child's table). Parents become increasingly frustrated and often resort to threats. In some cases, the child may speak as they enter their teens but I am aware of a teenager who went to University still mute in school. He had chosen computer science (what else?) as his course. Read about a case study here. |
How does one identify Selective Mutism? |
The diagnosis of Selective Mutism is made by a professional dealing with children. However, everyone should be aware of the common presentation. We use the Diagnostic Statistical Manual (4th Edition) which is the diagnostic criteria established by the American Psychiatric Association as a guide: 1. The child is able to speak. This ability has been demonstrated before (most commonly at home). 2. The child does not speak in some situations. It is important to recognise that the muteness occurs in some and not all situations. The child's muteness is thus selective. This also distinguishes the selectively mute child from one who is completely mute because of physical or psychological reasons. 3. The selective mutism has a duration longer than 1 month as long as it is not the first month of school. The duration criteria is meant for research purposes and should not be regarded as binding. After all a child who started school and doesn't speak in the first 1 month and 2 days would not automatically be regarded as selectively mute. We should also consider other factors such as an extremely strict teacher who may prefer that children are seen and not heard. 4. The mutism is not a result of being unfamiliar with a language. Thus children coming from "English as a second language" background, where they speak another language at home compared to English in school, should not be labelled selectively mute. It is important to note that a number of selectively mute children do come from ESL (or different languages other than the one spoken in school) backgrounds. These children can speak English but remain mute in school. The most common age in which children with selective mutism present is invariably between 5 and 7 years of age. In our experience, we have seen much older children and teens presenting mainly because the parents and teachers were not aware that this was a problem that needed intervention. |
Other conditions that may be mistaken for Selective Mutism? |
A number of conditions may mimic selective mutism and needs to be looked for when we suspect that a child may have selective mutism. These include: 1. Other forms of mutism. Mutism can be the result of physical or psychological conditions. Medical conditions that result in the loss of the ability to speak is manifold and includes brain disease as well specific injuries to the brain. If a child becomes mute when he/she was previously able to speak, there is a need to make sure that no physical malady has struck. We have seen a 13 year old with epilepsy presenting as mutism. It was the result of a rare form of mutism associated with epilepsy. Sometimes mutism can be the result of a psychological trauma as well. A child seen at the Child Guidance Clinic was mute after he witnessed his father murdering his mother. All these forms of mutism are often pervasive and not in particular situations. 2. Language disorders. Stuttering is common articulation problem and children with this difficulty may choose to minimise their speech for fear of teasing. This, of itself, should not lead to a diagnosis of selective mutism. We are aware that a number of studies have pointed to the fact that selectively mute children often have a number of language related problems and we are trying to study this understudied area. 3. Pervasive Developmental Disorders (PDD). Many children with PDD may be selective in their speech. However, they have far more problematic lives because they may have language disabilities, learning disabilities, socialisation problems as well as odd behaviours. If a child has PDD, he should not be diagnosed as selective mutism as his problem is more than just not speaking in specific situations. There is obviously some overlap in this area. But at this point in time, research is still not sufficient to determine the relationship between selective mutism and the autism spectrum disorders. 4. Not speaking the language of instruction in school. This is by far the most common reason why young children do not speak in school. In Singapore, most children speak their mother tongue at home and when they start school, the transition to English may be difficult for some. This should not be considered selective mutism. In Toronto, many children come from immigrant families where English is not the medium of communication at home. If such children start school and do not speak, it would be important to distinguish the inability of the child to speak the language with the inability to speak in that particular situation. |
Helping the child with Selective Mutism |
After almost 150 years of research, there is no gold standard of treatment in such children. Treatments have been described in many case reports but there has been few systematic studies of treatment procedures. This is not surprising because selectively mute children are often difficult to enroll in treatment (much less involve themselves in research). They often do not seek treatment and feel threatened when approached with the idea. In order to help such children, a multipronged approach may be required. Once again it depends on a few factors: 1. The child's willingness to participate. If the child/teenager sees the problem as it is and is willing to be helped, prognosis is good. The child's willingness to participate often depends on the parents' view of the situation. 2. The family situation and willingness to help. We have met several families in which one parent is deeply involved but another chooses to take a "back seat" This is common in Singapore, where the mother is often the only parent that is actively involved. What the parents expect also determine what kinds of treatments are available. For example, one parent felt that medications are a fast and easy way out and asked for that right upon seeing the doctor. On the other hand, some families expect family therapy to work out the problems at home. 3. The school's involvement in the problem. Schools that have specialised personal helping children are best equipped to help a selectively mute child. Some school boards have a psychologist or speech and language pathologist who can work closely with the teacher and develop a treatment plan. 4. The available resources. Selectively mute children require intensive work and this is best in the context of early schooling rather than when the problem becomes chronic. As such, early recognition and referral to appropriate professionals is crucial. Some areas are underserved and lack such services. The treatments currently popular in treating such children include: A combination of all these is often labelled as multimodal treatment. |
What happens to the child with Selective Mutism |
Most children improve over time. Interestingly, no long term outcome studies have been done but in our survey of 40 children, more than 60% did not continue follow-up, presumably improved. In a telephone survey of 20 previous cases of children diagnosed as selective mutism, only 5 had ongoing problems with selective mutism. It is likely that most children do recover. Of those that are more persistent, we have noticed a number of characteristics: 1. A family history of selective mutism 2. Associated learning disabilities of one form or another 3. Less social anxiety but more social awkwardness But these are anecdotal accounts. the verdict is still out as to what really happens to children with selective mutism. |
What can parents do if they have a child who is selectively mute? Step 1: Make sure that the problem is identified. Your child is not just shy. If your child's teacher is worried, you should be too. Step 2: Get a professional assessment. A complete assessment includes language assessment, psychoeducational assessment, Behaviour analysis of the child at home(with the family), in school (with teachers) and by observing the child. Often a referral to a speech language pathologist, a psychologist or a psychiatrist is necessary. Read about guidelines for schools: Step 3: Identify resources. Find out what kind of help is available at the school and community level. Approach private services if necessary. Step 4: You can help your child too! There are many useful ways that parents can help a child who is selectively mute. Look here. REMEMBER that your child needs your support so don't give up on them! |
This page was last updated on: November 21, 2001
What causes Selective Mutism? |
This is one of the most commonly asked questions by parents and teachers. Unfortunately, the answer is not a straightforward one. Over the years, different theories have emerged concerning possible causes for selective mutism. In the past, many investigators were concerned about the possibility of abnormal family relationships. They suggested that the selectively mute child had too close a relationship with the mother (what experts termed enmeshed) and a distant and uninvolved father. Even more frightening were the suggestions that the child was mute as a result of abuse (and since most selectively mute children were girls, sexual abuse). It is interesting that large studies of selectively mute children have consistently refuted this claim. The original term of elective mutism (SM was first used in 1992) suggested that a child elected not to speak and was voluntarily doing so. Treatment by some consisted of trying to force the child to speak. I remember a senior colleague related how she watched a selectively mute child being kept in a clinic until the child spoke! A large study of selectively mute children in 1980 by Hayden suggested that selective mutism is not homogenous but made up of different subgroups including children who were "speech phobic" as opposed to those with "passive aggressive" This marked a change in the thinking prevalent at that time, that the many children were defiant or controlling. It brought about the idea that such children were actually fearful or anxious. By the 1990s, this was the prevalent idea and a number of important scientific papers reinforced the notion. Today, North American psychiatrists believe that anxiety, particularly social anxiety is a major factor in the development of selective mutism. In fact, some psychiatrists suggest that selective mutism is not an entity by itself but merely a severe form of social phobia. However, in our own exploratory study, we do not find social anxiety as being any higher compared to social phobics who are not SM. During the 80s, a number of papers suggest a developmental basis for selective mutism. An important paper from Newcastle by Drs Kolvin and Fundudis mentioned the presence of developmental problems such as enuresis, speech delay and language difficulties. This area continue to be mentioned in a studies throughout the 90s and recently from Norway as well. I believe that selective mutism is indeed a heterogenous condition with several possible causes. To use an analogy, we can view it like an ant studying the elephant, it depends on where you are (and how you are looking at selective mutism). The main causes of selective mutism are listed below: - The child's innate temperament - The family interactions may play a role in some children - The developmental difficulties the child has, particularly in language development - The anxiety, particularly social anxiety the child has |
