Situational Mutism (SM)
Situational Mutism (SM), also known as ‘selective mutism’, is an anxiety-based mental health condition which usually emerges in the early years. It is predominantly a childhood anxiety disorder that is diagnosed when a child consistently does not speak in some situations, but speaks comfortably in other situations. Less than 1% of the population has SM and symptoms typically appear before the age of five but may become more obvious at the start of school. Children and young people with SM often have another anxiety disorder alongside it, most often a social anxiety disorder.
Children and young people with SM usually want to speak but they find themselves unable to due to anxiety. Some but not all children with SM have a form of social anxiety which leads them to be frightened about others hearing their voices. Research indicates that a ‘wait and watch’ approach is often unhelpful as the best outcomes are correlated with early identification and support.
In terms of presentation, SM can range from children who are reluctant to speak in some situations but will do so, those who are quiet and only use short phrases even though they are capable of lengthier responses, those who are silent some of the time and those who are mute consistently in certain settings, such as school. Most children and young people with SM function normally in other areas of their lives and are able to learn age appropriate skills despite not speaking in some important situations. Whatever their level of SM, the child’s inability to communicate verbally can affect their learning, their ability to make friends and succeed at school and their independence. It can eventually lead to complete speech avoidance, which can be harder to treat once established. Although it is common for children to become silent when they first start at a nursery or playgroup and are separated from their parents, if they don’t seem to grow out of it and become increasingly unable to verbally communicate as they mature and develop, they may need specific interventions to be put in place for them.
What causes SM?
The literature does not indicate one clear cause, although we know that there are a number of risk factors which play a key role in the development of situational mutism. These risk factors include being generally slow to warm up to new situations, the tendency to withdraw from new or unfamiliar situations early in life, a family history of anxiety disorders including SM, speech and language difficulties and a tendency to avoid unfamiliar settings. There is no evidence indicating that abuse or neglect can cause situational mutism in children or young people.
Most children with the condition are genetically predisposed to anxiety, often showing signs of anxiety from an early age, including tantrums and crying, separation and/or social anxiety, sleep difficulties and shyness. Others struggle to process sensory information, presenting as sensitivity to light, sound, touch, smell, and taste. They sometimes misinterpret social and environmental cues which causes anxiety and frustration and leads them to withdraw from social situations by not communicating verbally. Neuroscientific research shows that children with SM have a low threshold of excitability in their amygdala, the part of the brain that senses potential danger by processing signals from the sympathetic nervous system. In an anxiety-provoking situation, it triggers a series of reactions that help people protect themselves. Children with SM perceive some environments as fearful which triggers their anxiety and causes them to stop communicating verbally within that environment.
Speech or language difficulties are seen in approximately 25% of children with SM. For those children, the expectation of speaking increases their anxiety and can make them feel insecure. That said, the majority of children with SM are fluent speakers with no other signs of difficulty or disorder.
How is SM treated?
The effectiveness of treatment depends on how long the child or young person has had SM, whether or not they have additional communication or learning difficulties or anxieties and the consistency of support offered to them. Speech and Language Therapists can provide intervention, and psychotherapeutic intervention such as cognitive behavioural therapy (CBT) is often helpful. Treatment does not focus on the speaking itself, but focuses on reducing the anxiety the child or young person has for speaking to and being overheard by people outside their immediate circle of family and friends.
How is SM maintained?
SM is most commonly maintained through negative reinforcement. When a child is anxious and is mute, a parent or teacher with the very best intentions will often step in to help by answering the question on the child’s behalf. By doing this, the child learns that if they keep quiet, someone will ‘rescue’ them by talking for them. Every time this happens, the child feels temporarily better as their anxiety reduces, but it often leads to a cycle of anxiety avoidance in the child, as explained in our blog post about Emotionally Based School Avoidance (EBSA).
It doesn’t take long for this cycle to become a habit for the child and the adults who rescue the child and it becomes harder to break.
How can I help?
Here are ten ways parents and educators can help children and young people with situational mutism:
Don’t let the child or young person know you are anxious. Avoid bribing or putting pressure on a child or young person to speak as this is likely to make things worse.
Let them know you understand that they sometimes have difficulty speaking and reassure them that they'll be able to speak when they're ready. Until then, let them do what they feel able to.
Subtly praise any efforts the child makes to join in and interact with others and respond warmly and naturally to any attempts they make to communicate, such as gestures or whispering.
Don’t show that you are surprised when the child speaks, instead respond just as you would to any other child. If the child looks upset that they spoke, simply say ‘I heard your voice and that’s ok. You can speak again when you are ready.’
Don't praise the child publicly for speaking, as this can cause embarrassment. Wait until you are alone with them and consider a special treat for their achievement.
Comment on what you are doing rather than asking direct questions. This will help the child to feel relaxed and as if they are in a conversation without any pressure to answer.
Use “I wonder…” phrases rather than questions “I wonder if you did painting again today”.....pause, rather than “did you do painting?”
Give the child or young person tasks they can do which allows them to interact with others without talking, such as showing friends where things are or giving out books or equipment.
Encourage the child to use non-verbal communication e.g. nodding, pointing or waving to communicate, or allow them to write or text when they don’t want to speak but want to communicate with you.
Don't avoid parties or family visits, but consider what environmental changes are necessary to make the situation more comfortable for the child. Give them love, support and patience as well as verbal encouragement.
