I was working in a school recently and was approached by a teacher who wanted to talk with me about her concerns for a year 4 boy in her class who was presenting with many features of autism spectrum disorder (ASD). The teacher reported this little boy had deficits in social communication and social interaction, within and outside the classroom, with both adults and peers. He rarely communicated using speech, impacting on his capacity to engage in reciprocal conversations. If he did talk, he used one or two words only and typically in a quiet voice. He couldn’t answer the role each day when his name was called and would look down and stay silent. There were concerns about an underlying processing issue as he took a long time to respond with speech. Gesturing was his typical way to communicate but this was often done out of context. He wore a neutral or masked facial expression and avoided eye contact. If unexpected things happened, he would become rigid and oppositional and show signs of anxiety. He was avoidant when asked to do tasks that he didn’t want to do or that he perceived to be too challenging.
Although there are some features of ASD, these types of behaviours can also be explained by another type of disorder known as selective mutism (SM). SM is a very misunderstood condition and often goes undetected. These children are sometimes perceived to just be ‘shy’ or needing more time to ‘warm up’. They can be told they are rude because they find it excruciatingly difficult to say hello and goodbye or please and thank you. Apart from being labelled shy, they can also be described as oppositional, stubborn, detached, and rigid. As the years unfold, their peers may eventually get bored and give up, believing them to be antisocial, standoffish, or disinterested. Sadly, they are at risk of becoming these labels and without treatment, their long-term prospects can be poor.
So, what is SM? Put simply, it is an anxiety disorder in which there is a specific phobia relating to speech. It often develops at important transitional moments, usually when the child starts formal schooling. The child is confident and capable to speak in the family home and parents often say that they can be cheeky, outgoing, chatty, little people who show no signs of ‘shyness’ until someone visits the home or they go into the community. At these times, they lose their voice due to intense anxiety/freeze response in which the words literally get stuck in their throat. This can happen when talking to teachers, doctors and dentists, shop assistants, grandparents and other relatives, children and treating specialists. They have strict rules about who they believe they can speak with and who they won’t. This can seem like they are making a choice and for this reason, many with SM prefer the term ‘situational’ mutism. Unless the disorder is understood, it can be a great source of frustration for all. At the heart of the disorder is an intense fear of being noticed or judged by others and so the child will avoid any chance that attention could be drawn to them. Their inability to speak up often results in many their needs going unmet.
Well-meaning parents and teachers do all they can to help the ‘shy’ child communicate. They prompt the child to speak but this typically results in the child feeling very self-conscious and anxious and they are unable to speak. The lack of speech is unknowingly negatively reinforced by caring adults who speak on behalf of the child when no response is given. The child then learns that when speech is expected, anxiety rises sharply, silence results, the adult fills the silence, and the anxiety goes away for everyone. The child learns that staying silent temporarily reduces their anxiety and the cycle repeats.
Treating SM can be a complex process involving holistic assessment and collaboration between home, school and specialists (psychologists, speech pathologists, occupational therapists, and medical practitioners). Early intervention is best as a lack of treatment and understanding can lead to other issues such as school refusal. Treatment can involve any, or all, of the following:
- psychoeducation
- anxiety management training
- exposure therapy
- cognitive behaviour therapy (for children over the age of 7)
- contingency management
If you have any concerns about your child and think that they may have SM, make an appointment for them to see their GP so they can get a referral for treatment. Until treatment begins, here are a few recommendations for you to share with others if your child is unable to talk in their presence:
- Avoid forcing them to talk.
- Avoid insisting on greetings and manners – these will come in time. Encourage others to say hello and goodbye in different ways such as ‘It’s lovely to see you today’ and ‘I look forward to seeing you again tomorrow.’
- Avoid too much eye contact.
- Avoid questions that include a yes/no answers (do you want a donut)?
- Try using forced choice questions (would you like a cup cake or a donut) or open-ended questions (what would you like for morning tea).
- Allow up to five seconds for them to respond.
- If they respond with gesturing, thank them for letting you know what they want. Communication is more than just speech and any effort to communicate should be encouraged.
- If they do respond, don’t make a big deal about it as this will draw too much attention to them and make them anxious and less likely to speak again. Just thank them for telling you want they want.
SM will not go away on its own. The child will not outgrow it. Parents are urged to seek professional advice if they have any concerns that their child may have selective mutism.
