All material Copyright © 2009 Selective Mutism Group ~ Childhood Anxiety Network
Reprinted with the express permission of SMG as originally published on their website.
PLEASE NOTE: This document was written for parents rather than clinicians. We include it here on this website so that therapists may learn from it and also share this information with the parents of their students and clients.
What if I just found out my older child/adolescent has SM? Is it too late to get help for him/her?
No. Older children and adolescents also benefit from treatment. In fact, those who have had symptoms of social anxiety into adulthood have also been helped with treatment. Left untreated, SM is likely to persist into the upper grades of school and into adulthood (Thompson, 2000). Studies of adults with untreated social phobia (or social anxiety disorder) indicate that they are prone to developing more severe problems such as depression, suicidal ideation, substance abuse, limited occupational or educational achievement, avoidance and impaired social relationships. Social phobia also often co-occurs with other disorders, thus, older children and adolescents with SM may have other symptoms and diagnoses including depression, panic disorder, obsessive-compulsive disorder, and generalized anxiety disorder (Biedel and Turner, 1998). It is important that the child/adolescent receives an assessment to rule-out other problems that may be present along with SM. When in treatment, the child or adolescent will have a far greater opportunity to overcome his/her problems and be successful in adulthood.
What is the prognosis for SM? Will my child overcome this?
The prognosis for children and adolescents who are treated for SM appears to be excellent. With appropriate treatment, SM is often overcome successfully. Without treatment, however, SM is more likely to persist and comorbid symptoms in addition to SM are common. Longitudinal studies showing the course of SM following treatment are needed, however, in clinical settings, most children with SM show significant improvement.
When are most children diagnosed with SM?
The average age of diagnosis is between 3-8 years when the child enters school and the non-speaking behavior becomes problematic (APA, 2000). However, many parents will say that their child displayed signs of excessive shyness and/or inhibition since infancy. Once a child enters school there is increased expectation to perform, interact and speak and SM becomes apparent. It is at this time that teachers will point out the severity of the problem including concerns that the child is not speaking and participating in activities.
When do I need to seek professional help for my child?
SMG recommends that treatment be sought as soon as it is suspected that a child may have selective mutism (SM). It is especially important to seek help when it is clear that a child is having difficulty engaging in social situations, seems out of step with his/her peers, and is experiencing adverse consequences such as having difficulty adjusting to school, difficulty with social relationships or co-occurring symptoms such as depression. Treatment is not indicated during the first month of school when a child is adjusting to entering preschool or Kindergarten for the first time, as this behavior is developmentally appropriate for young children who are not yet familiar with the school routine and being around other adults and children. If the selectively mute behavior continues beyond the first month of school, however, a treatment should be considered.
Why do so few teachers, therapists and physicians understand SM?
Research studies on SM are scarce. Most articles and textbooks descriptions are based on subjective findings of a very limited number of children. In some cases, medical and educational professionals have not been taught anything at all about SM and in other cases they have been given very little training on SM and even inaccurate and misleading information on the subject. When confronted with a child with SM, doctors, teachers and other professionals will often tell a parent that the child is just shy or that he/she with outgrow the behavior. Other professionals incorrectly interpret mutism as oppositional or defiant behavior where mutism is a means of manipulation and control. Still other professionals view SM as a variant of autism or an indication of severe learning disabilities. This misunderstanding leads to misdiagnosis and ineffective treatment strategies, as SM is best viewed as an anxiety disorder.
The diagnostic manual most widely used by treating professionals is the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, now in a Text Revision (APA, 2000). Of all the anxiety disorders, selective mutism and separation anxiety disorder are the only two listed in DSM-IV-TR under “Disorders Usually Diagnosed in Childhood.” All of the anxiety disorders listed in the “Anxiety Disorders” section, however, may also be applied to children. There is much more research available on the anxiety disorders classified as such in the DSM. Also, due to the current classification system, a clinician is less likely to encounter SM in the manual if they suspect anxiety in a child, as it does not fall into the anxiety category. To make SM even more isolated in the classification system, it is listed in a smaller sub-category of the childhood section of DSM called “Other disorders of Childhood.” This classification does not clearly suggest that SM is associated with anxiety, only that it is a childhood problem associated with not speaking. Thus, further research and education is needed to help more teachers and treating professionals to understand the symptoms of selective mutism, its association with social anxiety, and its treatment as an anxiety disorder.
Why does a child develop SM/Etiology?
The understanding of SM as an anxiety disorder related to shyness, social anxiety and inhibited temperament has increased in popularity over the last decade. Reports of children with SM indicate that most are shy, inhibited and anxious. These reports combined with clinical experience suggest that SM may be the manifestation of an inhibited temperament, or inborn personality of mood (Dow et al., 1995). There is some evidence that there is a genetic link between children with SM and anxious parents or family members. Most commonly, social phobia, avoidant personality disorder, and parents with a history of SM themselves were more prevalent in families with a child with SM than those without (Black & Uhde, 1995; Chavira et al., 2005; Kristensen, 2001). In addition, most children with SM also have one or more other anxiety disorders, especially social phobia (Black & Uhde, 1995; Dummit et al., 1997). Other common comorbid anxiety disorders include separation anxiety disorder, generalized anxiety disorder and specific phobias (Dummit et al., 1997).
Behaviorally inhibited children may also have a decreased threshold of excitability in the almond-shaped area of the brain called the amygdala. The amygdala receives and processes signals of potential threat and sets off a series of reactions that will help individuals protect themselves. In anxious individuals, the amygdala seems to overreact and set off these responses even when the individual is not really in danger. In the case of SM, the anxiety responses are triggered by social interactions and settings where speaking is expected including school, the playground or social gatherings. Although there may be no logical reason for the fear, the feelings that the child with SM experiences are just as real as if an actual threat or danger were present.
Other factors may also contribute to the development of SM. A significant number of children with SM also have expressive language disorders and some come from bilingual family environments (Kristensen, 2000; Elizur & Perednik, 2003). While these factors do not cause SM, they can contribute to a child’s anxiety with speaking. The child may become more self-conscious about his or her speaking skills and may have increased fear of being judged negatively by others.
A stressful environment may also be a risk factor in the development and maintenance of SM. Although earlier reports of SM suggested that a history of abuse and trauma may be associated with the development of SM, there is no evidence that there is a causal relationship between trauma and SM (Black & Uhde, 1995). However, if significant stressors are present, they may contribute to the SM by exacerbating the child’s already present anxiety.
Featured Organization: Selective Mutism Group ~ Childhood Anxiety Network (SMG)
We thank Selective Mutism Group ~ Childhood Anxiety Network for allowing PediaStaff to reprint their article. Selective Mutism Group ~ Childhood Anxiety Network is the nation’s premier resource for information on SM. SMG, a part of the Childhood Anxiety Network is a nonprofit organization dedicated to providing information, resources and support to those impacted by a child with the anxiety disorder known as Selective Mutism (SM). Visit their website at :www.selectivemutism.org