Anxiety and Depression  |  Supporting Children

When Your Child Can But Won’t Speak: Selective Mutism

11 November 2020  |   7 min read

What is Selective Mutism?

Selective Mutism (SM) is an anxiety disorder that is typically diagnosed in childhood. For children with SM, anxiety prevents them from speaking in specific social situations where there is an expectation to speak. These situations include school, where they fail to speak to their teachers and/or peers, as well as outside of school such as with children at the playground, or unfamiliar family friends. In contrast, they can speak normally and freely with their family members usually in familiar settings (e.g., at home). While some children with SM may have reduced language abilities, language difficulties alone cannot explain their mutism.

Signs and symptoms

Parents usually notice the lack of speech with others when their child enters preschool. This may explain why the average age that SM is reported to begin is between 2.5 to 4.5 years old. For children who only start school at the primary school age, this condition may only be noticed then. The lack of speech and social communication can interfere significantly with academic learning, making friends, and developing relationships.

Prevalence of SM

SM is considered a relatively rare disorder, although its occurrence is higher in Singapore as compared to other countries. International rates range between 0.03% and 0.79%, while the last known rate for a Singapore sample was about 1.4% in 2010. SM is also more common in girls than boys.

When to seek help?

It is quite typical for children to take about one to two months to adjust to a new school or setting. However, if a child continues not to speak consistently to teachers and peers after this period of time, parents may want to consider seeking an evaluation for their child. Often times, parents want to know why their child has this condition, whether their child will outgrow this condition without intervention, and what does intervention usually involve.

Some children are also born with an anxious, slow-to-warm up, or shy temperament, and thus are more prone to developing an anxiety disorder, including SM.

1. Why does my child have this condition?

There are various genetic, environmental, and neurodevelopmental factors that can explain why a child develops SM. Children whose parents have increased anxiety, or anxiety disorders, have a higher chance of also having an anxiety disorder (which could be SM). Parents of children with SM that have been seen at the Department of Child Development (DCD), KK Women’s and Children’s Hospital (KKH), have reported that they have experienced anxiety issues themselves, were very shy as young children, or did not speak in school as well when they were younger. Some of these parents have also shared that while they have been able to cope over time, they do still face ongoing difficulties such as speaking up during work meetings. Some children are also born with an anxious, slow-to-warm up, or shy temperament, and thus are more prone to developing an anxiety disorder, including SM. Other risk factors include problems with speech and language development, or learning difficulties.

2. Will SM resolve without intervention?

It is hard to predict whether their child will or will not outgrow SM. Research suggests that about a third of anxiety disorders may resolve on their own, while another third continues to struggle with the disorder, and the remaining third goes on to develop additional disorders (e.g., depression). Thus, some children may “outgrow” SM and start talking in more settings.

However, it is very likely that this progression is slower, harder, and may affect their overall well-being. Children with SM are at an increased risk of developing social anxiety disorder, even after their SM has resolved. Furthermore, it is challenging to say how long it will take these children to outgrow SM, which could stretch into years of wasted time.

Parents have shared with me that they are worried about their child’s lack of speech when their child enters primary school. This is often the impetus for parents to seek an evaluation and intervention for their child. With intervention, children with SM are more likely to take a shorter time to start speaking to others (e.g., teachers and peers) and may also start talking to people in more settings (e.g., playground, restaurants). Furthermore, the ability to overcome SM can also increase their self-esteem, confidence, and resilience.

3. What does intervention involve?

Intervention for very young children with SM usually involves a behavioural approach, rather than medication or other types of therapy. This means that intervention will focus on concrete strategies to increase desired behaviours (e.g., talking) and decrease undesired behaviours (e.g., silence, ignoring others).

While the main outcome of intervention is speech, the bulk of intervention strategies focus on increasing the child’s comfort, which is a necessary first step before speech can occur. This is done by reducing pressure on the child to talk, following the child’s interest, and going at the child’s pace. For example, the psychologist will spend time to build rapport with the child by playing games and doing fun activities. The psychologist often refrains from asking questions (which places pressure on the child to speak) and instead will make comments, describe the child’s play or the psychologist’s own actions.

As the child’s comfort increases, the psychologist will start to prompt for speech but at the child’s comfort level. For example, instead of getting the child to answer the psychologist directly, the psychologist may ask a question and instruct the child to answer the child’s parent instead, which is easier for them to do. Additionally, the psychologist will usually ask questions that are easier for the child to answer. For instance, they may ask questions that the child would be confident in answering (e.g., numbers, letters, colours, shapes, animals). Questions that are close-ended such as forced choice (e.g., “Do you like cats or dogs?” or yes/no to e.g., “Do you like cats?”), are also easier for children with SM to answer compared to open-ended questions (e.g., “What animal do you like?”). These are just some of the strategies that are used to help increase the comfort level of a child with SM, which increases the likelihood for spontaneous speech.

As a child with SM becomes more comfortable, the psychologist will increase the intensity of the plan to include having the child speak to other people in the office, or other children (e.g., paired sessions with another child), or in other settings. Sessions with parents focus on teaching parents how to use these strategies in their social settings (e.g., visits to grandparents) through creating specific plans and role-playing these plans.

Where to seek help?

Parents can seek help for their child by bringing him or her to see a developmental paediatrician at KKH’s DCD, National University Hospital’s Child Development Unit, or in private practice. Alternatively, they can bring him or her to see a child psychologist. Online resources such as https://selectivemutismcenter.org, or books such as ‘The Selective Mutism Resource Manual’ by Maggie Johnson and Alison Wintgens can be a good start to learning more about SM and managing it.

The contributor is a Senior Psychologist at Department of Child Development, KK Women’s and Children’s Hospital.