Commonly Co-occuring Difficulties
The "typical" presentation of Selective Mutism (SM) is the child who is seen to be shy in most environments outside the home but can speak and interact appropriately with familiar adults and children. They will often be reported as being talkative and confident in the home but silent at school or around less familiar adults e.g. when in a restaurant, at a party. This is one example of SM - there are many different presentations ranging from being completely mute and frozen with fear in many social situations (including the home) to being confident, carefree in all situations and only unable to speak freely to a teachers and some peers despite being able to interact confidently with them non-verbally. Tools to help identify which stage/end of the spectrum the child is at can be found in the resources section under assessment. Examples of different presentations of SM can also be found in this section.
Below is a list of the difficulties that can co-occur with SM. These may be present in children at any level on the spectrum and should be explored with a team of health and teaching professionals. Treating these difficulties may be a key factor in addressing the child's speaking confidence.
It is important to differentiate SM from shyness as children who are shy have a tendancy to "warm up" to talking whereas children with SM will not. However, what is common between the two is that children with SM can often be timid and cautious in new or less familiar situations from an early age.
These may include difficulties with speech sound production e.g. speech sound delay, voice disorders, dysfluency/stuttering, expression of language or understanding of language. A full assessment from a Speech Pathologist will be required to identify the extent and impact of these difficulties.
Intervention for SM should be conducted alongside intervention focusing on the above areas if present. If the individual is not able to speak to the Speech Pathologist they can still provide support in the form of: intervention focusing on verbal comprehension/understanding of the difficulties; environmental supports such as visuals, providing advice to school/social activities; use of home programmes and video where possible for parental implementation of therapy techniques.
Social Anxiety and Phobia
Up to 90% of children with SM can present with some level of social anxiety. This may manifest in many different ways including: perfectionist tendencies - resulting in hesitance or slowness with any activity due to the fear of making a mistake; reluctance to meet new people or try new social situations; fear of the dentist/hospitals; avoidance of eating in public e.g. school; avoidance of use of less/unfamiliar toilets. The physical symptoms of anxiety may also be associated with these activities e.g. tummy ache, nausea/vomiting, shortness of breath, panic attacks, cold/hot flushes; joint pains, headaches, scary thoughts.
Social anxiety is explained in a child friendly way in the context of a daily routine in Dr Shipon Blum’s book Understanding Katie.
Other anxiety disorders
Children may experience or have experienced: Separation anxiety, Obsessive Compulsive Disorder (OCD), hoarding, Trichotillomania (hair pulling, skin picking), Generalized Anxiety Disorder, Specific phobias, Panic Disorder ()
SM can occur in conjunction with language, cognitive/intellectual or physical delays. It is important that professionals do not rule out the presence of SM if the child is experiencing these difficulties. Even children with minimal language can experience SM.
These delays/disabilities may include difficulties with learning new skills such as dressing, showering, sport skills; difficulty accessing the school curriculum; difficulties with spoken and written communication.
Difficulties in these areas may cause the child to have further anxieties around completion of new tasks or those that they find hard. Input from a team of professionals including Speech Pathologist, Occupational Therapist, Teacher or Education Professional with a Specialism in the area of Special Needs will be beneficial to reduce the demands on the individual and provide the necessary accommodations to support the individual to independently carry out tasks.
Autism Spectrum Disorder
There is a high overlap of SM and ASD reported in the literature. Of most importance is the need to identify the reasons behind why the individual is not speaking in order to ensure the most effective method of treatment – see diagnosis page on this website.
Individuals with ASD must also be receiving supports for the impact of their primary diagnosis – ASD. This link gives some information as to what those may be
Children with SM may demonstrate: difficulties with transitions; inflexibility; moodswings; bossyness; withdrawl, avoidance; sillyness at social events e.g. socially inappropriate behaviours such as pushing or pinching peers, burping. What appear to be controlling and defiant behaviours are often the childs attempts to control their own anxiety by instilling order or attempts at social interaction. These behaviours are OFTEN misinterpreted by professionals and families alike and it is vital the cause of these behaviours is addressed in order to help the child feel calm - rather than punishing the child which often causes more difficulties.
Sensory Processing Difficulties
Sensory and emotional regulation difficulties can present in a range of ways and often relate to processing information from our 5 external senses (with input from out to in) - touch, sight, vision, hearing, smell and our 2 silent senses - proprioception (our bodies awareness of ourselves in space.) and vestibular (our inner ear giving the body an understanding of movement in different planes). You may find that a child is: over sensitive to things such as noise, touch, smells or alternatively children can be undersensitive to these factors and have great difficulties in being fully alert. Resultingly children have great difficulty maintaining their attention to social, academic and physical tasks as they try to process this over or underexaggerated sensory information. This can result in "shut down" and muteness or behavioural outburts e.g. melt downs, withdrawl. These difficulties can often affect general learning and anxiety but can be greatly helped through increased understanding of the difficulties and strategies put in place to help lessen the effects.
Dr. Cheng from his practice of child, adolescent and family psychiatry in Ottawa, Ontario, Canada gives some really informative handouts regarding anxiety, attachment, emotional regulation and sensory processing disorders, which can be helpful to summarise this area
The expertise of Occupational Therapists in this area in invaluable, Speech Pathologists and Psychologists may work closely with these professionals to create treatment programmes for the individual to develop coping strategies in these areas. This may include treatments such as cognitive behavioural therapy, sensory diets and desensitisation programmes.
Most of these areas and more are explained in more detail in this useful handout devised by Michael Jones, an educational trainer and author based in Europe, with a background in Speech and Language Therapy and teaching.
It is important to remember that mutism is just one of the many characteristics that a child with SM may display. It is essential that we identify all other factors contributing to communication anxiety in order to fully remediate the difficulties.