Listen for the Sounds of Silence: Selective Mutism

The quietest children are often the ones who make office hours run smoothly. They're in and out during well-child visits, letting Mom or Dad field the questions. When the clock is ticking and the exam rooms are full, physicians rarely try to draw them into a chat. So it's easy to miss those with selective mutism.

Dr. Barbara J. Howard, of the department of pediatrics at Johns Hopkins University, Baltimore, says that selective mutism is treatable and that without treatment, it can lead to significant social and educational impairment. It is part of the spectrum of anxiety disorders and, unchecked, it has the potential to evolve into other potentially debilitating social anxiety and mood disorders.

The disorder affects about 0.1% of children overall and 1% of children seen in mental health centers, and is as common as cystic fibrosis, according to the American Academy of Pediatrics. Yet it is often dismissed as shyness or immaturity.

Part of the problem is that selective mutism begins to manifest just after the very normal phase of separation anxiety. “Who hasn't dealt with the 3-year-old who hides her face in Mom's clothes? We are not surprised to see this behavior in children younger than 4 years of age,” added Dr. Howard, codirector of the university's Center for Promotion of Child Development Through Primary Care. “Complicating the picture is the fact that the parents may not readily share with you the fact that 4-year-old Alex never speaks in public, even though he blabs up a storm at home.”

Anxiety disorders, particularly social anxiety, tend to be familial. Parents may empathize with—even unwittingly reinforce—a child's reluctance to interact socially outside of his immediate family by stepping in too soon or making excuses for him. Although selective mutism is thought to be to the result of a biologically determined temperament and a predisposition to anxiety, it can be promoted by parental reactions.

“Unless you ask directly about his verbalization patterns, you may never know,” Dr. Howard said. She advised that the 4-year-old visit is a good time to consider the possibility of selective mutism and other anxiety problems because that's about the time the development of social relationships becomes one of a child's main goals.

Start out by specifically engaging in a conversation with the child, she said. “One of my favorite icebreakers is to ask a child to draw a picture of a boy and a girl and then suggest, 'Tell me a make-believe story about this boy.' The average 4-year-old will launch into a story, allowing you to obtain a drawing sample, a language sample, an example of some projective material, and a sense of the child's social interactions.”

If a parent jumps in while the child remains silent, ask very directly if the child is used to speaking with people outside the family, and if so, with whom and under what circumstances. If the child speaks normally with the family and close relatives, but never with peers or adults in social situations, consider selective mutism in the differential diagnosis. Then one should ask the family for details on the child's previous attempts at peer communication, for example, does the child stutter in public and therefore keep quiet?

One should also consider what role the parents are playing in this problem. “Occasionally, I see what seems to be selective mutism in a highly pressured child who will not perform by fulfilling parents' requests to recite the state capitals or the Gettysburg Address. These children usually talk just fine when their parents are not asking them to speak. Removing pressure won't get a child with selective mutism to talk in public.”

Rule out—or diagnose as a comorbid condition—separation anxiety disorder (as opposed to normal developmental separation anxiety) and the inhibited form of reactive attachment disorder.

Selective mutism is more likely if the child consistently fails to speak in a variety of social settings; if this silence is interfering with normal functioning; if the symptoms have lasted for at least 1 month (but not the first month of school); and if it is not related to having a primary language other than English.

Some children with selective mutism can be helped within the primary care practice using the same approach as for anxiety. One of the keystones is to make unfamiliar situations as familiar as possible, another is to work with parents on ways to assess and hide their own anxiety about their child's condition.

The quietest children are often the ones who make office hours run smoothly. They're in and out during well-child visits, letting Mom or Dad field the questions. When the clock is ticking and the exam rooms are full, physicians rarely try to draw them into a chat. So it's easy to miss those with selective mutism.

Dr. Barbara J. Howard, of the department of pediatrics at Johns Hopkins University, Baltimore, says that selective mutism is treatable and that without treatment, it can lead to significant social and educational impairment. It is part of the spectrum of anxiety disorders and, unchecked, it has the potential to evolve into other potentially debilitating social anxiety and mood disorders.

The disorder affects about 0.1% of children overall and 1% of children seen in mental health centers, and is as common as cystic fibrosis, according to the American Academy of Pediatrics. Yet it is often dismissed as shyness or immaturity.

Part of the problem is that selective mutism begins to manifest just after the very normal phase of separation anxiety. “Who hasn't dealt with the 3-year-old who hides her face in Mom's clothes? We are not surprised to see this behavior in children younger than 4 years of age,” added Dr. Howard, codirector of the university's Center for Promotion of Child Development Through Primary Care. “Complicating the picture is the fact that the parents may not readily share with you the fact that 4-year-old Alex never speaks in public, even though he blabs up a storm at home.”

Anxiety disorders, particularly social anxiety, tend to be familial. Parents may empathize with—even unwittingly reinforce—a child's reluctance to interact socially outside of his immediate family by stepping in too soon or making excuses for him. Although selective mutism is thought to be to the result of a biologically determined temperament and a predisposition to anxiety, it can be promoted by parental reactions.

“Unless you ask directly about his verbalization patterns, you may never know,” Dr. Howard said. She advised that the 4-year-old visit is a good time to consider the possibility of selective mutism and other anxiety problems because that's about the time the development of social relationships becomes one of a child's main goals.

Start out by specifically engaging in a conversation with the child, she said. “One of my favorite icebreakers is to ask a child to draw a picture of a boy and a girl and then suggest, 'Tell me a make-believe story about this boy.' The average 4-year-old will launch into a story, allowing you to obtain a drawing sample, a language sample, an example of some projective material, and a sense of the child's social interactions.”

If a parent jumps in while the child remains silent, ask very directly if the child is used to speaking with people outside the family, and if so, with whom and under what circumstances. If the child speaks normally with the family and close relatives, but never with peers or adults in social situations, consider selective mutism in the differential diagnosis. Then one should ask the family for details on the child's previous attempts at peer communication, for example, does the child stutter in public and therefore keep quiet?

One should also consider what role the parents are playing in this problem. “Occasionally, I see what seems to be selective mutism in a highly pressured child who will not perform by fulfilling parents' requests to recite the state capitals or the Gettysburg Address. These children usually talk just fine when their parents are not asking them to speak. Removing pressure won't get a child with selective mutism to talk in public.”

Rule out—or diagnose as a comorbid condition—separation anxiety disorder (as opposed to normal developmental separation anxiety) and the inhibited form of reactive attachment disorder.

Selective mutism is more likely if the child consistently fails to speak in a variety of social settings; if this silence is interfering with normal functioning; if the symptoms have lasted for at least 1 month (but not the first month of school); and if it is not related to having a primary language other than English.

Some children with selective mutism can be helped within the primary care practice using the same approach as for anxiety. One of the keystones is to make unfamiliar situations as familiar as possible, another is to work with parents on ways to assess and hide their own anxiety about their child's condition.

The quietest children are often the ones who make office hours run smoothly. They're in and out during well-child visits, letting Mom or Dad field the questions. When the clock is ticking and the exam rooms are full, physicians rarely try to draw them into a chat. So it's easy to miss those with selective mutism.

Dr. Barbara J. Howard, of the department of pediatrics at Johns Hopkins University, Baltimore, says that selective mutism is treatable and that without treatment, it can lead to significant social and educational impairment. It is part of the spectrum of anxiety disorders and, unchecked, it has the potential to evolve into other potentially debilitating social anxiety and mood disorders.

The disorder affects about 0.1% of children overall and 1% of children seen in mental health centers, and is as common as cystic fibrosis, according to the American Academy of Pediatrics. Yet it is often dismissed as shyness or immaturity.

Part of the problem is that selective mutism begins to manifest just after the very normal phase of separation anxiety. “Who hasn't dealt with the 3-year-old who hides her face in Mom's clothes? We are not surprised to see this behavior in children younger than 4 years of age,” added Dr. Howard, codirector of the university's Center for Promotion of Child Development Through Primary Care. “Complicating the picture is the fact that the parents may not readily share with you the fact that 4-year-old Alex never speaks in public, even though he blabs up a storm at home.”

Anxiety disorders, particularly social anxiety, tend to be familial. Parents may empathize with—even unwittingly reinforce—a child's reluctance to interact socially outside of his immediate family by stepping in too soon or making excuses for him. Although selective mutism is thought to be to the result of a biologically determined temperament and a predisposition to anxiety, it can be promoted by parental reactions.

“Unless you ask directly about his verbalization patterns, you may never know,” Dr. Howard said. She advised that the 4-year-old visit is a good time to consider the possibility of selective mutism and other anxiety problems because that's about the time the development of social relationships becomes one of a child's main goals.

Start out by specifically engaging in a conversation with the child, she said. “One of my favorite icebreakers is to ask a child to draw a picture of a boy and a girl and then suggest, 'Tell me a make-believe story about this boy.' The average 4-year-old will launch into a story, allowing you to obtain a drawing sample, a language sample, an example of some projective material, and a sense of the child's social interactions.”

If a parent jumps in while the child remains silent, ask very directly if the child is used to speaking with people outside the family, and if so, with whom and under what circumstances. If the child speaks normally with the family and close relatives, but never with peers or adults in social situations, consider selective mutism in the differential diagnosis. Then one should ask the family for details on the child's previous attempts at peer communication, for example, does the child stutter in public and therefore keep quiet?

One should also consider what role the parents are playing in this problem. “Occasionally, I see what seems to be selective mutism in a highly pressured child who will not perform by fulfilling parents' requests to recite the state capitals or the Gettysburg Address. These children usually talk just fine when their parents are not asking them to speak. Removing pressure won't get a child with selective mutism to talk in public.”

Rule out—or diagnose as a comorbid condition—separation anxiety disorder (as opposed to normal developmental separation anxiety) and the inhibited form of reactive attachment disorder.

Selective mutism is more likely if the child consistently fails to speak in a variety of social settings; if this silence is interfering with normal functioning; if the symptoms have lasted for at least 1 month (but not the first month of school); and if it is not related to having a primary language other than English.

Some children with selective mutism can be helped within the primary care practice using the same approach as for anxiety. One of the keystones is to make unfamiliar situations as familiar as possible, another is to work with parents on ways to assess and hide their own anxiety about their child's condition.