The selective mutism is a childhood anxiety disorder characterized by the inability of a child to speak and communicate effectively in specific social settings, such as school. These children are able to speak and communicate in environments where they feel comfortable, safe and relaxed..
More than 90% of children with selective mutism also have social phobia or social anxiety, a very debilitating and painful disorder for the child. Children and adolescents with this disorder have a real fear of speaking and social interactions where there is an expectation of speaking and communicating.
Not all children express their anxiety in the same way. Some may be completely mute in a social setting, others may be able to speak to a few people or perhaps whisper.
They can be frozen, expressionless, emotionless, and socially isolated. Less severely affected children may appear relaxed and carefree, and are able to socialize with one or a few children, but are unable to speak and communicate effectively with teachers or most peers.
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Language skills are mostly preserved, and it does not present as a consequence of a communication disorder (eg, pervasive developmental disorders or stuttering). Also, it does not appear exclusively during the course of a mental disorder, such as schizophrenia or another psychotic disorder..
The essential characteristic of selective mutism is the persistent inhibition of speech in specific social situations, generally presenting itself in the first years of life and very often becoming evident once the child reaches the age when he / she begins to interact socially outside. the family environment, such as during the first stage of childhood schooling.
The child faces a high level of personal suffering and important problems of adaptation to the environment that can influence their personal, social and academic development.
Most of the child population with this disorder have a genetic predisposition to anxiety. This means that they have inherited a tendency to anxiety from various family members and are therefore vulnerable to developing disorders of this type..
Frequently, this behavior is shown before the difficulty to separate from their parents, or due to a very dependent behavior, extreme shyness, inflexibility, sleep problems, bad mood, frequent tantrums and crying.
The persistent fear of communicating begins to manifest itself through symptoms such as lack of expression in the countenance, being paralyzed, lack of reactions, maintaining a rigid posture, little smile and, of course, silence..
By avoiding the use of oral language, the child can develop other forms of alternative communication, using gestures or head movements, whispering in the ear, pushing or pointing to ask for something. If they are older, they usually communicate through written language.
Studies have shown that part of the child population is born with an inhibited temperament. This is manifested even in newborns, and parents notice that their children are more likely to be suspicious and fearful in new situations or environments..
The symptoms are as follows:
More self-confident children with selective mutism may use gestures to communicate - for example, they may nod their heads to say "yes" or shake their heads to say "no.".
However, the most affected children tend to avoid any form of spoken, written or gestural communication..
Some children may respond with a word or two, or they may speak in an altered voice, such as a whisper..
Most children with selective mutism have a genetic predisposition to anxiety. In other words, they have inherited a tendency to be anxious about one or more family members..
These children often show signs of severe anxiety, such as separation anxiety, frequent tantrums and crying, bad moods, inflexibility, sleep problems, and extreme shyness from infancy..
Research has shown that these temperamentally inhibited children have a lower excitability threshold in an area of the brain called the amygdala.
The amygdala receives and processes the signals of a potential danger, setting in motion a series of reactions that help the individual to protect themselves. It has been shown that, in anxious people, the amygdala seems to overreact and trigger anxiety responses, although the individual is not really in danger.
In selective mutism, responses to anxiety are triggered by social activity in school, play places, or social gatherings. Although there is no logical reason for fear, the sensations that the child experiences are as real as those experienced by a person with a phobia.
A child with this disorder becomes mute because he is unable to overcome the feeling of fear he experiences when others wait for him to communicate orally..
Some children with selective mutism have sensory processing issues, which means they have trouble processing specific sensory information. They can be sensitive to sounds, lights, touch, taste, and smells.
Some children have difficulty modulating sensory information that can affect their emotional responses.
This difficulty can cause a child to misinterpret environmental and social cues, which can lead to inflexibility, frustration, and anxiety. Experienced anxiety can cause a child to avoid a situation or display negative behaviors.
Some children (20-30%) with selective mutism have subtle speech and / or language disturbances such as receptive and / or expressive language abnormalities and language delays. Others may have learning difficulties, including auditory processing disorder.
Research at the Selective Mutism Anxiety Treatment and Research Center (SMart Center) indicates that there is a proportion of children with selective mutism who come from bilingual / multilingual families, have spent time in a foreign country, and / or have been exposed to another idiom.
These children are often inhibited by nature, but the added stress of speaking another language and being insecure with their skills is enough to cause increased levels of anxiety and mutism..
Not all children with selective mutism isolate themselves or avoid social situations. Many of these children do what they can to get the attention of others and use non-verbal language to communicate.
The reasons for the mutism in these children are unproven, but preliminary research from the SMart Center indicates that these children may have other reasons for the mutism. For example, years of life without speaking have ingrained mute behavior despite its lack of symptoms of social anxiety or other developmental / speech problems. These kids are literally stuck in the non-verbal stage of communication.
Studies have shown no evidence that the cause of selective mutism is related to abuse, neglect, or trauma..
Children with selective mutism speak in at least one setting and are rarely silent in all settings. For children with selective mutism, their mutism is a means of avoiding feelings of distress caused by expectations and social encounters.
Children with traumatic mutism usually develop mutism in all situations. An example would be a child who witnesses a grandparent's death or other traumatic event, is unable to process the event, and becomes mute in all settings..
With proper treatment, most children are able to overcome selective mutism. The later the condition is diagnosed, the longer it will take to overcome it. The effectiveness of the treatment will depend on:
Treatment does not focus on speech itself, but on reducing the anxiety associated with speaking. To begin, it is about removing the pressure on the child to speak. Progress is made by encouraging the child to relax in their school, nursery or social environment.
For example, trying to get the child to speak individual words and phrases to one person, before finally being able to speak freely to all people in all settings. It is therefore important go step by step. Some important points to keep in mind at the beginning of treatment are:
The most effective types of treatment are behavioral therapy and cognitive behavioral therapy (CBT)..
Behavioral therapy is designed to work on and reinforce desired behaviors, replacing bad habits with good ones..
Rather than examining the child's past or thoughts, this therapy focuses on helping the child cope with difficulties through a gradual approach step by step to conquer your fears.
The techniques discussed below can be used by family members and school staff, preferably under the supervision of a specialist..
In the fading of the stimulus, the person with selective mutism communicates comfortably with someone they trust, such as their father, when no one else is present.
Another person is brought into the situation and the father withdraws. The new person can introduce more people in the same way.
Positive and negative reinforcement involves responding favorably to all forms of communication and not encouraging avoidance and silence..
If the child is under pressure to speak, they will experience great relief when the moment passes, strengthening their belief that speaking is a negative experience..
Therefore, do not pressure the child to speak. It is necessary to reinforce with positive stimuli ("very good", a smile ...) from comfortable situations (like a game) and gradually increase the complexity.
For example, at first it is about the child saying "yes" or other simple words. Then they try to get him to say phrases, then games in which he has to show initiative ...
The child communicates indirectly with a person who is afraid to speak through means such as email, instant messaging (text, audio and / or video), online chat, voice or video recordings ...
This can make the child feel more comfortable and communicate personally later.
A child is taken to the classroom or to the environment where he does not speak and is videotaped. First, the teacher or another adult asks you questions that will probably not be answered. A parent or someone with whom the child feels comfortable talking, replaces the questioner and asks the child the same questions, this time getting a verbal response.
The two videos of the conversations are edited below to show the child responding directly to questions posed by the teacher or another adult. This video is shown to the child for several weeks, and each time the child sees himself / herself responding verbally to the teacher / other adult, the tape is stopped and the child is given positive reinforcement..
These videos can also be shown to classmates of affected children to set an expectation in their classmates that they can speak..
In graded exposure, the situations that cause the least anxiety are addressed first. With realistic goals and repeated exposure, the anxiety associated with these situations decreases to a controllable level..
Cognitive behavioral therapy (CBT) works by helping a person focus on how they think about themselves, the world, and other people, and how their perception of these things affects their emotions and feelings..
CBT is performed by mental health professionals and is most appropriate for older children, adolescents - particularly those with social anxiety disorder - and adults who have grown up with selective mutism..
Younger children can also benefit from CBT-based approaches designed to support their overall well-being.
The medication is only appropriate for older children, adolescents and adults whose anxiety has led to depression and other problems.
Medication should never be prescribed as an alternative to the environmental changes and behavioral approaches described above..
However, antidepressants or anxiolytics can be used in conjunction with a treatment program to lower anxiety levels and speed up the process, especially if previous attempts to involve the individual in treatment have failed..
Parents' participation from home is crucial, adopting measures that facilitate the child's socio-personal development and stimulate their expressive capacity in different situations of verbal interaction with others:
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