Selective Mutism

What Causes Selective Mutism?

Scientists don’t yet fully understand what causes selective mutism. An individual’s risk for developing SM or other anxiety disorders is probably due to a complex interaction of genetic and environmental factors.

Risk factors for SM include:

• Exposure to traumatic or stressful situations involving separation (loss of a loved one, severe illness of a loved one, loss of a pet, divorce, moving, changing schools)
• Extreme shyness or inhibition in childhood
• Family history of anxiety or other mental health-related issues
• Pre-existing anxiety disorders or other mental health-related issues
• Speech or language difficulties (e.g., a stutter)
• Low self-esteem
• Neurological problems with sound processing

Is Selective Mutism Hereditary?

People with a family history of anxiety or associated mental disorders have a higher risk of developing SM and other anxiety disorders themselves, suggesting an inherited component to anxiety. However, scientists have not identified a specific gene definitively associated with selective mutism or other anxiety disorders. Instead, anxiety is likely the result of a coincidence of multiple genetic and environmental factors.

How Is Selective Mutism Detected?

Early detection and treatment of SM can lessen the severity of symptoms and increase the likelihood of successfully controlling the disorder. However, when it occurs in preschool-aged children, it may go unnoticed until the child begins school and has trouble communicating.

Other behaviors may be associated with selective mutism, and they may serve as warning signs of the development of the disorder. These behaviors can include:

• Extreme shyness
• Social awkwardness
• Clinginess
• Nervousness or anxiety
• Sullenness or social withdrawal
• Temper tantrums associated with school or other social situations

How Is Selective Mutism Diagnosed?

Diagnosis of SM begins with determining that the patient has a cluster of symptoms that meet the diagnostic criteria for the disorder. A doctor will start with a physical exam to rule out medical problems that may be causing the symptoms. After these exams, if the doctor suspects that SM or another anxiety disorder is the cause of the symptoms, they may recommend a psychological or psychiatric assessment to solidify the diagnosis.

Diagnostic steps may include:

• A physical exam. This exam will be aimed at ruling out physical conditions that could be causing the symptoms.
• Assessment by a speech-language pathologist. This assessment will attempt to understand the person’s ability to speak and understand language.
• Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.

The results of the psychological assessments will be compared to the diagnostic criteria for selective mutism in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM criteria for SM include:

• Consistent inability to speak in specific social situations where speaking is expected.
• The symptoms cause impairment in school, social, or work situations.
• The symptoms have lasted at least a month (not including the first month of school).
• The problem is not related to a lack of fluency in or comfort with the language being spoken in the situation.
• The symptoms are not better explained by another mental health or communication disorder.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Selective Mutism Treated?

Psychotherapy is often the most effective approach to controlling selective mutism. The most common therapeutic approach is cognitive-behavioral therapy (CBT). This process focuses on helping the patient identify a pattern of harmful thoughts and construct strategies and solutions for dealing with them.

Other therapeutic approaches that may be used to treat SM include:

• Behavioral therapy

• Speech therapy

• Family therapy

• Stimulus fading, in which the person begins in a comfortable setting with a person they can easily communicate with, and other people are gradually added to the situation.
• Shaping, in which the person is encouraged to use other forms of communication (e.g., reading, whispering, gesturing, playing verbal games) with the goal of eventually being able to speak

Medications are not usually used to treat selective mutism, but antidepressants may be used to treat co-occurring symptoms in older children or adults.

How Does Selective Mutism Progress?

SM usually responds well to treatment. However, untreated selective mutism can lead to potentially severe complications, including:

• Depression
• Relationship problems
• Problems at school or work
• Other anxiety disorders

How Is Selective Mutism Prevented?

There is no known way to prevent selective mutism. However, children who observe their parent’s anxiety are more likely to develop an anxiety disorder themselves. Because of this, parents with anxiety disorders should get treatment from a mental health professional to reduce the likelihood that their children will develop the condition.

Some strategies may also help parents control or prevent episodes of their child’s anxiety:

• Seek help from a mental health professional as soon as possible.
• Adhere to the treatment plan prescribed.
• Help your child plan for situations that cause anxiety.
• Encourage your child to be as independent as appropriate for their age.

Selective Mutism Caregiver Tips

Selective mutism often exists alongside other mental health and brain-related conditions, a condition called co-morbidity. Here are a few of the disorders commonly associated with SM:

• Depression and anxiety are among the most common comorbid mental disorders.
• People with SM may have other anxiety disorders as well.
• Obsessive-compulsive disorder (OCD) and SM may be associated with one another.
• SM is sometimes an effect of post-traumatic stress disorder (PTSD).

Selective Mutism Brain Science

Scientists believe that anxiety symptoms come from activity in the parts of the brain that control emotions and our reactions to them. These parts of the brain are called the limbic system. The limbic system is associated with anxiety in several ways:

• The amygdala, the part of the brain responsible for detecting threats, may be hyperactive and may misidentify causes for fear or worry when none exist.
• An overactive amygdala may persistently cause the hypothalamus to trigger the hormonal response that produces the physical symptoms of anxiety.
• Communication between the amygdala and the prefrontal cortex (PFC) may be impaired. The PFC is responsible for triggering a rational response to threats, and it may not be able to do so when it is unable to communicate with the amygdala effectively.
• The hippocampus, the part of the brain responsible for processing long-term memory, may be underdeveloped or dysfunctional in the case of anxiety. As a result, it may have a preference for retaining stress-related memories rather than more rational memories.

Selective Mutism Research

Title: Brain Response Associated With Parent-based Treatment for Childhood Anxiety Disorders

Stage: Recruiting

Contact: Eli R. Lebowitz, PhD

Yale University Child Study Center

New Haven, CT 

This study investigates whether a parent-based treatment for childhood anxiety disorders engages child brain circuitry implicated in children’s reliance on parents to reduce anxiety (R61) and whether a change in child brain circuitry is associated with a reduction in child anxiety (R33).

Anxiety disorders impact up to one-third of children, cause tremendous suffering, increase the risk for psychiatric and medical morbidity, impair school and social functioning, and cost billions of dollars each year. Data consistently show that child anxiety is characterized by amygdala hyperactivity and deficits in prefrontal control of the amygdala. Emerging data link these disruptions to anxious children’s over-reliance on parents for amygdala-medial prefrontal cortex (mPFC) engagement and anxiety reduction.

In the first phase of this study, researchers aim to demonstrate that an entirely parent-based psychosocial treatment with no child involvement, Supportive Parenting for Anxious Childhood Emotions (SPACE), engages an amygdala-mPFC target in anxious children, lessening child reliance on parents to reduce amygdala reactivity.

Cross-species neurobiological evidence indicates that parental presence reduces amygdala reactivity and activates the mPFC to reduce offspring anxiety. In humans, we recently demonstrated that parental presence increases functional connectivity between their child’s mPFC and amygdala, reducing their amygdala reactivity and anxiety. In a healthy sample, parental engagement of child amygdala-mPFC connectivity was linked to the child’s reliance on parents for help with anxiety. Data from clinically anxious children likewise show parental presence engages child mPFC. Data collected since the previous submission demonstrate that parental presence reduces amygdala reactivity in clinically anxious children.

Title: Improving Access to Child Anxiety Treatment (IMPACT)

Stage: Recruiting

Principal investigator: Jennifer Freeman, PhD

Bradley Hospital

Riverside, RI 

There is strong evidence that cognitive-behavioral therapy (CBT) with exposure is the preferred treatment for youth with anxiety disorders, but outpatient services that provide this type of treatment are limited. Even for those who have access to anxiety-specific treatment, a traditional outpatient treatment delivery model may not be suitable. Among the numerous logistical barriers to treatment access and response is the inability to generalize treatment tools to settings outside of the office. Patient-centered (home-based or telehealth; patient-centered telehealth closed as of 5/1/21) treatment models that target symptoms in the context in which they occur could be more effective, efficient, and accessible for families. The present study compares the efficacy, efficiency, and feasibility of patient-centered home-based CBT and patient-centered telehealth CBT with a traditional office-based model of care. The proposed question, including proposed outcomes, has been generated and developed by a group of hospital, payer, patient, and family stakeholders who will also contribute to the iterative protocol revision process. The investigators anticipate 379 anxious youth to be randomized to receive outpatient treatment using telehealth (patient-centered telehealth closed as of 5/1/21), home-based services, or treatment, as usual, using a traditional outpatient model. Results of this study are expected to provide evidence for the efficacy and efficiency of patient-centered treatment, as well as increase treatment access and family engagement in the treatment process.

Title: Threat Interpretation Bias as Cognitive Marker and Treatment Target in Pediatric Anxiety

Stage: Recruiting

Principal investigator: Michelle S. Rozenman, PhD

University of Denver

Denver, CO

Anxiety is the most common mental health problem in children and adolescents. This two-phased study will test the effects of an experimental computerized intervention to reduce threat-based thinking (i.e., interpretation bias) in anxious youth. Participants in both the R61 (N=46) and R33 (N=72) trials will be youth ages 10 to 17 with a primary anxiety disorder (Separation, Social, Generalized). In the R61 trial, youth will be randomly assigned to receive 16 sessions over four weeks of either a personalized cognitive bias modification program for interpretation bias (CBM-I) or a computerized control condition (ICC). If CBM-I reduces interpretation bias significantly more than the ICC, the R33 trial will commence. In the R33, youth will be randomly assigned to either CBM-I or an equal amount of time in a cognitive restructuring intervention, which also aims to reduce threat-based thinking in anxiety.