Five-year-old Zoe is a chatterbox around her parents and her mom's parents, but she won't talk to her dad's parents. She talks to a few of her cousins but not the rest. In preschool, she never speaks out loud. She occasionally whispers to her best friends but only if no one else is looking. On the day of her kindergarten-readiness test, she didn't talk to the tester.
Zoe has selective mutism (SM), an anxiety disorder characterized by the ability to talk comfortably in a given situation (such as at home) almost all the time -- and the inability to talk in others (such as at school or in public) at all. One in 140 kids ages 4 to 7 in the United States has SM, says Steven Kurtz, Ph.D., director of the Selective Mutism Program and senior director of the ADHD and Disruptive Behavior Disorders Center at the Child Mind Institute in New York City. More than 50 percent of kids with SM also have another anxiety disorder -- most typically social phobia but sometimes separation anxiety and other phobias. Twice as many girls are affected as boys.
Because kids with SM often talk just fine at home, parents may not realize there's a problem for years. "The problem usually starts when the child is 2 to 3 years old, but the age of seeking help is between 5 and 6," says Dr. Kurtz. "The lag time is a real problem -- the condition is there, and it gets worse." A child who originally started out not talking in preschool, for example, may wind up not talking at softball practice, day camp, and Grandma's house. This causes a significant disruption to the child's life: It may affect her achievement in school and her social relationships with both children and adults.
Because kids with SM usually don't talk at school, it's often a teacher who brings the problem to the parents' attention. "The teacher will say she's worried because although the child seems to be happy, she's not talking to friends or to her," explains Dr. Kurtz. Instead, in order to communicate, the child points, nods, and gestures only.
SM should not be confused with a speech delay or language-processing problem -- kids with SM can be developmentally on target with their language skills. It should also not be confused with what commonly happens at the beginning of the school year with some students, especially those for whom English is a second language: "They will often have a silent period for the first month or so, but then they bounce back. Most do not develop SM," says Dr. Kurtz.
There is a strong genetic component to SM, with about 75 percent of kids having at least one parent with an anxiety disorder. The child who feels anxious in new, unexpected, or unwanted situations may feel unable to speak. An adult may rush in to "rescue" her -- by, in effect, speaking for her. That person likely just wants to make the situation easier for the child, but when the child doesn't talk, she feels short-term relief from her anxiety, and the behavior is reinforced. "It becomes a habit incredibly quickly," says Dr. Kurtz.
By the time this happens, kids don't see themselves as having the option to talk, he says. "They don't look scared, so people think this is something they're choosing to do. But they're not being willfully defiant. They're holding back because they literally can't get the words out."
Depending on the severity, SM is typically treated with behavioral therapy (a form of CBT), medication, or both. "For young kids who are going to school and enjoying it, we would start them on behavior therapy alone. For older kids who are having trouble going to school and have a strong family history and have tried therapy alone without success, we may start them on medication along with behavioral intervention," says Dr. Kurtz. When medication is used, it's typically a selective serotonin reuptake inhibitor (SSRIs), such as Prozac. The important thing is not to underdose, and to always aim to get rid of the SM, not just slightly improve it.
During behavioral treatment, the child and parent play games together that reinforce the child's ability to do what Dr. Kurtz calls "brave talking." If they're playing with Legos, for example, the parent will be taught to avoid yes or no questions, which don't foster any real conversation. "Yes/no questions are the hardest habit for everybody to change," says Dr. Kurtz. So instead of asking a child, "Do you want to play with the Legos next?" the parent will be encouraged to ask, "Do you want to play with the Legos or the blocks next?" (a forced-choice question) or "What do you want to play with next?" (an open-ended question). Just as important, the parent will also be encouraged to wait five seconds after asking the question before saying anything else, giving the child a real chance to respond. "After about five seconds, the child realizes she's not going to be rescued and she'll step up," says Dr. Kurtz.
The parent will also be taught to use "labeled praise" when the child engages in brave talking. Instead of saying "Good job," for example, the parent will say, "I love how you told me what you wanted to play with next." "This lets kids know they were heard and praises them for their specific behavior," says Dr. Kurtz, who has parents reflect and praise roughly 80 percent of everything the child says. "Eighty percent of the time, we want them reflecting and praising." His other guidelines: Do wait the five seconds. Do not mind read. Don't criticize a child for not responding.
Once the child is comfortable doing this with a parent in the therapist's office, the child will begin doing the same with a therapist alone by gradually fading the parent out of the room. After that, the therapist goes with the child to school and does the same there. Teachers and counselors at school are also trained in the therapy, and eventually the child reaches a point when she can speak on her own in the classroom. If the child has trouble speaking in other settings, such as at sports practice or a relative's home, the same strategies are used there.
Some children take longer than others to move through the treatment -- it might take some several months and others a few years. But at the end of the treatment, says Dr. Kurtz, "parents can expect their children to be answering in class, having playdates, talking to all their relatives, and ordering their own ice cream." And the treatment usually sticks, he says: "Once kids start talking, they almost never look back."
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