Many children with Selective Mutism do also have a diagnosis of Autism. One study showed that 7% of children with selective mutism also had Asperger’s disorder (now called Autism), however another study using a sample of children treated at a hospital outpatient clinic showed a massive 63% of children with Selective Mutism had Autism (these were obviously a more severe sample, but a very high comorbidity). However we also see cases where selective mutism has been misdiagnosed as autism.
One telling indicator of whether a child has selective mutism or autism is the difference between communication at home and at school and other social situations. A child with Autism would show impairments in social/emotional communication (amongst other factors) across all settings, whereas in Selective Mutism, the impairments in communication are only seen in situations where the child is anxious, such as school or even home when there are visitors.
At the start of treatment we conduct a comprehensive assessment of the child’s current and past communication and developmental and family history to help determine whether there is a diagnosis of Selective Mutism alone, or a possible additional diagnosis of Autism. When we do suspect the child might have both diagnoses we generally treat the Selective Mutism first before we recommend testing for Autism.
Engaging a child of this age can be very difficult and will take a lot of time. Two basic things that would help are to find an interest or hobby to do together that will help them to relax. The second strategy would be not to ask any questions at all, to chat a lot, be very friendly, and use humour and silliness to engage them. Don’t expect a response right away; you will need to be patient and persistent.
I would also be encouraging the family to seek treatment from a clinical psychologist to work on their anxiety and communication.
We consider children who whisper in social situations instead of talking to be a form of selective mutism. The child often fears that their voice sounds strange or different in some way to other children, and so whispering is used as a strategy to mask their true voice. We would generally use similar strategies with these children as those who are mute.
Yes, the program at the clinic is tailored to your individual situation. We may find that the teacher and school do not need any input from us, so our strategies will be focused on those other social situations where your child finds it difficult to communicate.
In those situations where children with selective mutism don’t seem to have a problem at school, there are sometimes still subtle difficulties with communicating – such as asking for help, contributing to class discussions, telling the teacher when there is conflict with a peer, and so on. These children may answer teachers when spoken to, but say very little spontaneously. They may also answer with limited words instead of full sentences. Our assessment will look at all of these aspects of communication and assist the teacher where necessary to help build your child’s communication to the level of their peers.
Yes, the clinic provides treatment for adults with selective mutism. Selective mutism is treated using similar principles as other anxiety disorders such as phobias and Social Anxiety Disorder. A large part of treatment will involves learning to understand feelings and sit with feelings, with strategies such as ‘mindfulness’. Another large component is ‘Graded exposure’. This could mean starting with entering social situations rather than avoid them, then practising nonverbal communications such as nodding or writing notes, and finally working your way up to recording your voice on recording devices and playing back to others, using someone as a verbal intermediary and finally talking directly to a person.
We understand that as an adult with selective mutism it can be very hard to reach out to get treatment, and we will work out ways initially that you can communicate with us. This could be via writing, or talking to a friend or parent when we are not in the room, or responding nonverbally to our questions. We do not ask or expect you to communicate in a way that is too uncomfortable or difficult for you.
Treatment for adults generally takes longer than it does for young children (2 or more years, compared to 6-18months for children), but it is possible to get to a stage where you can eventually talk to people in social situations.
The Selective Mutism clinic also holds seminars about selective mutism. These seminars are run by the director of the Selective Mutism Clinic, Dr Elizabeth Woodcock, and explain key information such as what selective mutism is, why it occurs and treatment strategies.
For more details about our seminars and to register, please click here.
You can also purchase a DVD copy of our seminars here.
Some (but not all) cases of selective mutism can resolve spontaneously and these children will eventually start talking in those situations where they had been mute. If this does happen, it is usually in preschool or in the first year of school. Once children with selective mutism enter their second year of school, the mutism becomes more entrenched. In fact, many of the older children we see with selective mutism have had a period in the past of ‘wait and see’ where people have waited to see if the child has ‘grown out of the condition’.
It is difficult to distinguish those cases that may resolve spontaneously from those that won’t, although an important factor appears to be how well the child’s parents and teachers intuitively help the child to gradually face their fear of communicating, without placing too much pressure on them to do so. If the child’s condition is not talked about and there are little opportunities for them to socialise and communicate with peers and adults, then there is a greater chance that the mutism will persist.
Even when selective mutism does resolve without intervention, these children tend to remain socially anxious and may also develop other anxieties or emotion regulation difficulties. They will generally find it difficult to talk in front of groups, ask for help, contribute to discussions, and be assertive. This could affect their academic performance at school and the development of important social skills. Treatment is therefore beneficial for all cases of selective mutism or extreme shyness as it can help your child learn about their anxiety and be comfortable communicating in all situations.
A face-to-face assessment can be beneficial because it allows the psychologist to meet you and observe your child’s level of anxiety. The psychologist can also demonstrate how to conduct one of the main treatment strategies, ‘Sliding In’, to you in that session. However, we recognise that the cost of airfares and accommodation for a family can be expensive, and our program is just as successful for those families who do not have a face-to-face assessment. For families in our Outreach program, we have many handouts and a video to show how to do one of the main strategies called ‘Sliding In’ and we find that this is sufficient to train the parent and the classroom teacher in how to use this strategy.
For remote families, during the phone or Skype sessions with the parent (the child is not included), we teach the parent strategies to teach their child about anxiety and how to help the child work on building their communication at home and at school. The ‘school program’ is pretty much exactly the same as for clients in Sydney, as we provide all of our support to schools via regular phone consultations with the classroom teacher and other relevant school personnel. We have a phone consultation with the classroom teacher every 4 weeks and teach the classroom teacher (through discussion, handouts, and videos) how to do ‘Sliding In’ with the child and parent at school, and also how to build the child’s communication in the classroom.
There are a number of options for support and help for teachers:
1) For families who are receiving treatment at the clinic, we provide ongoing consultations to the classroom teacher (usually one every 4 weeks) to help them to implement an intensive program to address the child’s selective mutism. These consultations are generally paid for by the family.
2) From time to time we run evening seminars for teachers and parents. Details about our upcoming seminars are here.
3) Where families are not linked in with treatment yet, teachers/schools are able to access phone consultations with one of our experienced clinical psychologists to discuss the child and our recommendations for school treatment. The cost of these are the same as our usual session cost plus GST. For details of our fees click here.
4) We have DVDs of previous seminars available to purchase through our website here or by calling our office on 0405 430 530. The most relevant DVD for teachers is of a 3-hour seminar called ‘Treatment of selective mutism in schools and preschools’. There is an equivalent DVD about treatment for selective mutism in high schools.
A standard 50-minute therapy appointment is $230 and the initial assessment (1 hour) is $260. It is recommended that rural and interstate families who are travelling to Sydney for an assessment have a three-hour assessment and session ($690). Fees can be paid by EFTPOS, cash, or credit card (no AMEX) at the end of the appointment.
Rebates for psychological services are available from several sources including:
Under the Medicare ‘Better access to mental health‘ scheme you can obtain a rebate for part of the session cost for up to 10 therapy sessions in each calendar year. To be eligible to receive the rebate you must visit your GP, Psychiatrist, or Paediatrician and obtain a referral for psychological services as part of your overall treatment plan. If you have reached your Medicare family ‘safety net’ threshold for the calendar year, the rebate will be almost all of the session cost. Click here to read more about the Medicare safety net.
During the COVID-19 outbreak Medicare rebates are available for telehealth sessions for children with an eligible mental health care plan from their GP. Rebates are not currently available for consultations that do not involve the child such as the the initial assessment with the parent(s) alone. However, you may be able to claim a rebate for these services through your private health insurance. Medicare has also recently introduced rebates for children who live in very remote areas (further details can be found here).
Private Health Funds
Most private health funds provide rebates for psychological services depending upon your level of cover. Please contact your health fund to find out more.
Extreme shyness and selective mutism can be thought of as being on a continuum with selective mutism being a more severe condition. Shy children are generally able to respond when they are asked questions, even though it may be quietly and with very few words. Children with selective mutism have specific situations or people (particularly at school) where they are not able to respond verbally at all.
Some (but not all) cases of selective mutism can resolve spontaneously and these children will eventually start talking in those situations where they had been mute. If this does happen, it is usually in preschool or in the first year of school. It is difficult to distinguish those cases that may resolve spontaneously from those that won’t, although an important factor appears to be how well the child’s parents and teachers intuitively help the child to gradually face their fear of communicating, without placing too much pressure on them to do so. If the child’s condition is not talked about and there are little opportunities for them to socialise and communicate with peers and adults, then there is a greater chance that the mutism will persist.
Even when selective mutism does resolve without intervention, these children tend to remain socially anxious and may also develop other anxieties or emotion regulation difficulties. They will generally find it difficult to talk in front of groups, ask for help, contribute to discussions, and be assertive. Treatment is therefore beneficial for all cases of selective mutism as it can help your child learn about their anxiety and be comfortable communicating in all situations. Once children with selective mutism enter their second year of school the mutism becomes more entrenched. Therefore, the older the child, the less likely the mutism will resolve without treatment.
Children with selective mutism can often look stubborn, particularly when you know that they can talk without any difficulty in some situations. They may not become anxious unless they are asked to talk, so they often look very relaxed and can smile, laugh, sometimes make other noises, and join in activities just like other children. Despite this appearance, and the fact that many children with selective mutism are strong-willed, these children do want to talk, but don’t because they are too afraid to do so. When adults interpret a child’s selective mutism as defiance, they are more likely to place consequences on the child for not talking, show frustration, or pressure the child to talk. However, such approaches will worsen the mutism. By understanding that the child is extremely anxious about talking, adults are more likely to help the child face this fear in a gradual way and the child is more likely to be better able to attempt tasks.
Anxious children will typically avoid anything that makes them feel anxious – including acknowledging or discussing their anxiety or difficulties talking. This is not a reason to avoid talking about it, as their anxiety is likely to worsen over time. Children need support to learn to understand and talk about their anxiety and other feelings in order to manage them. Although this may be difficult for them and you, wIth time and support from the psychologist, your child’s distress will gradually lessen and they will find it helpful to talk about their worries. During the first session which only the parents attend, the psychologist can talk with you about how to best explain treatment to your child, and why they will be attending.
The Selective Mutism Clinic uses Cognitive Behavioural Therapy (CBT) because research and our experience has shown this is the most effective treatment for selective mutism. CBT addresses children’s avoidance of talking by helping them to gradually confront and practise increasingly more difficult forms of non-verbal and verbal communication. This is done at a pace that the child can cope with. Children with selective mutism also have particular anxious beliefs about how other people might respond or think about them if they heard them speak (e.g., ‘they might tell everyone that I talked’, ‘they might think my voice sounds funny’). CBT helps them to start to think in a more helpful and rational way about talking.
The program requires parents and teachers to be committed to implementing strategies both within and outside of school, both of which are extremely important. Parents will be given skills to help their child gradually increase their communication with extended family, friends, in public places and in other settings. The Clinic implements an intensive school or preschool program and provides the classroom teacher and other relevant school personnel with regular phone consultations to support them to implement this program (i.e., a phone consultation every 4 weeks). Your family will be seen by one of our Clinical Psychologists who are all registered psychologists and have Masters or Doctorate level training in Clinical Psychology as well as specialised training and experience in treating selective mutism.
Selective mutism is one of the more severe anxiety disorders in children. It therefore takes some time for a child to learn to talk freely and spontaneously to everyone in all situations. Our experience shows that it takes approximately 12-24 months for selective mutism to resolve with an intensive treatment program. However, there are various factors that will impact on the rate of progress. These factors include the age of the child when they first present to treatment, the severity of the condition, the commitment of families and schools to implement the treatment program, and the existence of co-occurring anxieties or other behavioural problems. A child in preschool will often take less time than the above estimate (e.g., 6-12 months), and a child in high school will generally require longer treatment.
This will vary from family to family and will be arranged with the psychologist throughout the course of treatment. Treatment for selective mutism is generally lengthy (i.e., 12-24 months) so we attempt to space the sessions out to keep treatment affordable for most families. We would normally see children and their families more frequently at the start of treatment (e.g., every 2-3 weeks).
This is to provide more intensive support initially while developing and getting the treatment program underway. We then gradually lengthen the time between sessions (e.g., every 3-6 weeks depending upon the child’s progress, the family’s budget, and how confident you feel in being able to continue the strategies between sessions). Because we are not seeing families on a weekly basis (like many treatments), it is crucial that parents and teachers continue to work on the strategies every day with the child in order to help improve their anxiety. We recommend that the school has a consultation with the psychologist every four weeks.
Selective mutism is generally more difficult and slower to treat once a child reaches school. There are a few reasons for this: 1) In general the older the child, the more resistant the selective mutism is to treatment because their avoidant behaviours and anxious thinking styles are more entrenched and habitual; 2) School teachers generally find it more difficult than preschool teachers to find the time to devote to the program; and 3) Preschool is a less structured environment than school and children with selective mutism generally become more anxious and less communicative once placed in the more structured environment of school. Our experience is that children who receive treatment in preschool can make solid gains which place them in the best possible position to start school.
Selective mutism generally starts to emerge around three years of age, sometimes slightly earlier, and this is a wonderful age to start intervention. We find that children respond so much more quickly to the intervention the younger they are, for the reasons outlined in the question above. Many of the children attending the clinic are three years of age and we have even seen children just under three.
A face-to-face assessment can be beneficial because it allows the psychologist to meet you and observe your child’s level of anxiety. The psychologist can also demonstrate how to conduct one of the main treatment strategies to you in that session. However, we recognise that the cost of airfares and accommodation for a family can be expensive, and our program is just as successful for those families who do not have a face-to-face assessment.
Comments such as these are often a child’s way of expressing that they really want to talk, but find it too hard to talk currently. They sometimes feel pressured by others asking them when they are going to talk, and if they talked at school that day. They often say that they will start talking at some point in the future to stop people asking them. Children often have a strong desire to talk, but don’t necessarily know how to move from their current level of communication toward free and spontaneous speech. In very rare circumstances children have started talking at the point that they predicted, however most cases in our experience children’s communication remains the same and they still require treatment.
It is more helpful to start intervention in term 4 than to wait until the new school year as there are many procedures that can be put in place to ensure that the child’s transition to the new year goes as smoothly as possible. This includes advising the school in selecting an appropriate teacher, placement with with appropriate classmates, building rapport with the new teacher, and preparing the teacher for how to manage a child with selective mutism. If these things are not addressed prior to your child starting the new school year their anxiety may be unnecessarily high and it will be harder for them to communicate. Also, the school holidays provide many more opportunities to practise communicating with others, and therefore can be a fruitful time to facilitate a child’s progress with their communication.
Children with selective mutism typically have the most difficulty communicating in the school environment. Most parents will need to be involved in the school treatment program, however you can also help your child with other skills such as understanding and managing their anxiety and other emotions, change their anxious patterns of thinking, and improving their communication outside of school. Children with selective mutism will often have deficits in their social skills as well as friendship difficulties, which is another important area that you can help your child with.
Children with selective mutism are born with an anxious temperament. It is therefore common for them to be vulnerable to developing additional anxieties, such as phobias, general worries, fears of trying new things, separation anxiety, performance anxiety, fears of the dark and sleeping on their own, and perfectionism and fears of getting things wrong. In some cases, particularly as the child gets older, they may also experience low mood as a result of reduced self-esteem, their frustration about not talking, and the social implications of this. Some children with selective mutism may also have other behavioural problems such as aggression, tantrums, and noncompliance. The Selective Mutism Clinic can assist your child and family with any other kinds of difficulties that may arise and our treatment is tailored to the individual needs of your child.
Selective mutism varies in severity. When a child’s selective mutism starts to resolve, there will often be some (often subtle) aspects of the child’s communication that need to be improved. These include their voice volume, moving from using a whisper to using their vocal chords, initiating speech rather than only speaking when prompted, increasing the length of their responses, being assertive, asking for help, joining in discussions, talking in front of larger groups, and generalising talking to other teachers and staff. Furthermore, children with a history of selective mutism have potential to regress in the future unless they are encouraged to communicate in all of the above situations to a level that produces minimal anxiety.
Because children with selective mutism talk freely and normally at home, sometimes parents are not aware of the extent of their child’s difficulties with talking. Begin by giving the parents detailed information about how the child is communicating in your classroom. Express your concerns openly to the parents, provide reading material about selective mutism, and invite them to observe their child at school. Give information about the effects of the condition on the child’s social skills (e.g., difficulties building friendships, asserting themselves, and telling teachers when there is a problem) and academic skills (e.g., not able to elaborate ideas, explain how they reached a particular answer, ask for help, contribute to class discussions, or complete oral tasks in the classroom). If over time the child’s condition does not improve naturally (or worsens), you can provide this feedback to the parents. You can also encourage the parents to speak to a psychologist about selective mutism and what is involved in treatment.
Our treatment program is fairly intensive, as this is what is needed for selective mutism to resolve. We often invite principals/deputy principals and other support staff to sit in on the phone consultations that you have with us, and we can assist with writing letters to support applications for funding. If the special needs teacher and/or school counsellor are also involved in consultations with the Clinic, this can provide you with additional support in terms of the day to day implementation. However, it is important to note that the classroom teacher needs to play a primary role in our school program or else it will be difficult to generalise any gains in the child’s communication to the classroom setting.
Children with selective mutism commonly feel less anxious talking with their peers than with adults. If the child is already speaking to some of their peers, this is a good sign. It is important that you make the classroom environment as relaxed as possible and build good rapport with the child. Ensure that no consequences are placed on the child for not talking (by you or any auxiliary teachers) as this will worsen the mutism. Also ensure that no-one is placing pressure on the child to talk, making comments about her lack of talking, or asking open-ended questions if she is unable to answer. Those strategies will give you a good start. However, in order for the selective mutism to resolve, the child, their family, and the school will need support from a mental health professional. The Selective Mutism Clinic provides ongoing training and support for classroom teachers to implement a program that gradually builds the child’s communication until they can eventually talk directly to the classroom teacher and in front of the whole class.
The clinic also has DVDs available to purchase, which provide details about strategies that teachers can use in the classroom. We also regularly run seminars for teachers.
The Clinic has successfully treated adolescents with a long history of selective mutism using our intensive home- and school-based program. When selective mutism persists into adolescence, it is understandable that the young person and their parents can feel stuck, discouraged or helpless about whether the condition will improve.
They have often tried various strategies and treatments that have largely been unsuccessful, and many families have also had a period of years without treatment where they have hoped that the condition would have resolved by itself. While treatment will take longer for older children, it is never too late to get help. Not only is it possible for the child to start communicating more freely with peers and adults but treatment can have enormous benefits in terms of enhancing the adolescent’s current and future quality of life, including vocational study and employment, living independently, and building friendships and intimate relationships.
The clinic will typically implement a Cognitive Behavioural Therapy (CBT) program before considering medication as an option, as CBT is an effective treatment for selective mutism. Most of the children we have worked with at the Selective Mutism Clinic respond well to CBT by itself. However, there are some cases where medication has been indicated; for example, if there is concern that a child is also suffering from clinical Depression and their low mood is a barrier to them implementing the strategies that we have recommended. Children in the latter primary school years and high school often benefit from a combination of CBT and medication.
The medication prescribed in these instances is typically an antidepressant medication as these are effective at reducing anxiety, have the least side-effects, and are the safest type of medication to provide to children. Antidepressant medication typically acts by helping to reduce the child’s anxiety sufficiently to help motivate them to work on the behavioural strategies in the program. The emphasis remains on the child, the parents, and the school learning and practicing CBT strategies that they can continue using once medication has been ceased. In those cases where we feel that a child might benefit from medication, a referral will be made to a child psychiatrist or paediatrician, who will assess the child independently and liaise with the psychologist at the clinic.