What is Selective Mutism?

It is a complex disorder that is first seen in early childhood and is characterized as an anxiety disorder.¹ It is a condition in which a child is unable to speak in certain social situations, despite being able to talk normally in general. It involves more than just shyness, it is a fearful feat for that kid. It is caused by the result of a mix of genetic, environmental, and developmental factors. Early intervention is crucial to help children overcome this challenge and process the anxiety associated with selective mutism. This article intends to inform about selective mutism and the importance of speech therapy.

Diagnostic criteria

Selective mutism is an anxiety disorder resulting in the inability to speak in specific social situations.² The International Classification of Diseases (ICD-11) was created by the World Health Organisation (WHO) in 2018 and then started to be used in 2022. The ICD-11 is the diagnostic criteria used to diagnose selective mutism, it provides extensive details in relation to behaviour and mental health disorders.

The criteria states the following are required to diagnose selective mutism:

• Recurring failure to speak in particular social situations where speaking is expected despite speaking in other circumstances
• The difficulty lasts for a minimum of a month and is not only present in the first month of school.
• Educational/occupational achievements are affected by the failure to speak
• The failure to speak is not the result of a lack of knowledge or level of comfort in the spoken language
• There is no other mental or neurodevelopmental disorder, there is no disease affecting the nervous system
• Symptoms are not due to the effects of any medication/substances that affect the central nervous system

It is also important to note that selective mutism is seen in early childhood and is strongly associated with anxiety and fear; hence, selective mutism is under ‘Anxiety or fear-related disorders’. 

Causes of selective mutism 

Genetic factors

The genetic factors involved in selective mutism are not fully understood, and further research is required. However, some associations have been identified. 

Genetic predisposition

Children who are affected by selective mutism have a strong genetic likelihood of anxiety disorders.³ This means that they have inherited genes that are linked to anxiety disorders from their parents or other family members. Having these genes means these kids are biologically prone to suffer from anxiety disorders which is what selective mutism stems from.

Inhibited temperament

• Those with selective mutism show early signs of inhibited or shy temperament
• This is where the child socially withdraws, and displays fear and avoidance towards new people/events
• This characteristic is thought to be heritable, so the shy and anxious trait is passed down from one generation to the next
• An inhibited temperament has been associated with a decreased excitability of the amygdala. This is an area in the brain that controls our response to stress and fear
• As a result, the brain is much more sensitive to what’s going on in the environment, causing a heightened emotional state that can trigger selective mutism in social situations

Family and heritability

• Twin studies have suggested evidence for the genetic causes of selective mutism⁴
• These studies show that if one identical twin (who shares 100% of their genes) has selective mutism, the other twin is much more likely to also develop the disorder compared to fraternal twins (who share around 50% of their genes)
• This high concordance rate (i.e., the presence of the same trait in both members of a pair of twins) in identical twins highlights a strong heritable component in the development of selective mutism
• First-degree relatives (parents, siblings, children) of a child with selective mutism have a much higher risk of also having the disorder compared to the general population
• The high occurrence of selective mutism in family relationships further supports the role of genetic factors in the cause of selective mutism

What is speech therapy?

Speech therapy is a specialised field of healthcare that focuses on diagnosing, treating, and preventing communication and swallowing disorders in individuals of all ages. ⁵. Speech therapists are trained professionals who work with patients to improve many aspects of communication including producing speech, understanding language, fluency, quality of voice, and social communication skills. They also address swallowing difficulties and provide strategies for safe eating and drinking. Speech therapy interventions are specialised to each individual's needs and may involve exercises to strengthen oral muscles, practice articulation of specific sounds, improve vocabulary and sentence structure, or develop alternative communication methods. These professionals work in several settings, including schools, hospitals, rehabilitation centres, and private practices. They work with other healthcare providers, educators, and families to ensure detailed care. 

Speech therapy can benefit individuals with a wide range of conditions like developmental delays, autism spectrum disorders, hearing impairments, stroke, brain injuries, and degenerative diseases. By improving communication skills, speech therapy enhances an individual's quality of life, social interactions, and overall well-being, enabling them to more effectively express their thoughts, needs, and emotions.

Types of speech therapy

• Articulation therapy: Focuses on helping individuals produce specific speech sounds correctly. This often involves exercises to strengthen oral muscles and practice proper tongue and lip placement
• Language therapy: Addresses difficulties with understanding or using language. This can include work on vocabulary, grammar, sentence structure, and comprehension
• Fluency therapy: Targets stuttering and other fluency disorders. Techniques may include controlled breathing, slowed speech, and gradual progression to more complex speech patterns
• Voice therapy: Aims to improve voice quality, pitch, and volume. This is often used for individuals with vocal cord injuries or disorders
• Cognitive-communication therapy: Helps individuals with cognitive impairments affecting communication, often due to brain injuries or neurological conditions
• Social communication therapy: Addresses pragmatic language skills, helping individuals understand and use appropriate social language and non-verbal communication
• Phonological process therapy: Targets patterns of sound errors that children make when learning to speak
• Orofacial myofunctional therapy: Addresses disorders of the muscles and functions of the mouth and face

Importance of speech therapy in selective mutism

Speech therapy is essential to treat selective mutism. Speech therapists address both the communicative and anxiety-related aspects of this condition. They use many techniques to slowly expose children to speaking situations, helping build confidence and lessen anxiety around verbal communication.

These professionals use systematic desensitization (i.e., exposure therapy), play-based activities, and role-playing to create a safe environment for children to practice speaking. They also work with parents, teachers, and other professionals to create strategies that can be used across different settings, ensuring a comprehensive treatment approach.

Speech therapy focuses on encouraging speech and also addresses any underlying language or articulation problems that may lead to the child's reluctance to speak. Therapists incorporate cognitive-behavioural techniques to help children challenge negative thought patterns linked to speech. They also work on developing social skills, which are essential for successful social interactions.

By providing the necessary tools and techniques for effective communication, speech therapy helps children with selective mutism overcome their fears, improve their social interactions, and ultimately find their voice in all situations. This comprehensive approach contributes to the child's overall emotional and social development, significantly improving their quality of life.

Summary

Selective mutism poses a challenge for affected children and their families. This anxiety-based disorder stops kids from speaking in certain social contexts, despite being able to communicate normally in familiar situations. Early intervention is crucial, as the condition can greatly impact a child's educational progress and social development if left untreated.

Although genetic factors play a role in selective mutism,  as studies show a higher prevalence among first-degree relatives, environmental influences also contribute to its manifestation. The amygdala's decreased excitability in individuals with an inhibited temperament offers a potential neurological view of the cause.

Speech therapy emerges as a cornerstone in the treatment of selective mutism, offering a unique approach that is more than simply promoting verbal output. Therapists use many techniques, which can act as a bridge to verbal expression. 

The gradual transfer of skills from therapy sessions to real-world situations is an important aspect of treatment. Speech therapists may conduct sessions in various locations or incorporate field trips, creating newly found communication skills. This comprehensive strategy not only targets the immediate symptoms of selective mutism but also equips children with lifelong tools for effective social engagement and emotional resilience.