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BEYONDSHYNESS.By:Wallis,Claudia.ScientificAmerican
Mind.May/Jun2015,Vol.26Issue3,p5055.6p.Abstract:The
articlereportsonanxietydisorderinchildrencalledselective
mutismisnowbelievedtoaffectbetween0.5and0.8percent
ofthepopulation.Childrenwithselectivemutismspeaksbut
onlywhenoutofthepubliceyeandinthecomforting
environmentoftheirownhomes.Thisdisorderusually
emergeswhenachildbeginspreschoolorkindergarten,
however,pediatriciansoftendismissit.(AN:101872149)
Database: AcademicSearchComplete

BEYONDSHYNESS
Thatboywhoneverspeaksinclass?Chancesarehehasananxietydisordercalledselective
mutismthatdemandstheonethinghedreadsthemost:attention
Itis11:30onanAugustmorninginNewYorkCity'sCentralParkZoobreakfasttimeforthesea
lions.Ajoyfulcrowdoohsandaahsastrainersputtheanimalsthroughtheirpaces:catchingtossed
fishinmidair,highfivingwiththeirflippers,squirtingwaterandtorpedoingaroundthepool.Amidthe
raucousthrong,ninesmallchildrenwatchinwideeyedsilence.Whenasealionzipspastatstunning
speed,theydonotaddtheirvoicestothesquealsofdelight.Someofthesechildrenaretalkingquietly
toacampcounselor.Otherssitwithworriedexpressionsthatseemsadlyatoddswiththescene.
Theninechildren,agesthreetosix,aresubduedbyananxietydisordercalledselectivemutism,a
conditionthatoftenlooksandfeelslikeverypainfulshynessbutwithatwist.Thesekidswillgenerally
speakandsomewillblithelychatterawaywhenoutofthepubliceyeandinthecomfortingcocoon
oftheirownhomes.Butincertainsettingsandmosttypicallyinschool,theyshutdownandgosilent.
ThezoooutingispartofafourdayprogramcalledCampCourage,offeredbytheChildStudyCenter
atNewYorkUniversity.Itisthemodelforhalfadozensummercampprogramsforkidswithselective
mutism.Oncethoughttobeextremelyrare,thedisorderisnowbelievedtoaffectbetween0.5and0.8
percentofyoungstersmeaningthereisatleastonesuchchildinmostelementaryschools.
Thesearethekidswhoneverspeakinclassorwhispertoonlyoneortwoconfidantsonthe
playground.Theyarethekindergartnerswhowettheirpants,orworse,becausetheyaretoomortified
toaskpermissiontousethebathroom.OnechildatCampCourageaccidentallyhammeredhisthumb
duringaschoolcraftprojectandsaidnothingateacherfinallycametohisaidafternoticingthetrailof
blood.
Pediatriciansoftendismissthedisorder,whichtypicallyemergeswhenachildbeginspreschoolor
kindergarten,asapassingphasethatwillresolveitself.Inthemeantime,parentsgetinthehabitof
speakingfortheirchild,askingotherstoacceptshrugsandgesturesascommunicationandexplaining
theiryoungster's"shyness"tobaffledteachersandneighbors.Butselectivemutismdoesnotalways
fadeaway.Surveyfindingsandclinicalexperiencesuggestthatmanyaffectedchildrencontinueto
struggleformorethanfiveyears,accordingtochildpsychologistRichardGallagher,whoheads
N.Y.U.'sselectivemutismprogram.Asmallpercentageofchildrenremainmuteintohighschool.
Psychologistsandeducatorsfamiliarwithselectivemutismnowbelieveinterveningtobreakthemute
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behaviorpatternisimportantsothatitdoesnotcompromiseachild'sacademic,socialand
psychologicaldevelopment.Thatbeliefisinkeepingwithabroadertrendtowardearlyinterventionin
otherchildhoodconditionsthataffectlearningandsocialization,suchasattentiondeficit/hyperactivity
disorder,communicationdisordersandautism.Selectivemutismislesswellrecognized,however,and
manykidswhowouldbenefitfromtherapyeitherreceivethewrongkindornoneatall.Onlyinthepast
fewyearshasrigorousresearchvalidatedatherapeuticapproachtoselectivemutism.Atthesame
time,scientistsarebeginningtoexplorethemysteriousandinsomecases,surprisingrootsofthis
onceobscuredisorder.
NamingtheSilence
Spendafewdaysaroundchildrenwhohaveselectivemutism,andyoubegintowonderiftheyhavea
hiddenon/offswitch.Inthelarge,airyclassroomwhereCampCourageconvened,Isawachildstop
aconversationinitstrackstheminuteanunfamiliartherapisttriedtojoinin.Conversely,aboywho
hadbeenlargelysilentalldaygotintoanelevatorwithhismomatpickuptimeandbeganaperfectly
ordinarychataboutwhereshehadparkedthecar.
Becausethesekidsarecapableofspeakingnormally,theirmutebehaviorcanlookwillful.In1877,
whenGermanphysicianAdolphKussmaulpennedwhatmaybetheearliestdescriptionofselective
mutism,henameditaphasiavoluntaria(Latinfora"voluntarylackofspeech").Inkeepingwiththeidea
thatthechildhaschosensilence,psychiatristscalledthedisorderelectivemutismwhenitfirst
appearedintheDiagnosticandStatisticalManualofMentalDisorders(DSM)in1980.Thename
changedinthe1994editionafterresearchandclinicalexperiencemadeitclearerthatselectivemutism
wasdrivenmorebyanxietythandefiance.Thecurrentedition(DSM5),publishedin2013,classifies
selectivemutismasauniquechildhoodanxietydisordermarkedbyafailuretospeakincertainsettings
thatcannotbeexplainedbycommunicationorlanguagedifficulties(seeboxabove).
Mostchildrenwhoaretreatedforselectivemutismarealsodiagnosedwithanadditionalanxiety
disorder.Usuallythisissocialanxietydisorder,whichinvolvesgravedistressinsocialsettingsand
oftenaparalyzingfearofmakingasocialmistake.Althoughmostsociallyanxiouskidsarewithdrawn
butnotmute,morethanhalfandperhapsasmanyasnineoutof10selectivelymutechildrenalso
sufferfromsocialanxiety.Anumberofcliniciansregardselectivemutismasasubtypeofthisdisorder.
Despiteitssometimesdramaticsymptoms,selectivemutismisoftenoverlooked.In2002R.Lindsey
Bergman,achildpsychologistattheUniversityofCalifornia,LosAngeles,studiedtheprevalenceof
thisdisorderamong2,256kindergartnersandfirstandsecondgradersinalargeCaliforniaschool
district.ShenotedthatmostofthechildrenwhomatchedDSMcriteriaforthedisorder(basedon
detailedinputfromtheirteachers)hadnotbeenpreviouslyidentified."Teachersjustthinkthekidsare
super,supershy,"Bergmansays."Andatthisage,theteacherismoreworriedaboutthechildwhois
actingoutandnotstayinginhisseat."
Anothercommonissueismislabeling.Inherclinicalpractice,Bergmanhasseenyoungsterswith
selectivemutismwhohavebeenincorrectlydiagnosedwithaspeechandlanguageproblemoran
autismspectrumdisorder.SueNewman,codirectoroftheSelectiveMutismFoundation,saysthatshe
frequentlyhearsaboutmisdiagnosedchildrenwhohavebeenplacedineducationalsettingsdesigned
forkidswithautismorspeechdisordersthatnotonlyfailtoaddresstheirmutismbutmaymakethem
feelmoreselfconsciousandanxious.
Evenwhentheproblemiscorrectlydiagnosed,findinghelp(andaqualifiedtherapistwhoaccepts
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healthinsurance)isachallenge.AccordingtoBritannyRoslin,whoisoneofthreeN.Y.U.child
psychologistsatCampCourage,"alotofcliniciansdon'twanttoworkwiththesekids,becausethey
don'tknowwhattodo.Youcanbesittingacrossfromakidforyearswithoutspeaking."
WhyTheyGoQuiet
Achild'smutebehaviorcancomeasashock.Susan*stillgetsemotionalrecallingeventsonherson's
thirddayofkindergartenwhenateachercameuptoherspouseatpickuptimeandcheerilyasked,
"So,isheevergoingtostarttalking?"Evan*wasexuberantandverbalathomeandhadbeenvocal
duringthreeyearsofpreschool."Weweretotallyflabbergasted,"sheremembers."Wewerebothup
allnight."Onlyinhindsightdidtheyseethewarningsigns:Evan'srefusaltosayhellotowaiters,store
clerksandadultneighbors.Thecouple,wholiveinNewYorkCity,recognizedtheirson'ssymptoms
fromonlinedescriptionsofselectivemutismandquicklymadecontactwithN.Y.U.'sprogram.
Clinicianswhoworkwithkidswiththedisordersaythatparentsoftendescribethemashavingbeen
cautiousandsociallyreticentsinceinfancy.Thesecharacteristicswhatpsychologistscalla
behaviorallyinhibitedtemperamentaretypicalof15to20percentofbabiesandtoddlers."Theyare
hesitanttointeractwithpeerstheywithdrawfromsocialsituationsandarehighlyvigilant,"says
developmentalpsychologistNathanFoxoftheUniversityofMaryland.Althoughmostgoontobe
perfectlyfine,behaviorallyinhibitedchildrenhavea30percentincreasedriskofdevelopingananxiety
disorder,especiallysocialanxiety.
Aswithmostpsychiatricdisorders,thecausesofselectivemutismarenotwellunderstood,buta
geneticcomponentseemslikely.Studieshavefoundthatanxietydisordersofvarioustypestendtorun
inthefamiliesofaffectedkids.Bergmansays,"WhenIseeparentsofkidswithselectivemutism,about
75percentofthetimeIcansay,'Whichoneofyouwaslikethisasakid?'andonewillsaytheyeither
didnotspeakinclassorsatthereinfearthattheywouldbecalledon."
A2011studyinvolving106childrenwiththedisorderoffersahintastoitsgeneticorigins.Universityof
California,SanDiego,psychiatristMurraySteinandhiscolleaguesfoundpreliminaryevidencethata
variationinagenecalledCNTNAP2raisestheriskofthedisorder.Thestudyalsodiscoveredthatthe
samegenevariationwasassociatedwithsymptomsofsocialanxietyinagroupof1,028youngadults.
TheCNTNAP2genecodesforaproteinthatisexpressedinthedevelopingcortexofthebrainand
playsaroleinbraincellconnectivity.Intriguingly,variantsofthegenehavebeenimplicatedinautism
andcertainlanguageimpairmentsfindingsthatsuggestthegenemighthaveapartinavarietyof
socialandcommunicationdisorders.
OneresearchgroupinIsraelhasfoundevidencethatmanychildrenwithselectivemutismhavea
hearingabnormalitythataffectsthewaytheyperceivetheirownvoice.Inaseriesofsmallstudies
publishedbetween2004and2013involvingatotalof75subjectswithselectivemutism,psychologist
YairBarHaimofTelAvivUniversityandhiscollaboratorsfoundthatroughly50percentofaffected
childrenhavesomekindofproblemwiththeir"efferent"auditorysystem.Thissystemwhichinvolves
themiddleear,brainstemandcerebralcortexnormallyattenuatesthesoundofone'sownvoice,
which,asBarHaimsays,isotherwiseloudly"boneconducteddirectlyintoourownbrain."Quieting
downourvoicehelpsustuneintoourenvironmentwhilespeaking.BarHaim'sfindingscouldhelp
explainwhysomechildrenwiththisdisordercomplainthattheirvoicesoundsfunnyorloudtothem.If
heiscorrect,thentreatinganxietyalonewillbeinsufficientformanycasesofselectivemutism.
Indeed,numerousfactorscancontributetoanxietyaboutspeaking.Accordingtoosteopathicphysician
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ElisaShiponBlum,directoroftheSelectiveMutismAnxietyResearchandTreatmentCenterin
Jenkintown,Pa.,developmentaldelays,learningdisabilities,speechandlanguageissues,andsensory
processingchallengescancauseachildtoshutdowninanoisy,overstimulatingclassroom."Wemay
seeadeficitintheirnarrativeskillstheirabilitytotellastory,totellyouwhattheyreadinabookor
whatamovieisabout,"ShiponBlumsays.
Forthemostpart,childrenwhohaveselectivemutismaretooyoungtooffertheirownexplanationsfor
theirbehavior,butapreoccupationwithmakingverbalorsocialmistakesseemstobecentralfor
many.DanicaCotov,arecentcollegegraduatefromNewJerseywhostruggledwithmutismfor16
years,givesthisaccount:"Ilivedinconstantfearofbeingjudgedbymypeers,whoIwascertain
wouldthinknegativelyofme.Ihadaconstantstreamofthoughtsandworriesrunningthroughmy
head."Afteryearsofsilence,shedreadedthefussthatwouldbemadeifsheeverdidspeakup.
FindingHelp
AtCampCourage,eachoftheninechildrenwasworkingtowardaspecificgoal.ForCindy,*anelfin
girlwithbig,browneyesandahoneycoloredbraid,itwastouseher"fullvoice"insteadofawhisper.
EvanwasworkingonallowinganyonebesidesGallagher,withwhomhechattedeasily,tohearhis
voice.CampersearnedpointsbyparticipatingingroupgamessuchasGoFishthatrequiredsimple,
predictableutterances("Doyouhaveanyzebras?").Attheendofeachday,theycouldpickabigor
smallprizedependingonhowmanypointstheyhadrackedup.
PsychologistsatN.Y.U.andelsewheretypicallytreatselectivemutismwithamodifiedversionof
therapiesshowntobeeffectiveforotheranxietydisordersandphobias.Firsttheyencouragekidsto
speakwithparentsinaclinicalsettingandeventuallytospeakwiththetherapist.Inclosecollaboration
withteachers,theygraduallymovethechildthroughahierarchyofbehaviorsfromnonverbal
exchangestomouthingwordstowhisperingandthenusingafullvoiceincircumstanceswherehe
orshewouldordinarilybemute.Theyalsoworkonwideningthecircleofpeopletowhomthechildwill
speak.Atschool,forexample,teachersmaybecoachedtopermitsilentnods,thenonewordanswers
promptedbysimple,limitedchoicequestions(suchas"Istheanswer5or7?").Alongtheway,kids
earnrewardsforspeakingup.Theideaisthatgradualexposuretospeakingwilldefangtheirfears.
In2013Bergmanandhercolleaguespublishedastudyonthistypeoftreatment.Shedivided21
childrenwithselectivemutism,agesfourtoeight,intotwogroups.Onegroupwasplacedona12
weekwaitinglist.Theothergroupreceived24weeksofaninterventionthatincluded20hourlong
privatesessionswithatherapistandassignmentsdesignedtograduallyincreasethechild'sexposure
tospeakinginfearedsettingsmainlyschool.Therapistsworkedcloselywithteachersandparents,
whoweretaughthowtocontinuetohelpthechildoncetheexperimentwasover.Independent
evaluators,whodidnotknowwhichkidshadtheintervention,ratedtheirprogress.
After12weeks,aquarterofthechildrenreceivingtreatmentshowedmajorimprovement,whereas
noneonthewaitinglistimproved.Aftercompletingthefull24weeksoftherapy,75percentofthe
treatedchildrenhadprogressedintheirspeakingbehaviors,andtwothirdsofthemnolongermetthe
criteriaforselectivemutism.Threemonthslatertheywerefoundtohavemaintainedtheirprogress.
Asidefromasmallscaledrugstudypublishedin1994,Bergman'sresearchappearstobethefirst
everrandomizedcontrolledstudyofatherapyforthecondition.
GettingResults
InGallagher'sexperience,thechildrenwhorespondfastesttotherapyarethosewhoaresocial,
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despitethedisorder."Theylookliketheywanttobeinvolvedwithotherkids,"hesays."Theyplay,they
usealotofgestures,theyhavefriends."Morechallengingarethosewhohavesomefeaturesof
autismandlackmotivationtoengagewithothersandyoungsterswithsymptomsofabroadersocial
anxietywhoappeardistressedoruncomfortableevenwhenplaying.Severalstudieshaveshownthat
somechildrenimprovewhengivenaselectiveserotoninreuptakeinhibitorsuchasProzac,which
reducesanxiety.Addingelementsofcognitivebehaviortherapycanhelpolderkidslearntousereason
tomaketheirfearsseemmoremanageable.
Whenschoolgotunderwaythisfall,Cindy'sparentswerepleasedwithherprogress."She'sinitiating
conversationwithherteacher,"hermothersays."Thatdidn'thappenlastyear."ForEvan,progressis
slower."Whenwewalkintoschool,he'ssaying,'Hey,everybody,'tothekidsandhashis
rambunctious,easygoingpersonality,"Susanreports."Thenwhenwesay,'Gottago,haveagreat
day,loveyou,'that'swhenhestopstalking.He'smissingoutonsomuchofschool,and[histeachers]
aremissingoutonsomuchofhim."
Fewstudieshavefollowedchildrenwithselectivemutismthroughoutchildhoodandadolescence,so
noonecansay,withauthority,howlongthedisordertypicallylasts,whatpercentagewillremain
sociallyanxiousorwhattraitspredictagoodoutcome.Onepointdoesseemclear:trainingteachers,
specialeducationpersonnelandspeechandlanguagespecialiststobetterrecognizeselectivemutism
andtointervenemoreeffectivelycouldhelpmanychildren.Oncetheyhavebeguntospeak,most
remaintimid,butforothers,Bergmansays,"it'salmostlikethey'vehadtheflu.Theygoontobethe
mostgregariouspeople,andyoucanimaginethatyearslatertheirfamilieswillsay,'Oh,mygosh,
rememberwhenMarydidn'ttalk?'"
Somekidsgoontobecomequitegregarious,Bergmansays.Shecanimaginetheirfamiliessaying
yearslater,"Oh,mygosh,rememberwhenMarydidn'ttalk?"
*Nottheirrealnames.
FASTFACTS
STRUCKSPEECHLESS
1Selectivemutism,adisorderthatleavesindividualstooanxioustospeakincertaincontexts(usually
school),isnowbelievedtoaffectbetween0.5and0.8percentofyoungchildren.
2Evidencesuggeststhatgeneticsplaysasignificantroleinthedisorder.Issueswithauditory
processingmayalsocontribute.
3Therapiesfocusongraduallyincreasingachild'sexposuretospeakingindistressingsituations
andprovidingrewardsforbravinghisorherfears.
SelectiveMutismintheDSM5
Fivediagnosticcriteriadistinguishthedisorder:
*Thechildconsistentlyfailstospeakincertainsettings.
*Theproblemhaslastedatleastamonth(notincludingthefirstmonthofschool).
*Theissuecannotbefullyexplainedbyacommunicationdisorder.
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*Theconditioninterfereswiththechild'seducationorsocialcommunication.
*Thechild'ssilencecannotbeattributedtoanunfamiliaritywithspokenlanguage.
FURTHERREADING
*IntegratedBehaviorTherapyforSelectiveMutism:ARandomizedControlledPilotStudy.R.Lindsey
Bergmanetal.inBehaviourResearchandTherapy,Vol.51,No.10,pages680689October2013.
*BreakingFreeofaSilentPrisontoServetheWorld.DanicaCotovinStarLedger(Newark)July9,
2014.
*AnAuditoryNeurosciencePerspectiveontheDevelopmentofSelectiveMutism.YaelHenkinand
YairBarHaiminDevelopmentalCognitiveNeuroscience,Vol.12,pages8693April2015.
FromOurArchives
*FearNot,Child.JerryBubrickMarch/April2014.
Somechildrenwithselectivemutismareoutgoing,butmostarenot.Somewherebetweenhalfand90
percentalsosufferfromsocialanxiety,whichcancausethemtopullbackinsettingssuchasa
crowdedplaygroundfullofunfamiliarchildren.
Kidswiththedisordertendtobeselfconsciousandfretfulaboutmakingmistakes."Theyreactto
speakingasifitwereaperformance,"sayspsychologistR.LindseyBergmanofU.C.L.A.
TeachersusuallyplayanImportantroleinhelpingachildconquerselectivemutism.Atherapistmay
coachthemtogentlynudgeastudentfromnonverbalparticipationinclasstobrief,whisperedanswers
tofullengagementwithrewardsforprogress.
~~~~~~~~
ByClaudiaWallis
CLAUDIAWALLISisanawardwinningsciencewriterwhoseworkhasappearedinnumerous
nationalpublications.SheisthenewlyappointedmanagingeditorofScientificAmericanMind.

CopyrightofScientificAmericanMindisthepropertyofScientificAmericananditscontentmaynotbe
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