The Older Child or Teen with Selective Mutism
Selective Mutism in the Older Child
Selective Mutism (SM) is usually noticed when a child begins pre-school or kindergarten, if not before. So when a student in the upper elementary or secondary grades has SM, it’s safe to assume that he or she has been living with Selective Mutism for many years. Within the lifetime of today’s teens, researchers and treating professionals have learned much about this anxiety condition. Young children who receive prompt and appropriate treatment now make great strides. But information about SM is still not as widely available as it should be—educators, doctors, and psychologists often fail to recognize SM or understand how to help affected children. Consequently, many children do not receive early diagnosis or appropriate support.
Older students with SM may have received no treatment or may have suffered years of inappropriate treatment and negative reinforcement. Instead of being helped to control their anxiety and become more comfortable at school, they may have been pressured to do the things they feared, such as speaking. Over the years they have developed ingrained behavior patterns and maladaptive coping mechanisms by which they avoid situations that make them anxious. Not speaking has become a habit that is difficult to break. They begin to see themselves as “the kid who doesn’t speak” as do many people around them. The fear of receiving attention if they should start to speak makes it harder to imagine changing. They may also have developed phobias about speaking or having their voice heard. Older children with SM often lag behind their age peers in social competence because they’ve had less experience with peers and adults. Treatment plans for the older child must take these complications into account. 1
Students with SM are, in general, extremely sensitive individuals. Older children and teens are acutely aware of their differences and the responses they elicit from their teachers and other adults. People have been trying to get them to talk for years! They understand that they repeatedly fail to meet standard expectations in the school setting. Consequently, they are wary and keenly aware of the most subtle pressure to communicate. Wanting to avoid attention, they typically have learned to hide the appearance of anxiety; while younger children may freeze and show a blank expression, older students more commonly appear relaxed and “ok,” even when they’re not.
In summary, older children have developed more complicated profiles, influenced by their experiences and environmental stressors. Their individual profiles tend to show more variation than with younger children, and treatment needs to be tailored to the individual.
Helping the Student Make Progress
For all of the above reasons, you can expect progress to be more difficult and slow once a child has reached the age of eight or nine. Different strategies and interventions are needed for older children or teens. Consider, for instance, a fading strategy, in which a child first talks with a parent in a private room at school, and over time other individuals are gradually drawn into the conversational group. This often succeeds with a very young child. Older children, on the other hand, have developed a self-image as a noncommunicator and would recognize the situation as a set up aimed at getting them to talk.
The fading strategy doesn’t work for them. As experienced treating professionals have found, the older child or teen needs to be actively involved and in control of their therapy, which aims to help them recognize their anxiety and take small, controlled steps in real life situations. In younger children, medication to reduce the anxiety often produces quick and dramatic results. With older students who have many habits to unlearn, medication is often an important adjunct to behavioral therapy but many treating professionals have found that it not as effective on its own.
For older children, the thought of changing longstanding habits and exposing themselves to anxiety-provoking situations is frightening, and they can become quite resistant to therapy. Dr. Elisa Shipon-Blum, the Medical Director of the Selective Mutism Group/Childhood Anxiety Network, has observed that if a child is not verbal in school by the age of eight or nine, he or she is unlikely to talk at school until at least high school, and possibly later. For students in this age range, she has suggested that the emphasis be on helping the student realize his or her academic potential and remain socially connected. This will usually require flexibility about assessment and participation.
The student’s self-consciousness usually extends to situations beyond speaking and commonly affects non-verbal as well as verbal communication. In general, the student with SM finds it much easier to respond to another individual than to initiate communication. A student who is able to respond to a teacher’s question, (verbally, in writing, or with a gesture) may be unable to initiate with that same teacher to ask a question or contribute to a class discussion. He or she may be unable to take a note to the attendance office, check out a library book, or make a purchase at the snack bar. SM has an impact both academically and socially, and students can feel left out because of their inability to interact with ease.
If teachers can help decrease anxiety at school and increase the student’s self-confidence, there will be a greater chance of progressing communicatively, both non-verbally and verbally. Perhaps the student will interact with new work partners, carry notes to the office without a friend, or respond more easily, in writing, to discussion questions. It is important to recognize even small improvements and not become discouraged! Measure success by how well the student functions at school in general, and not by his or her communicative relationship with the teacher. Even the most empathetic and skilled teacher is an authority figure, and students with SM are commonly more inhibited with teacher than with other people. At the beginning of a new school year, new teachers should start allow for plenty of “warm-up” time. Start slowly with the goals of getting to know the student, gaining their trust, and helping the student become as comfortable as possible at school. Emphasizing or pushing for communication in any form, non-verbal, written, or oral, is likely to cause the student to withdraw. Communication will develop as the student becomes less anxious.
Helping the student make and maintain social ties is vital. It is, unfortunately, too easy for a socially anxious individual to become isolated and depressed. Depression is more likely as a child enters adolescence and can lead to more severe anxiety, social isolation, lower performance in school, suicidal thoughts, and self-medication with alcohol or drugs.
It’s More than Not Talking
Studies have shown that over 90% of children with SM have Social Anxiety Disorder, also known as Social Phobia. 2 3 4 5
In fact, some experts have suggested that SM may be a manifestation or variant of social anxiety. These students are excessively selfconscious. They are afraid of being embarrassed, judged or criticized, and of receiving scrutiny or attention. 6
Social anxiety does not make a child anti-social or even asocial. A socially anxious child can be very social and enjoy the company of family and friends when in a familiar and comfortable setting. Many students are more comfortable with their peers (this is more common), but others are more comfortable with a trusted adult.
Some students, who may have partially overcome their SM, do speak at school. Most likely, these students still experience anxiety, even though it is less obvious. 7 8
They may not be able to speak in all situations or with all people. A student who is able to respond to a teacher’s question or even contribute to a discussion may be completely unable to ask a question or express a concern.
Anxiety can affect academic performance in many ways, even in a student who begins to talk at school. Not talking is only the tip of the iceberg! Other manifestations of anxiety include:
- Perfectionism; worry that work is inadequate in quality and/or quantity
- Procrastination and avoidance
- Problems with test-taking and timed testing; may rush for fear of not finishing in
time; may panic; may be too anxious to check answers or may check answers repeatedly and not finish
- Problems with open-ended or unclear assignments; worry that they don’t know what the teacher wants or that they will do the wrong thing
- Unable to ask for help or clarification; unable to express worries or complaints
- Afraid to express an opinion, even to express likes or dislikes
- “Blanking,” or panic-like reactions
- Easily frustrated
- Illegible, tiny, or faint writing to obscure answers they’re unsure of
- Difficulties with group work; may be unassertive or passive; conversely, may be a “control-freak” if worried that the group’s work is inadequate
- School refusal or faked illness to avoid social situations at school or because of worries about schoolwork
The first step in helping a student with these difficulties is to recognize that they are manifestations of anxiety. The student is not choosing to behave this way and is neither unmotivated nor oppositional. Then,
- work to build the student’s self-esteem and self-confidence,
- increase the student’s comfort and reduce anxiety at school,
- back off on all pressure to speak, and
- make accommodations, such as those suggested in the following section, that allow the student to progress academically.
Mild expressive language difficulties may be more common in students with SM, and they can be a source of added self-consciousness and anxiety.9 10 Subtle effects on oral and written expression can include: word retrieval glitches, terse writing with few descriptive details, and the use of non-specific language (e.g. “that thing” instead of a precise noun). A screening by a Speech and Language Pathologist or Neuropsychologist may be appropriate if there are concerns about language difficulties.
Accommodations and Classroom Strategies
Listed below are suggestions for strategies and accommodations that may be helpful for the older student with Selective Mutism. 11 Accommodations and modifications may be specified in an IEP or 504 Plan (in the US). Some accommodations are appropriate for almost any student with SM:
- Training for teacher(s) covering the nature of SM and classroom strategies; training before the start of the school year followed by on-going support
- Brief training so that all adults who might have contact with the student understand SM and how to interact with the student.
- No grading down for not speaking or for any failure to communicate that is due to the anxiety condition.
- No pressure to speak. No teasing, threatening, limiting the student’s participation, or punishment for any failure to participate that is related to the anxiety condition.
- Alternative forms of assessment and participation to substitute for speaking, such as: written work, non-verbal communication, audio- or video-taping, collaboration with friends, practice at home under parent’s supervision, the use of a computer, or the use of another person as a verbal intermediary. Individual work may be allowed for a student who is unable to participate in a group.
- Warm, flexible teachers who understand SM as an anxiety condition
- Avoid singling out the student or calling attention to any differences.
- Avoid calling attention to any new steps the student makes, such as talking in a new situation; other students should be told, without the student present, to not comment if the student with SM talks
- Do not attempt therapeutic interventions except under the guidance of an authorized treating professional or as specified in the IEP or 504 Plan, and keep written records of interventions.
- In general, except as specified in the IEP, treat the student as much as possible like any other student.
Other accommodations and strategies to consider, depending on the individual student, include:
- Clear, specific assignments and expectations; detailed grading standards or rubrics that reduce the student’s worries about what is expected
- Clear and specific prompts and questions for written work and discussion topics, rather than open-ended topics
- Place trusted friends in the same class(es). In secondary school, this probably will require hand scheduling.
- Frequent opportunities for small group activities, preferably with at least one trusted peer.
- Frequent opportunities for hands-on activities, since many students are more engaged and less distracted by worries when physically active.
- Frequent opportunities for gross-motor activity (not only organized physical activities, but also informal opportunities to get up and move around) to help the student with self-regulation.
- Teachers initiate a regular check-in with student to compensate for student’s difficulty in initiating verbal or non-verbal communication; ask if the student has any questions or anything they want to communicate.
- Seating in less conspicuous locations: back half of the room, towards the sides, and away from the teacher’s desk
- Seating next to a trusted friend and near students identified as good work partners
- Vary modes of participation for the entire class to include non-verbal communication, e.g.: students write on individual small white boards, students signal “thumbs up” or “thumbs down,” students indicate a numerical response by raising the corresponding number of fingers, students write a question or comment (possibly anonymously) to hand in
- Advance preparation for class discussions; present questions to the student the day before or earlier in the day. If the student is unable to respond, move on rather than waiting for the student to answer.
- Extended time for testing and assignments, or non-timed testing.
- Advance notice for large projects; help break projects into smaller chunks to avoid overwhelming the student.
- Alternative forms of participation in school performances. Some students with SM enjoy acting and find it easier to speak in the role of a character, and some sing or do cheerleading in a group.
- Many are too self-conscious to appear onstage even in a non-speaking role but contribute as a writer, publicity artist, set designer, or lighting technician.
- A private location to dress for PE
- Support social connections: identify potential friends and work partners; initiate activities with those students and monitor as necessary; teacher assigns partners rather than let class choose
- Encourage the student to tell others how he or she would like to be contacted, for instance if they are working together on a project that requires some contact outside of school
- Set aside an area within the classroom where a pair or small group of students can work more privately, so as to encourage more easy communication. The area might be equipped with small whiteboards, office supplies, etc.
- Social support at lunchtime, on field trips, and at other unstructured times
- Support for participation in extracurricular activities
- A steady adult, such as a trusted teacher or counselor, responsible for maintaining a continuous relationship with the student from year to year
- Disability awareness and sensitivity training for other students; monitoring for bullying; be prepared to answer questions from other students, help them understand SM, and address their
- Regular and frequent communication with the parents and outside treating professionals; communication mechanisms, such as email or voicemail, so that the parents can alert the school to immediate problems
- Support for the student’s goals in behavioral therapy under the guidance of an outside (or in-school) treating professional, including: communication with treating professional (possibly through the parents), record keeping and reporting, and carrying out the specified communication activities. Examples of activities: send student on an errand to the office with or without a buddy, student “interviews” teacher with written questions, student mouths words while class recites poem.
With appropriate support the older student with SM can achieve academically and develop social relationships. Helping students gain comfort and confidence at school fosters an environment in which they experience less anxiety and can increase the level and variety of communication at school.
1 The discussion in this and the following two sections are based on a series of lectures given by Elisa Shipon-Blum, D.O. at the conference Speaking Out for Our Children. Quality Resort Hotel, San Diego, California. 17-18 January 2004.
2 Bruce Black and Thomas W. Uhde, “Psychiatric Characteristics of Children with Selective Mutism: A Pilot Study.” J. Am. Acad. Child and Adolescent Psychiatry 34:7, July 1995: 847-856.
3 Denise Chavira et al., “Selective Mutism and Social Anxiety Disorder: All in the Family?” J. Am. Acad. Child and Adolescent Psychiatry 46:11, November 2007: 1464-1472.
4 E. Steven Dummit III et al., “Systematic Assessment of 50 Children with Selective Mutism.” J. Am. Acad. Child and Adolescent Psychiatry 36:5, May 1997: 653-660.
5 “Practice Parameters for the Assessment and Treatment for Children and Adolescents With Anxiety Disorders.” J. Am. Acad. Child and Adolescent Psychiatry 46:2, February 2007: 267-283.
7 R. Lindsey Bergman, John Piacentini, and James T. McCracken, “Prevalence and Description of Selective Mutism in a School-Based Sample.” J. Am. Acad. Child and Adolescent Psychiatry 41:8, August 2002: 938-946.
8 Bruce Black and Thomas W. Uhde, op.cit.
9 Hanne Kristensen and Beate Oerbeck, “Is Selective Mutism Associated With Deficits in Memory Span and Visual Memory?: An Exploratory Case-Control Study.” Depression and Anxiety 23:2, 2006: 71-76.
10 Katharina Manassis et al., “The Sounds of Silence: Language, Cognition, and Anxiety in Selective Mutism.” J. Am. Acad. Child and Adolescent Psychiatry 46:9, September 2007: 1187-1195.
11 School accommodations for younger students are discussed in Elisa Shipon-Blum, The Ideal Classroom Setting for the Selectively Mute Child (Jenkintown, PA, The SMART Center, 2003) and in Angela E. McHolm, Charles Cunningham, and Melanie K. Vanier, Helping Your Child with Selective Mutism (Oakland, CA, New Harbinger, 2005).