Selective mutism is an anxiety disorder and currently one of the most misunderstood, underdiagnosed and undertreated conditions in mental health. When children with selective mutism feel expected or pressured to speak in social situations, they become terrified, resulting in their level of anxiety increasing significantly. By remaining silent, they decrease this anxiety level slightly and obtain some relief for themselves.
For these children, remaining silent serves as a defense mechanism or a maladapted solution to create a sense of safety within themselves. Their instincts guide them to believe that their best chance to maintain themselves at a baseline level of homeostasis comes with no action at all. 
Hence, their voices freeze, and they are silent. This provides them with temporary relief but, longitudinally, these children suffer in silence if not treated effectively.
It can be challenging to really understand the anxiety behind selective mutism, especially for the parents, teachers and clinicians working with these children. In trying to conceptualize the experience of selective mutism, I have an analogy to help clarify. When I go to the eye doctor for the glaucoma screening with the “puff of air in the eye test,” my eyes actually freeze shut. It’s clear that I physically know how to open my eyes, and despite what the eye doctor thinks, I actually want to keep my eyes open. But my anxiety takes over, and my fear physically closes my eyes. In this heightened state of anxiety, I have an inability to open my eyes.
It is the same for people with selective mutism. They know how to speak (although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders has documented that approximately 20-40 percent of these individuals have a form of a speech and language delay). It’s also important to understand that most of these children desperately want to be able to speak to others, but they are unable to do so because their fear creates an inability to speak in that moment. In other words, they are not trying to be manipulative or defiant.
Is my fear of the eye test that administers a puff of air in my eye a realistic fear? No, of course not! The air is not going to hurt me. I logically know that, so it is an irrational fear that is disproportionate to the event. Most people have some irrational fears throughout their lives. This doesn’t mean that they have a full-blown anxiety disorder. However, when an irrational fear such as the fear of speaking to other human beings gets in the way of functioning — whether that involves social, academic or occupational functioning — it is a serious issue that needs to be addressed therapeutically (and possibly with medication in addition to therapy.)
Brain science
To further grasp what is going on in the anxious brain of selective mutism, it is crucial to understand a key autonomic mechanism in the brain. In 1915, Walter Cannon coined the term “fight or flight” to describe the instinctual, physiological reaction to fear. Fight or flight consisted of only two fear responses. More recently, clinicians have added a third fear response — to freeze. In his book Nerve: Poise Under Pressure, Serenity Under Stress and the Brave New Science of Fear and Cool, Taylor Clark explains that when a person freezes from this autonomic nervous system response, the person becomes an alarmed-looking human statue.
This is how children with selective mutism can appear. When children with selective mutism take no action, this means their mouths freeze, but sometimes their whole bodies are paralyzed by fear too. In our ancestors’ days in the wild, the brain’s autonomic freeze reaction may have been a valuable tool to save lives, but in cases of selective mutism in today’s society, this response makes lives worse. Aaron T. Beck, the developer of cognitive behavior therapy (CBT), states that evolution has long favored our anxious genes. This is because way back in our ancestors’ time, it was obviously better to experience “false positives” (false alarms) than “false negatives” (which miss the danger). Evolution’s favoring of anxious genes may explain why so many anxiety disorders are rampant today.
The autonomic system that was so beneficial to protecting and saving people’s lives many years ago has its roots in the amygdala of the brain. Research has shown that a person with anxiety experiences a hypertrophy in the volume of neurons in the amygdala, heightening fear responses and causing an overactive amygdala. The amygdala receives information from the sensory modalities. With selective mutism, this translates to people with selective mutism coming into contact with others through seeing or hearing them, which in turn activates their fear response. This means that once a person with selective mutism comes into contact with someone else, his or her autonomic nervous system — specifically the sympathetic nervous system — is activated with the fight, flight or freeze response, signifying extreme danger.
Once sensory information activates the amygdala, it triggers a response in the hypothalamus, which results in secretion of the adrenocorticotropic hormone from the pituitary gland. At about the same time, the adrenal gland is activated and releases the neurotransmitter epinephrine (adrenaline). All of this produces the stress hormone cortisol, which creates an acute boost of energy. Catecholamine hormones such as adrenaline (epinephrine) or noradrenaline (norepinephrine) facilitate immediate physical reactions and prepare us for danger. In response, the body instinctively fights, flees or freezes.
The body cannot physically stay in such a heightened state of arousal for long periods of time, so the parasympathetic nervous system then activates the release of acetylcholine, the neurotransmitter that brings the body back to homeostasis after the fight, flight or freeze response. It is important to understand that the definition of “homeostasis” is different for a person with any anxiety disorder than it is for a person without an anxiety disorder. At a baseline level, research shows that people with an anxiety disorder will still be in a more-heightened state of anxiety than will a person without an anxiety disorder. This means that even at baseline level, children with selective mutism will most likely still not be able to speak to others outside of their immediate families without having been through treatment.
Treating selective mutism
How can children with selective mutism’s severe fear response be better managed so that they can more effectively function at school and in social situations in the community?
First, there needs to be antecedent management to adjust the environment and the triggers to the child’s anxiety. Antecedent management can be accomplished using concepts from Sheila Eyberg’s parent-child interaction therapy (PCIT). This includes incorporating her concepts of child-directed interaction and PRIDE skills (praise, reflect, imitate, describe and enjoyment) both at school and in community settings.
PCIT can also be used in combination with a gradual exposure model in which B.F. Skinner’s operant conditioning is implemented. However, it is important to remember that operant conditioning is effective only when the environmental expectations of the child match the skills the child is capable of. How does a child become capable? This is when the psychoeducational skills from Beck’s CBT and mindfulness from Marsha Linehan’s dialectical behavior therapy can also be beneficial.
It is important to note that any and all of these techniques can be tried with many different anxiety disorders. As a clinician, I have tried all of these techniques in the therapeutic day school in which I work with students with generalized anxiety disorder, social anxiety disorder, school anxiety (school refusal), posttraumatic stress disorder and obsessive-compulsive disorder. Many of these techniques, originated by well-known clinicians, have been researched to show statistically significant results in managing anxiety in many anxiety disorders.
Once these children’s environments are controlled with antecedent management, their behaviors are shaped with successive approximations, working toward an incentive in which they are positively reinforced through operant conditioning and they have the psychoeducational skills to reduce their anxiety. When this happens, they will be more likely to be able to speak.
Many times, a foundation of intensive treatment for selective mutism is beneficial in getting a head start with this type of treatment because of the combination of interventions. Outpatient intensive treatment typically equates to 30 hours in one week with clinicians specializing in selective mutism. The skills practiced during the 30 hours of intensive treatment seem to hold their gains better than they do when acquired and practiced one hour per week in therapy. Imagine getting a 29-week head start and saving 29 weeks of a child’s life. Multiple intensive treatment centers exist across the country, many of which are based on a “day camp” model running roughly six hours per day for one week at a time. The child is typically placed with a group of children based on age level, and each child has a one-on-one clinician who rotates throughout the week.
Once the foundation of these skills has been built in an intensive program, the skills can be generalized into the child’s school environment and social situations within the community. Clinicians from the intensive treatment programs for selective mutism can then help train the parents, the child’s regular therapist and the child’s school staff members on how to best utilize antecedent management with the child, while also teaching them how to help the child manage anxiety so she or he can continue to be verbal with other people outside of the intensive programming setting.
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Donna Mac is a licensed clinical processional counselor conducting psychotherapy in a therapeutic day school, treating children diagnosed with many mental health conditions. In addition, she is the mother of identical twin daughters, age 6, diagnosed with selective mutism, apraxia of speech, attention-deficit/hyperactivity disorder and a mood disorder. Her latest book is titled Suffering in Silence: Breaking Through Selective Mutism. Visit her website at www.breakingthroughselectivemutism.com for more information on selective mutism.
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