How to Overcome Selective Mutism

Are you or someone you love being affected by selective mutism? Selective mutism is a relatively rare disorder in children causing inability to speak under certain situations (e.g. classroom) where speaking is expected, despite ability to speak normally in other situations.^[1] Selective mutism is estimated to affect 0.1-0.7% of the population, but the condition is likely under-reported due to poor understanding of this condition by the general public. Symptoms usually begin between 2.7 and 4.2 years of age.^[2] This article will offer some tips on how to overcome selective mutism and minimize its detrimental effects on the affected individual's social functioning.

EditSteps

Check to see if you, a friend, or loved one, meet(s) the criteria for having selective mutism:
- Consistent inability to speak at specific social situations (e.g. at school) where speaking is expected.
- Ability to speak and interact normally at other situations.
- The inability to speak under certain situation is having a negative impact on social and academic functions.
- The symptoms lasts for longer than 1 month, excluding the first month of school (takes time to adjust to new environment).
- The symptoms cannot be accounted for by unfamiliarity with the spoken language under the given social situation (i.e. a girl fluent in another language who knows very little English and remains quiet in situations where English is spoken does not have selective mutism!)
- The symptoms cannot be accounted for by another disability, such as autism/Asperger syndrome, schizophrenia, or general psychotic disorders.
- The inability to speak is not by choice, but rather by extreme anxiety preventing the individual from speaking.
Recognize the extent to which selective mutism is affecting your daily functioning. In order to overcome selective mutism, you must first recognize how it is affecting you. Find out the specific circumstances under which you are unable to speak. For example, a child may speak normally with peers, but unable to speak with adults. Another child may speak and behave totally normal at home, but remains completely silent at school. By identifying the specific situation where selective mutism manifests, you can help direct your efforts to overcome selective mutism under these circumstances.
If you can get others to help, try to overcome selective mutism gradually with the "Stimulus Fading technique": under a controlled environment (where help is readily available), interact with someone whom you can communicate with comfortably. Then gradually introduce another person to interact with to join the conversation. Start with the most comfortable person you can talk with and progress gradually to the most uncomfortable person for you to talk to. The idea of this technique is that the anxiety caused by the persons you feel uncomfortable interacting with will "fade" away when this stimulus is associated with another person you feel very comfortable interacting with.
If the technique above fails to work completely, or cannot be carried out readily, try to overcome selective mutism using the "Systematic Desensitization technique":

First imagine yourself in the situation wherein you cannot speak, then imagine speaking, then try to interact with persons in that scenario indirectly, e.g. via letter, e-mail, instant message, online chat, etc.

Then progress to more interactions, such as by phone, then interact at a distance, and eventually to more direct interactions. This method is also highly effective for numerous other anxiety disorders, such as specific phobias. The idea of this method is to overcome the anxiety causing inability to speak by gradual exposure to increasing levels of the anxiety-provoking stimulus, eventually becoming desensitized enough to overcome the actual situation.
Practice as necessary with all kinds of communications; become comfortable getting attention, raising your hand, nodding/shaking your head, pointing, writing, making some eye contact, etc.

Introduce speaking a little at a time, and progressively speak a little more. Gradually increase the comfort level. Due to the extreme anxiety, it is crucial to get as much help and encouragement from others as possible.

Try audio recordings of one's own voice, then replaying the speech to develop comfort with speaking -- this technique is known as Shaping. Practice whispering at a public place as in an office or classroom with a friend/parent or teacher; and practice gradually increasing the volume to a talking level.
Use "Contingency Management," whereby you get a simple reward for speaking under anxiety-provoking situations.
Focus on positive thinking to help overcome the anxiety. Instead of thinking "I can't talk..." think "I can try to talk and make it possible if I work at it! "
Realize that butterflies (nervousness or even shaking) are common in certain situations; hence, you should start with smaller groups. One may benefit from public speaking classes for learning to do presentations, and even for small venues such as job interviews. Entertainers and other public speakers get used to having that stress when speaking or singing for a large audience. Sometimes, however, even well-experienced entertainers turn to drugs to attempt to control these stressful feelings, to relax on stage. Later in one's career while being naturally relaxed, one may desire to feel the old excitement, when it is rarely felt at all. Often, at the head table or on stage one may look at each other to offer support and to get a smile or a nod of appreciation.

There is considerable stress related to new social situations as well as in the larger venues with crowds.
For severe selective mutism, the above techniques may not work adequately to overcome the disability. In that case, you should seek professional help and may require the use of medications to cope with selective mutism. Common medications prescribed to help reduce anxiety to allow speaking and interaction include fluoxetine (Prozac) and other selective serotonin reuptake inhibitors (SSRIs). Use of medications should be combined with repeated practice of the above techniques and anxiety-reduction techniques for greatest likelihood of overcoming selective mutism.

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EditTips

Selective mutism can be a very disabling and difficult condition to overcome. The techniques outlined above may not work for everyone, especially the more severely affected. Do not be disheartened, but keep trying to overcome and use as much support as possible.

EditPersonality Considerations

For an older child or adult, it is more important to focus on positive thinking and improving interpersonal skills to reduce anxiety under social situations. A good book to read is "How to Win Friends and Influence People", by Dale Carnegie.
You should start using these methods to overcome selective mutism as soon as possible. Waiting will only reinforce the maladaptive behaviors and makes it more difficult to overcome later.
Introverted personalities tend to like to be sure of what to say, and then may condense it to a paragraph, sentence or only a phrase to avoid talking without "thinking it through." They may close up if challenged.
- Introverts may distance themselves from controversy or self-revealing comments or negative attention.
- Extroverts, on the other hand, may enjoy thinking aloud and even "pontificating," holding attention for as long as possible and using techniques to get and call attention to oneself even when others would consider it negative attention.
Seek professional help early if symptoms are severe.
Non-aggressiveness seems more likely for the introvert, but might be exhibited by passive-aggressive secretive practical jokes, "trick or treat" activity, since that might not entail a direct confrontation as no one may know who did the covert behavior... Sometimes a recessive reaction (withdrawal) may seem to be due to passive-angry or paranoid feelings.
- Some introverts may experience a more severe kind of stage-fright and may react by being totally-quiet.
  - An extrovert may react by becoming challenging, angry or excessively acting out under the circumstances that would overwhelm the introvert.
- Introverts may be open and more outgoing when playing a game that allows mistakes and foolishness, but seek to be less public and to not be noticed when mistakes would be corrected or subject to cut-downs.
Consider ambiversion (balanced interactivity), introversion (covertness, recessiveness) and extroversion (overtness, assertiveness) as basic personality types, but running a broad scope or full spectrum of variations.^[3] Those called ambiverts appear noticeably well-rounded, balanced and not extreme in either regard (recessive or assertive). Extroversion and introversion may be typically viewed as a single continuum. So, to be high on one is necessarily to be low on the other:^[4] Extreme recessive traits (including tongue-tied reactions in certain public settings) may be quite common to a very introverted person's life, but may seem selective -- if that person is rather assertive and expressive when not feeling insecure at certain places or when among trusted colleagues, friends and family.
For a young child, contingency management and shaping tend to work better, and have been shown to maintain speech at 13-week follow-up.^[5]

EditWarnings

The use of medications should be considered last resort, especially for selective mutism. All drugs have adverse effects. Fluoxetine, in particular, may cause drowsiness, trouble sleeping, excessive sweating, headache, yawning nausea, diarrhea, nervousness, feeling weak. Infrequent, but severe, side effects may include itching, hives, joint and muscle pain, fever, chills, rash, and trouble breathing. Rare side effects include neuroleptic malignant syndrome, serotonin syndrome, adverse drug interaction (e.g. when taken concurrently with a monoamine oxidase inhibitor, such as phenelzine, tranylcypromine, or isocarboxazid, may lead to serotonin syndrome), hepatitis, erythema multiforme, seizures, swollen lymph nodes, abnormal liver function tests, allergic reactions, causing low blood sugar, hyponatremia (low amount of sodium in the blood), increased risk of bleeding, excessive cheerfulness and activity, mild degree of mania, or having thoughts of suicide.^[6]

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