While selective mutism (SM) is an anxiety disorder often associated with young children, teens and adults can also suffer from SM. In many cases, teens with SM have been struggling with anxiety for years. It could be that the SM was not treated or perhaps was not responsive to the level of treatment provided in childhood. There also may be environmental factors that have maintained the anxiety inadvertently. For example, a well-meaning parent or teacher might assist an anxious child in avoiding distressing situations, and thereby reinforce the anxious avoidance cycle. After many years of practicing this avoidance, a child with SM may evolve into a teen who is very adept at not talking. While research on adolescent SM is still fairly limited, SM specialists have identified important factors to consider in supporting teens with SM.
Entrenched Avoidance Requires Treatment
Teens with SM often have ingrained patterns of avoidance and ineffective coping skills for managing anxiety. By this point, not speaking has become a familiar response and a teen’s identity as the ‘One Who Does Not Talk’ has likely been reinforced. At the same time, teens have increased self-consciousness about what others think and increased reflective capacity. As you might imagine, teens with SM often have comorbid anxiety or depressive disorders. Social anxiety is an especially common comorbid disorder which can make behavioral engagement with peers and adults difficult. For example, teens with social anxiety may struggle to raise their hand in school or to participate in gym class. Adolescents with SM are more at risk for these comorbid disorders given continued struggles over an extended period that result in impairment in school, social, and family functioning. Other manifestations of anxiety may also arise in the school setting such as perfectionism, procrastination, test anxiety, or even school refusal behaviors. For example, a teen might resist going to high school due overwhelming anxiety about participating in class and socializing with peers. A student with SM and social anxiety may struggle to turn in materials to the teachers, particularly if speech is expected in the transaction. These entrenched avoidance behaviors require treatment in order to reduce the risk of longer-term poor outcomes.
Social Isolation May Increase
As children evolve into teenagers, they inhabit a more cliquey social world. High schoolers often establish social groups, and friends will confide in one another and engage in shared hobbies. This evolution of socialization can be quite challenging for teens with SM who may struggle to share personal information, advocate for themselves, and initiate interactions. Because of this, teens with SM will increasingly stand out as different and may be at increased risk for teasing or bullying from peers. In the school settings, teens with SM benefit from warm relationships with teachers as well as thoughtful pairings in group assignments. Given increased social pressures in high school and college years, older teens and adults with SM are at increased risk for using substances such as alcohol or drugs to self-medicate for their anxiety. While many people find alcohol to be a social lubricate—making conversations and small talk more manageable—there is a thin line between appropriate use and self-medicating that must be monitored.
A Robust Treatment Plan
By the time children with SM reach adolescence, they have likely been struggling with anxiety about speaking for years. SM symptoms will be more deep-seated and may be more resistant to treatment. For this reason, it’s critical that the treatment approach for a teen with SM is comprehensive and well-staged to provide the extra boost needed to see progress. A teen with SM may require more intensive treatment—for example, scheduling 20–30 hours of treatment in one week versus 1 hour weekly sessions over the course of many months. More intensive treatment can build up more momentum in anxiety exposures and allow for greater gains in a short period of time. Exposures for teens may focus on real-life skills such as rehearsing interview questions, practicing presentations, or asking a question at the grocery store. Additionally, for teens with a history of selective mutism, a psychiatric evaluation is recommended to determine appropriateness of medication. For some children, getting on a stable dose of an anxiety medication before beginning treatment is critical to successful engagement in exposures. Who tends to be a good fit for medication? Often, kids who have already been anxious for years who have more pervasive SM symptoms will benefit from medication. Children who have difficulty engaging in CBT treatment may benefit from medication in order to participate in a meaningful way. Additionally, if a teen’s SM is comorbid with another disorder (such as depression), the symptom presentation will be more complex to treat and could benefit from medication.
What Are Medications for SM?
The most popular medications for SM are selective serotonin reuptake inhibitors (SSRI’s). These are considered the first-line treatment for anxiety disorders more broadly. Common SSRI’s used include Prozac and Zoloft, and the specific medication chosen may be influenced by family history of SSRI use. For example, if an anxious child’s parent has responded positively to Medication X with limited side effects, the child’s biochemistry could be similar and an appropriate fit for Medication X. Child psychiatrists would start a child on a small dose and gradually increase the dose while monitoring side effects. Some children may respond to a low dose of medication and others will require a larger dose to see a therapeutic effect. While parents may worry about potential side effects, there are also risks of under-treating. Every day that a child is impaired is demoralizing and negatively impacts self-esteem and self-efficacy. Long term, risks of under-treating anxiety disorders such as SM can be immense—including increased school absences, underachievement, impaired peer relations, and continued anxiety disorders in adulthood.
Getting Accommodations in School and at Work
For adolescents and adults with SM, school and work may be difficult to engage in successfully or fully. It can be hard for a teen to present, ask clarifying questions, and to engage behaviorally by raising their hand. Accommodations, such as an Individualized Education Plan (IEP) or 504 Plan from the teen’s school will be helping in obtaining a formal assessment and identifying the best supports for the child in the school setting. If your teen is struggling to engage in schoolwork or to attend school due to SM challenges, school accommodations will be particularly useful to create a more supportive environment at school to allow for learning. For example, assignments can be adjusted for teens with SM (e.g. presentations may evolve into a smaller group presentation or 1:1 presentation). A student could be permitted to write or videotape particular assignments. At the college level, school and work accommodations can also be provided. At this stage, assessment is often conducted through a private psychologist.
While it can be very challenging to see your teen struggle with SM symptoms, it is never too late to engage in behavioral treatment for SM! A thorough intake evaluation can support your family in identifying the best course of treatment including the frequency and intensity of sessions as well as medication considerations. Normalizing your teen’s experience with SM can be beneficial. Young adult books, like After Zero, tell empowering stories of children contending with SM. Such readings can help teens with SM to know that they are not alone.
Boorady, Roy, et al. “When Should Medication Be Used to Treat Selective Mutism?” Child Mind Institute, 17 Jan. 2020, childmind.org/article/when-should-medication-be-used-to-treat-selective-mutism/.
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“How Can You Help a 16-Year-Old Who Still Has Selective Mutism?” Child Mind Institute, 26 Oct. 2016, childmind.org/ask-an-expert-qa/how-can-you-help-a-16-year-old-who-still-has-selective-mutism/.
“Info: Older Children & Teens.” SMIRA, 11 Sept. 2017, www.selectivemutism.org.uk/info-older-children-teens/.
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“What Success Rate Is given to Treating Teens with SM?” Selective Mutism Association, 13 June 2016, www.selectivemutism.org/learn/ask-the-doc/ask-the-doc-archives/what-success-rate-is-given-to-treating-teens-with-sm/.