It’s Not Just Being Shy

Authored by: Saki Kuramoto

Art by: Eileen Cho

"She is just shy. Give it time, and she will grow out of it.” 

That was what everyone else would say, but it was not just shyness. This was the case of my cousin, who was recently diagnosed with selective mutism. Selective mutism is a severe anxiety disorder that prevents an individual from speaking in certain situations, such as public settings or novel environments [1]. These situations trigger the individual to become tense, expressionless, and unable to say a word. Veronica Raggi, a child psychologist in Maryland, notes that selectively mute children are often "talkative and expressive at home." However, as soon as they enter school, they become mute, unable to voice even one word, "all day, every day" [2]. 

Selective mutism comes in different forms, with varying degrees of severity and multiple symptoms.  For example, even with basic communication, individuals respond to their anxiety differently, with the most severe form leaving people with a total inability to communicate, leading them to avoid eye contact, have a paralyzed face, and behave irrationally to avoid talking [3]. Some selectively mute individuals have a lesser degree of mutism, which means that they predominantly rely on gestures or noises such as "uh-huh" to avoid speaking, and when they do speak, it is often slowed and stuttered.[4]. In communication alone, selective mutism is a broad anxiety disorder. 

The onset of selective mutism is predicted to begin at either the age of 3 or 6 and is often only discovered after the child enters school [5]. One of the difficulties with diagnosing selective mutism is that it is often mistakenly considered as a child being "shy", which unfortunately leads to untreated anxiety disorders that carry over into adulthood [6]. For this reason, although it is said that 1 in 140 children are affected by selective mutism, psychologists believe this number is underestimated [7]. 

Although parents and guardians seek psychological therapy for their children, one major issue, according to the American Psychological Association, is that only 4% of clinical psychologists in the U.S. are trained in selective mutism therapy [8]. The U.S. is experiencing a nationwide shortage of school psychologists, barring selectively mute children from getting the adequate attention and treatment they need [9]. Interestingly, researchers and speech pathologists have noted an increase in the diagnosis of selectively mute children after the COVID-19 pandemic lockdown [10]. Clinical psychologist Elizabeth Woodcock notes that through pandemic lockdowns, the children missed out on "socialization during the critical period of around preschool age," leading to general anxiety regarding speech. 

The current treatments for selective mutism fall under the umbrella of behavioral and cognitive-behavioral therapy. As mentioned earlier, the degree of selective mutism varies for each individual, which leads to the need for personalized therapy and treatment options. The three main speech therapy approaches are stimulus fading, shaping, and desensitization [12]. Stimulus fading is when people are gradually added to the environment, and the children are continuously rewarded for talking to new individuals [13]. Shaping is quite similar in that the goal is to create a gradual improvement to the desired behavior and long-term goal [14]. An example would be transitioning from simple nods to a question to using the words ‘yes’ and ‘no’. The third prominent speech therapy intervention is desensitization. In desensitization, psychologists attempt to reduce the anxiety and promote relaxation within the selectively mute individual [15]. The goal is that after some exposure, the selectively mute will become more sensitized to new encounters and begin speaking more.

It is imperative to note that the topic of selective mutism opens a new discourse of healthcare issues: invisible disabilities. Just by looking at my cousin, one would not be able to guess her selective mutism diagnosis. Many may not have heard of selective mutism until now, since the disability itself is invisible, and public awareness and engagement on invisible disabilities remain minute. Forbes reports that over 42 million Americans have a disability, and 96% of those are invisible, which means that around 40 million Americans go unsupported in daily life. Through this paper, I hope that I was able to shed light on selective mutism and created conversations regarding other invisible disabilities that society has disregarded. My goal is to shed light on these invisible disabilities to help create an environment where all different disabilities are supported and cared for.

References:

1. Hipolito, G., & Johnson, M. (2021). Selective mutism. In L. Cummings (Ed.), Handbook of pragmatic language disorders : Complex and underserved populations (pp. 247–281). Springer Nature Switzerland AG. https://doi.org/10.1007/978-3-030-74985-9_10

2. Raggi, V. (2023, April 3). Silent and overlooked: Children with selective mutism. Psychology Today. https://www.psychologytoday.com/us/blog/brave-voices/202204/silent-and-overlooked-children-selective-mutism

3. Selective Mutism: Symptoms & Treatment. (2023, October 2). https://my.clevelandclinic.org/health/diseases/selective-mutism

4. Selective Mutism: Symptoms & Treatment. (2023, October 2). https://my.clevelandclinic.org/health/diseases/selective-mutism

5. Koskela, M., Chudal, R., Luntamo, T., Suominen, A., Steinhausen, H.-C., & Sourander, A. (2020). The impact of parental psychopathology and sociodemographic factors in selective mutism—A nationwide population-based study. BMC Psychiatry, 20(1), 221. https://doi.org/10.1186/s12888-020-02637-6

6. Hipolito, G., & Johnson, M. (2021). Selective Mutism. https://doi.org/10.1007/978-3-030-74985-9_10

7. Muris, P., & Ollendick, T. H. (2021). Current Challenges in the Diagnosis and Management of Selective Mutism in Children. Psychology Research and Behavior Management, 14, 159–167. https://doi.org/10.2147/PRBM.S274538

8. Raggi, V. (2023, April 3). Silent and overlooked: Children with selective mutism. Psychology Today.

9. Raggi, V. (2023, April 3). Silent and overlooked: Children with selective mutism. Psychology Today.

10. May, N. (2023, December 9). ‘That’s not Maebel, she’s so fun’: The rising number of children who are afraid to talk. The Guardian. https://www.theguardian.com/society/2023/dec/10/selective-mutism-why-what-is-the-rising-number-of-children-mute-who-are-afraid-to-talk

11. May, N. (2023, December 9). ‘That’s not Maebel, she’s so fun’: The rising number of children who are afraid to talk. The Guardian. https://www.theguardian.com/society/2023/dec/10/selective-mutism-why-what-is-the-rising-number-of-children-mute-who-are-afraid-to-talk

12. Treating selective mutism. (2021, August 6). Selective Mutism Association. https://www.selectivemutism.org/treating-selective-mutism/

13. Treating selective mutism. (2021, August 6). Selective Mutism Association. https://www.selectivemutism.org/treating-selective-mutism/

14. Selective mutism. (2023, February 17). nhs.uk. https://www.nhs.uk/mental-health/conditions/selective-mutism/

15. Treating selective mutism. (2021, August 6). Selective Mutism Association. https://www.selectivemutism.org/treating-selective-mutism/