Michael A. Tompkins, Ph.D.
Co-Director of the San Francisco Bay Area Center for Cognitive Therapy
I met Margaret when she was 5-years old. She wore faded overalls inherited from her older brother that her mother had embroidered with flowers, stars, and hearts. Her mother had to pull Margaret into my office. Once there, Margaret burrowed her head into her mother’s side and would not look at me. When I asked Margaret a question, she whimpered but otherwise said nothing. Margaret’s mother told me that Margaret had been shy all her life. She spoke only to them, her brother and her younger cousin when she came to visit. Margaret’s older brother would often communicate for her and was quite protective of her. Margaret’s parents had stopped taking her to family gatherings because she would whine for days before the scheduled event and then, once there, she would run to a room where she could read or play alone. Margaret’s teacher no longer encouraged Margaret to speak or to read during circle time and would often permit Margaret to sit at her desk rather than in the circle with the other kids. Margaret’s parents no longer had friends or family members to their home because it was so stressful for Margaret and they had become quite isolated themselves.
Social phobia appears to affect approximately 1% of the general population kids and teens. A small percentage of socially anxious kids are selectively mute, that is, children who are particularly shy and fearful of social situations in which others expect them to speak, interact, or perform. Therefore, selectively mute children speak only in certain situations or only to certain people. The prevalence of selectively mute children in the general population is quite small (perhaps less than 0.5%) but may be underreported as most children “outgrow” the problem. Although selective mutism is viewed by some researchers as a form of social anxiety, it can be a symptom of other psychiatric disorders such as schizophrenia, depression, neurodevelopmental disorders (such as autism spectrum disorders or severe expressive language disorders), or hearing problems.
For socially phobic kids, silence is a way of coping with anxiety (or even terror) and requires a flexible and comprehensive treatment approach. The components of cognitive-behavior therapy for selective mutism includes varies from child to child but always includes graduated exposure, modeling, and reinforcement of approach behavior (speaking to peers or teachers, or in any social situation in which the child is expected to speak). Here are a few guidelines that I follow when I work with selectively mute kids.
Use a variety of exposure-based approaches. A central ingredient in the treatment of all anxiety disorders is exposure to the feared situation or object. In the case of a selectively mute kid, this usually means social or performance situations of one sort or another. When selecting exposure tasks, it is essential that clinicians consider the child’s age and developmental level. For example, systematic desensitization is effective for older children and adolescents but younger children may have trouble imaging fear stimuli or mastering progressive muscle relaxation (key components of this intervention). Emotive imagery in which the child imagines a favorite fearless superhero while in the presence of the feared social situation or event may be more effective for young children or children who have trouble imaging. Videotaping the child speaking, singing or performing is another useful exposure-based approach. For example, I videotaped Megan, a socially anxious 7-year old, reading a favorite story. Megan, her mother, and I then develop a list of various “audiences” that she rated according to how scary it would be for her to have someone watch the videotape. Her list included (in order of difficulty) her parents, cousins, aunts, and uncles; her school friends and her teacher; relatives she was less acquainted with; and, friends of her parents who she did not know. At first the videotape was shown to each audience without Megan present because this was less anxiety provoking for her. Later, Megan was in the back of the room with the audience as they viewed the videotape, and as she became less anxious, she sat with the audience while they watch the videotape together. Gradually, Megan moved through these exposures until she was ready to try reading aloud to the audience herself. Additionally, therapists can reward selectively mute children for speaking to them by saying words using a kazoo or paper-on-comb. This is more fun for the child and often less anxiety provoking.
Reward Pro-social behavior, including speaking. It is essential that parents learn to reward the child for remaining in the presence of an anxiety-provoking stimulus for progressively longer periods of time or for any pro-social behavior they observe. For example, parents might work with their child to set small goals for each social encounter, “Wave hi to your Uncle Jim when we see him at the party.” I work with parents to create a clear and simple incentive system (such as chip or point systems) to reinforce appropriate social behavior in the home, school and other settings. I like to ask parents to take photos of these successes and then they and the child post somewhere in the house. One selectively mute child posted her photos in the hallway to her bedroom. She proudly called it her “Walk of Talk.”
Encourage an attitude that expects and rewards pro-social behavior. Often socially anxious children are not adequately reinforced for social behavior or are inadvertently reinforced for nonsocial behavior. For example, Jill a shy 5-year old would drift off to her room whenever her parents had visitors to their home. Jill’s parents had given up encouraging Jill to speak even to friends and family members and admitted that it was easier to let her play in her room alone. Over time, Jill’s parents stopped taking Jill to family gatherings altogether. Eventually they stopped seeing friends and family themselves because they felt guilty about leaving Jill so often with a sitter. I encourage parents (and others who are part of the child’s social network) to adopt an attitude that the child can and will speak or engage in pro-social behavior of some kind in every social situation. This may be difficult for parents who are socially anxious themselves and are giving their child mixed messages regarding social behavior. I recommend clinicians meet with parents to assist them to develop an attitude that their child can speak and engage in other pro-social behaviors.
Remember that socially anxious kids may have socially anxious parents. We are not born with a complete set of social skills. Many are learned and acquired through modeling and direct instruction by others, including parents, siblings, teachers and peers. Children who have anxious parents may fail to acquire these important skills because their parents seldom have friends over to their home or take their child to social events, or have serious social skill deficits themselves. Such children have few opportunities to observe pro-social behavior and appropriate and effective social skills (i.e., introductions, eye contact, hand shakes). I encourage parents to consider making changes in their own social lives in order to help their child. Some parents may require treatment. Others may be able to make these changes themselves. Parents who are working on improving and increasing their pro-social behavior are terrific models for their socially anxious kids.
Don’t underestimate or minimize how difficult pro-social behavior may be for some kids. Because nearly everyone has some social anxiety, parents, teachers and even clinicians can minimize the distress a socially anxious kid experiences in social situations or the impact social anxiety can have on a child’s life. This can result in clinicians and parents pushing a child too fast when doing exposures or overlooking a child’s true social skills deficits. Therefore, I recommend clinicians spend considerable time educating parents, teachers, and others involved in caring for the child about social anxiety and selective mutism. In particular, I try to help caretakers see that the anxiety a child experiences in social situations can be every bit as intense as separation or other common childhood fears. Understanding social anxiety and selective mutism can help parents set appropriate expectations for their socially anxious child that results in small but consistent successes in and out of therapy.