Some children speak abundantly and easily at home but demonstrate minimal speech in social settings outside of the home. These kids are often chatty and have good communication with people they feel comfortable with but restrict their speech when anxious. They carve up the world into distinct boundaries for who, where, and when they will speak. For example, a child may feel comfortable talking to their grandparents, but will not talk to neighbors or anyone in the community. Another child may talk to everyone in the community but exhibit no speech in school. Some kids will talk to select adults at school, but not to peers.

This predicament can be overwhelming and stressful for both kids and parents alike. It is easy for parents to feel uncertain about how to navigate this scenario and resort to short-term solutions that inadvertently maintain the problem. For example, parents and teachers may answer for the child when he is asked a question, rescuing him from his anxiety in the moment. Over time, rescuing by adults leads to an over-reliance on gestures to communicate and an even lower likelihood the child will respond verbally.

What can parents, teachers, and other concerned adults do to break this cycle? Here are some specific evidence-based guidelines for working with your anxious child to break the sound barrier.

Resist Asking Abrupt Questions at the Start of a New Interaction

Give your child time to warm up in any new social setting without prompting them with an immediate question. For example, when you arrive at the birthday party, don’t encourage your child to say “Happy Birthday.” Instead, explore the birthday area with your child, giving them freedom and positive attention without expectation or demand.

Provide Positive Attention and Let Your Child Lead

Use specific statements that demonstrate positive attention to the child’s actions and speech. That is, narrate your child’s actions and reflect any speech you hear. For example, “I see you checking out the birthday presents. Wow, those are some really colorful packages.” When you hear your child speak, repeat back what she shares with you. “Ahh, you are telling me you think there are Legos in that package.”

Many parents and teachers initially feel it can be awkward or uncomfortable to converse with children without leading, instructing, or asking questions. But with a little practice, this approach starts to feel natural and intuitive.

Consider Your Physical Proximity to Others

When your child has warmed up, start asking questions at a distance from the others present. The goal is to make it easy for your child to respond verbally because they are focused on talking to YOU and having fun. “Do you think Max’s cake will be vanilla or chocolate? I wonder if there will be a clown or magician?” Once your child is consistently answering your questions, start to move your conversation closer to others at the party. As your child becomes more comfortable with other adults and peers overhearing them speak, the likelihood they will answer others directly will increase.

If your child is still silent, take him to a quieter area (this may only need to be a few steps away or with your body blocking the visual view of others) and prompt again. When your child answers verbally, share your child’s response with others. “Ben said he would like the chocolate cupcake. Thanks, Ben for letting us know.”

This action is what psychologists refer to as “shaping” a behavior. When a child is having difficulty demonstrating a preferred skill or behavior, we often work towards the desired behavior by approximating it or developing it in smaller steps. Saying the words verbally at a distance or whispering into the ear of the parent is an approximation of the ultimate goal, that of full speech with the adults and peers at the party.

Praise and Reinforce All Verbal Behavior

There is a general rule in child behavior that whatever we give our attention to will increase in frequency. When a child responds verbally, it is important that this behavior is attended to and praised. You can reinforce speech by using both a reflection (repeat back what your child said) as well as specific praise (compliment aspects of her sharing). For example, your child says that she wants the chocolate cupcake. You say, “You want the chocolate cupcake. Thank you for letting me know what you want.”

It is important that any praise is natural, specific to the situation, and delivered in a manner that is comfortable for the child. Instead of saying, “Good job!” try statements such as, “I really like that idea. Thanks for telling me”, or “It is so helpful when you tell me what you want. Now I know just what to do.” Also, consider whether your child appreciates praise delivered calmly and nonchalantly or more enthusiastically. Many anxious children prefer praise that is relaxed and not too dramatic.

What Are My Next Steps?

Helping children work through a pattern of non-speech in community and school settings takes energy, time, and attention from all involved. If you are struggling to make progress and/or these concerns are causing distress to you and your child, consider seeking an evaluation from a mental health professional.

Children who speak expressively and easily in situations where they are comfortable, but display minimal or a lack of speech in situations when they are anxious, often meet the criteria for an anxiety disorder known as Selective Mutism (SM). Children with SM are speech-phobic and typically hyper-attuned to their social environment. They may feel frozen or panicky when speech expectations are present. Additionally, they often display broader self-conscious and socially anxious behavior, feeling easily embarrassed and disliking being the center of attention.

A full evaluation can determine whether your child meets the criteria for SM and support in the development of treatment goals and a specific plan to address it. The strategies presented above are part of an evidence-based program known as Parent/Child Interaction Therapy for Selective Mutism (PCIT-SM). Many children with SM and their parents benefit from working with a specialist to learn the techniques and strategies in a systematic way that is consistent with best practices and most likely to lead to success.

It is important to note that a full evaluation should also assess for other conditions that may be contributing to or explain the lack of speech. For example, developmental delays, deficits in receptive or expressive language skills, a social communication disorder, or struggles with second language acquisition, all can impact speech behavior. Understanding why your child is not speaking is an important precursor to having a treatment plan that works for your child. When children have other comorbid conditions, or the lack of speech is due to another reason, other interventions may be warranted and/or most appropriate. This post specifically covered tips and strategies for developing and increasing speech in children with primary anxiety.

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Project to Learn About Youth – Mental Health

The Project to Learn About Youth – Mental Health (PLAY-MH) analyzed information collected from four communities. The focus was to study attention deficit/hyperactivity disorder (ADHD) and other externalizing and internalizing disorders, as well as tic disorders in school-aged children. The purpose was to learn more about public health prevention and intervention strategies to support children’s health and development.

Read about the results of the Play-MH study

Study questions included:

• What percentage of children in the community had one or more externalizing, internalizing, or tic disorders?
• How frequently did these disorders appear together?
• What types of treatment were children receiving in their communities?

This project used the same methodology as the original Project to Learn about ADHD in Youth (PLAY) project. Read more about the original study approach here.

Other research

Read more about research on

• ADHD
• Tourette syndrome

CDC and partner agencies are working to understand the prevalence of mental disorders in children and how they impact their lives. Currently, it is not known exactly how many children have any mental disorder, or how often different disorders occur together because no national dataset is available that looks at all mental, emotional, or behavioral disorders together.

Research on prevalence

Data Governance for Children’s Mental Health

What is It and Why is It Important?

Learn more

Using different data sources

Healthcare providers, public health researchers, educators, and policymakers can get information about the prevalence of children’s mental health disorders from various sources. Data sources, such as national surveys, community-based studies, and administrative claims data (like healthcare insurance claims), use different study methods and provide different types of information, each with advantages and disadvantages. The advantages and disadvantages of different data sources include the following:

• National surveys have large sample sizes that are needed to create estimates at the federal and state levels. However, they also generally use a parent’s report of the child’s diagnosis, which means that the healthcare provider has to give an accurate diagnosis and the parent has to remember what it was accurately.
• Community-based studies offer the opportunity to observe children’s symptoms, which means that even children who have not been diagnosed or do not have the right diagnosis could be found. However, these studies are typically done in small geographic areas, so findings are not necessarily the same in other communities.
• Administrative claims are typically very large datasets with information on diagnosis and treatment directly from the providers, which allows tracking changes over time. Because they are recorded for billing purposes, diagnoses or services that would not be reimbursed from the specific health insurance might not be recorded in the data.

Using different sources of data together provides more information because it is possible to describe the following:

• Children with a diagnosed condition compared to children who have the same symptoms, but are not diagnosed
• Differences between populations with or without health insurance
• How estimates for mental health disorders change over time

Read more about using different data sources.

Rural Communities: Children’s Mental, Behavioral, and Developmental Disorders

Read more

National data on children’s mental health

A comprehensive report from the Centers for Disease Control and Prevention (CDC), Mental Health Surveillance Among Children —United States, 2013–2019, described federal efforts on monitoring mental disorders and presented estimates of the number of children with specific mental disorders as well as for positive indicators of mental health. The report was developed in collaboration with the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute of Mental Health (NIMH), and the Health Resources and Services Administration (HRSA). It represents an update to the first-ever cross-agency children’s mental health surveillance report in 2013.

Read a summary of the findings for the current report using data from 2012-2019

Read a summary of the findings for the first report using data from 2005-2011.

The goal is now to build on the strengths of federal agencies serving children with mental disorders to:

• Develop better ways to document how many children have these disorders,
• Better understanding of the impacts of mental disorders,
• Inform needs for treatment and intervention strategies, and
• Promote the mental health of children.

This report is an important step on the road to recognizing the impact of childhood mental disorders and developing a public health approach to address children’s mental health.

Reference

Holbrook JR, Bitsko RB, Danielson ML, Visser SN. Interpreting the Prevalence of Mental Disorders in Children: Tribulation and Triangulation. Health Promotion Practice. Published online November 15, 2016 https://www.ncbi.nlm.nih.gov/pubmed/27852820.

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It’s normal for children to experience sadness, irritability and anxiety every now and then. Sometimes it can be hard to tell whether your child is dealing with standard day-to-day stressors, such as juggling homework, sports, and social activities, or if it’s something more serious.  

In observance of Children’s Mental Health Awareness Week, Weill Cornell Medicine is helping families understand common children’s mental health issues, along with signs to look out for and tips for when to get help. 

Mental Health Challenges Children Face

Children and teens faced many pressures throughout the COVID-19 pandemic, and some of the effects of school closures and isolation may have lingered. Additional factors impacting children’s mental health include: 

• Bullying and peer pressure  
• Juggling school, sports and social activities  
• Busy schedules that preclude adequate time for rest and relaxation 
• Pressure to achieve good grades  
• Changing schools 
• Going through body changes  
• Fears about climate change and other serious issues 
• Discrimination based on race, gender, sexual orientation, religion, weight or disability  
• Lack of stable housing and food  

Not all of these challenges create long-lasting mental health issues for children and teens. There has been a lot of evidence showing that in the face of traumatic events, most kids do really well, as children are resilient and adaptive.

It’s when persistent, serious changes in how children behave in ways that interfere with their normal daily activities that may be cause for concern.  

How to Know If Your Child Is Struggling

As a parent or caregiver, you know your child best and understand what typical behavior looks like. Here are some signs that indicate your child may be having mental health challenges that go beyond ordinary daily stressors: 

• Loss of interest in the things they used to enjoy 
• Changes in sleep, weight or eating habits 
• Withdrawing from friends and family 
• Nightmares or other sleep disturbances  
• Heightened anxiety or worry 
• Inability to relax 
• Difficulty controlling emotions  
• Aggressive or stubborn behavior  

Having one of the symptoms on this list doesn’t mean your child is experiencing a mental health crisis. Hormonal changes typical of early and middle adolescence can affect your child’s moods and behavior. If you notice one or more of these signs and they persist over time, have a conversation with your child or talk to their pediatrician or another healthcare professional.  

Most Common Mental Health Conditions in Children 

According to the Centers for Disease Control and Prevention (CDC), attention deficit/hyperactivity disorder (ADHD), anxiety and depression are the most commonly diagnosed mental health disorders in children. Among U.S. children aged 3 to 17: 

• ADHD affects approximately 6 million children. Children with ADHD might experience trouble paying attention, controlling impulsive behaviors or have difficulty getting along with others.   
• Anxiety affects approximately 5.8 million children. Anxiety in children may manifest as excessive worry and fear that interferes with school, home or play activities, or physical symptoms such as fatigue, trouble sleeping or headaches. 
• Depression affects approximately 2.7 million children. Children with depression may experience changes in eating and sleeping patterns, feel sad or hopeless, have difficulty paying attention, or exhibit self-destructive behavior.  

Other mental health conditions that affect children include eating disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). 

What to Do If Your Child Is Having Thoughts of Suicide 

Mental health disorders such as depression and anxiety are significant risk factors for suicide. Other risk factors include social pressure relating to sexual orientation or gender identity, bullying, racism, alcohol and substance use, easy access to guns, and family experiences such as divorce, deployment, incarceration or unstable housing. 

If your child is experiencing mental health challenges that get in the way of normal day-to-day activities and functioning, open a conversation with them about what they’re going through. Talking about suicide won’t increase the risk your child will attempt it.  

“It’s a myth that the more you talk about suicide, the more likely the person will end up thinking about it,” says Cori Green, M.D., M.S., Vice Chair of Behavioral Health in the Department of Pediatrics and associate professor of clinical pediatrics at Weill Cornell Medicine, and associate attending pediatrician at NewYork-Presbyterian Phyllis and David Komansky Children’s Hospital at Weill Cornell Medical Center. “Opening  the  door to have a conversation about suicide can be protective.”  

You can also raise your concerns with your child’s pediatrician during a well-child visit. If your child is in immediate danger, call the Suicide & Crisis Lifeline at 988 or text “TALK” to 741741.  

How to Talk to Your Child About Mental Health  

Mental health issues can still carry a stigma, so it’s important to let your child know that they can talk to you about how they’re feeling, and that you love and support them no matter what. Assure them that everyone struggles occasionally and that help is available.   

When talking to your child about their mental health, the National Alliance on Mental Illness (NAMI) recommends: 

• Comparing mental health concerns to physical conditions to reduce stigma 
• Discussing self-care and prevention 
• Letting your child know their condition is not their fault 
• Validating their experiences 
• Checking in with them about suicidal thoughts.  

“It’s important for parents to know that anxiety is a normal part of life but to keep an eye out for when anxiety or mood symptoms are crossing that threshold for their children,” says Shannon Bennett, PhD, licensed clinical psychologist, assistant professor of psychology in Clinical Psychiatry at Weill Cornell Medicine, and director of psychology for the Division of Child and Adolescent Psychiatry at NewYork-Presbyterian/Weill Cornell Medical Center. “When kids are starting to withdraw or avoid meaningful life activities, that’s a time to talk to your doctor, find a therapist, or seek additional assessment or help.” 

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