What is Selective Mutism?
Selective mutism is a diagnosis that describes a child who does not speak in certain situations where speech is expected (such as at school or in public) but is able to speak normally in at least one other setting (such as at home). According to the Diagnostic And Statistical Manual (DSM-V), this impairment must be interfering with the child’s education or occupational achievement or be impacting his/her social communication in order for the child to qualify for the “Selective Mutism” diagnosis. The child must also have been experiencing the selective mutism for at least one month, cannot be due to a lack of knowledge or comfort with the language in use, and cannot be better explained by some other communication disorder (ex. stuttering). Keep in mind that this is much more severe than the typical “shy” child.
Treatment for Selective Mutism:
Unfortunately, the research base for treatments of selective mutism is limited. There have been many studies published presenting treatment methods for selective mutism but few are based on large populations to give us a good idea of how those methods perform on more than 1-2 subjects. Also, there haven’t been any large scale studies comparing the different treatment methods.
In other words, there is no research that tells us which therapy method is the best for children with selective mutism. We must simply review the current treatment models and select which method we think will work best for a certain child. Then, we must take careful data and change course if we see that the treatment model is not working.
Who Should Be Involved in Treatment:
Selective mutism is defined in the DSM-V as a psychiatric disorder. However, selective mutism is also a disorder of communication. For that reason, a psychologist or psychiatrist must work together with a speech-language pathologist to provide treatment for a child with selective mutism. One of these professionals working alone will not be sufficient to fully help the child.
4 Components of Treatment for Children Selective Mutism:
In 1996, Holly Harris wrote an article called “Elective Mutism” for the Language, Speech, and Hearing Services in Schools Journal. In this article, she outlined the 4 main components of treatment methods for selective mutism. Although you could just select one component to use as your entire treatment plan, it makes more sense to select multiple components and combine them together based on the needs of the individual child.
Component One: Psychodynamic Treatment Approaches
This first component of treatment is what we would call “psychotherapy” or therapy that is conducted by a psychologist or psychiatrist to address psychological concerns in the child. The speech-language pathologist would not be heavily involved in this type of therapy unless additional communication concerns arose during the treatment. However, the other components of selective mutism treatment can be combined with this component (with appropriate collaboration) to create a balanced and cohesive treatment plan. Since I am not a psychotherapist, I will refrain from commenting any more on this component of treatment.
Component Two: Family Intervention Approaches
Some children experience selective mutism as a result of family conflict and problematic family dynamics. If this is the case, family counseling should be provided to alleviate some of these concerns. Again, this would be done by a counselor and not a speech therapist, but the speech therapist does have an important role in family counseling when it comes to teaching appropriate communication strategies and techniques to families.
Families should be kept informed of strategies that are being used at school or in therapy so they can use those strategies at home or in other settings.
To download my handout for parents and teachers on what selective mutism is and how they can help at home and in the classroom, click the button below:
Component Three: Behavior Modification Approaches
Enter: The Speech Therapist! Ok folks, here’s where we jump in. Behavior modification can be added to a treatment plan as a way for speech therapists to help improve functional communication in the school environment (or other settings if working in private practice). For this we will use our trusty sidekick of “Operant Conditioning”. Remember him? Ok, maybe he’s more of a rusty sidekick. Let’s brush off the ole’ college textbook and refresh our memories on this one.
Operant Conditioning comes from our buddy BF Skinner and is based on the premise that behavior which is reinforced tends to be repeated (i.e. strengthened); behavior which is not reinforced tends to die out-or be extinguished (i.e. weakened). Therefore, Operant Conditioning is simply when we change a child’s behavior by reinforcing desired responses and not reinforcing (or sometimes punishing) non-desired responses. Ok, not so rusty, huh? You probably do this every day, you just don’t think about it in such formal terms.
One type of behavioral modification therapy that has been described in the literature is called “Stimulus Fading”. In this approach, you create an environment that the child will be comfortable communicating in. This may include bringing the parent into the school setting (if the child speaks only with the parent) or taking the therapy to the child’s house (if the child only speaks at the home).
Once the child is comfortable and communicating, you gradually make the communication situation more like your target situation (which is usually communicating in the classroom). You will start by gradually introducing a new person to the room (like a teacher or a peer) by first having them in the room but not participating and slowly have them come closer and closer to the child (over a course of several sessions). Then, you have that person interact with the child through the therapist or parent and then eventually get to the point where that person is interacting with the child directly.
Once the child is communicating with several communication partners, then you move those exact people to a new location. For example, you would move the therapy back to school if it was being done at home or you move from the therapy room to the hallway and gradually move closer to the child’s classroom. This gradual transition helps the child become comfortable communicating with different people and in different settings.
A second behavior modification technique is called “shaping”. In this approach, the child is reinforced for any attempts at communication, starting with gestures or non-verbal communication and those attempts are gradually shaped to audible speech. Once the child is used to being reinforced for non-verbal communication, the child is encouraged to try mouthing words, then whispering, and eventually speaking. This transition is done gradually and at a pace that the child is comfortable with.
When using the shaping technique, the child is reinforced more heavily for communication attempts that are farther along this continuum. For example, if the child merely points to the M&M, she gets one piece of candy. If she mouths the word, she gets two. If she whispers the word, she gets 3. And if she says the word out loud, she gets a whole handful of candy. Keep in mind that the reinforcement must be motivating to that particular child. You may think that getting super excited and loud and hugging a child would reinforce the behavior but if she has some social anxiety already and doesn’t like that kind of attention, it may actually encourage her not to speak out loud again. Some of these children may just want you to very quietly give them a whole bunch of what they wanted as a reward. Just judge what you think the child will like based on his/her reactions.
Component Four: Drug Treatments
The final treatment approach which has been mentioned in the literature is certain medications that are designed to alleviate anxiety symptoms in children (or adults). Again, this is not my area of expertise so I will not be speaking more on that topic, but I wanted you to know what’s available.
Combining Therapy Methods
A complete therapy program should be designed through collaboration with the child’s family, speech therapist, psychologist/psychiatrist/counselor, and teachers/educators. The components listed above should be combined in any manner that best suits the needs of the individual child. For example, the psychologist could be doing psychotherapy and family counseling while the speech therapist is doing behavior modification at the school.
Download the Handout:
Click the button below to download a handout that will explain what selective mutism is and give suggestions for how to help a child with selective mutism: