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Introduction
Those that have worked with selectively mute children have encountered wide variations in their social actions. Some children enjoy contact with others and will play easily, but remain silent. Some have a close friend who often speaks for them by interpreting gestures. Others find all aspects of social situations uncomfortable and do not participate at all. Whatever form the condition takes, it can persist. There are children in the 2nd, 3rd, and 4th grades who have never spoken in school. There are students in high school who have not uttered any or no more than a few words in a school setting. As you can imagine, the condition can have dramatically negative effects on social functioning.
What is Selective Mutism?
Selective mutism refers to selective silence in a child who speaks freely in very familiar situations. Children who demonstrate this condition appear comfortable and talkative with close family members. However, whenever people other than the closest family members are present, the child is quiet and shy. Some children avoid eye contact and do not communicate in any form with others. They refrain from the use of gestures or changes in facial expression.
Selective Mutism is defined by:
1) a persistent failure to speak in special social situations despite speaking in other situations
2) lack of speech which interferes with educational or occupational success
3) silence is of at least one month's duration after the beginning of the school year
4) failure to speak not due to lack of knowledge of language used in the situation
5) the disturbance is not solely accounted for by a Communication Disorder, Psychotic Disorder, or a Pervasive Developmental Disorder.
How prevalent is selective mutism?
Selective mutism occurs in a small number of children, probably less than 1% of children in the elementary school settings. It is not known how often children demonstrate the problem during the pre-school years. Prevalence may be higher in the pre-school years because many more children are attending preschool programs than in the past. Children who have developmental language or articulation problems and children whose first language is not English are more likely to be selectively mute. In both circumstances, children may be quiet because of concerns about accents and limited fluency.
How does selective mutism develop?
Research shows that most children with selective mutism were anxious in social situations from an early age. Contrary to many popular ideas, most selectively mute children have not experienced trauma. Rather their history often includes a toddler period of appropriate language development at home, but clingy, dependent behavior in the presence of unfamiliar or infrequently encountered people. Some children have shown mild forms of separation anxiety, although overt refusal to attend school is not usual. For children for whom English is a second language, case studies usually indicate that the children were not comfortable speaking with people in their first language either.
At this time, researchers believe that most selective mutism is a form of social phobia: that is, an anxiety disorder that reflects inhibited social actionts for fear of embarrassment or concerns that others will judge them negatively. Some children have reported that their throats clog up when looking at others as if their vocal chords will not permit them to speak. It is probable that children with the condition have inhibited dispositions as part of their personality characteristics. Extensive studies by Dr. Jerome Kagan and his colleagues have found that about 5% of children react to novel situations with high levels of uncomfortable arousal and a tendency to withdraw. This pattern is observed as early as infancy and can persist into the school-age years. Anxiety disorders often develop in such inhibited children because they have not learned to quiet their reactions or they have not learned to cope with their fears. It is believed that children who demonstrate selective mutism are a subset of inhibited children who have not learned to quiet their nervous reactions in social situations. Well-intentioned family members who are aware of a child's anxiety probably supported their limited use of speech by talking for them. Initially, this is not a problem, but, as the condition persists, support has probably become overly protective. By the time the condition is diagnosed, children have learned to communicate nonverbally for several years so that their patterns are usually well developed. Often, when the children are pushed, even mildly to speak for themselves, they may have overt outbursts and oppositional behavior. In summary, most professionals believe that selective mutism results from a negative interaction of a child's disposition with family reactions that inadvertently support withdrawal and lack of communication.
Treatment approaches
The effective treatment of selective mutism consists of steps to address three basic problems:
* The child's high level of anxiety in social situations.
* The limited experience the child has had in speaking with people other than family members.
* The high level of support that is present for nonverbal communication.
Supportive or exploratory psychotherapy has not proven very successful. Although these approaches may be important in building greater confidence and a more relaxed orientation in life, they have not been successful in altering the problem of limited speech in social settings. Therefore, professionals have turned to methods helpful in anxiey reduction and skill building. Behavioral therapy with family intervention and the use of medications, alone or in combination have been described most recently. We describe elements of a behavior therapy approach that is utilized at the NYU Child Study Center and review the use of medication next.
Behavior therapy: Psychoeducation Following a thorough assessment of the child's development and psychosocial history through interviews with parents or guardians and with contact persons such as teachers, the parents and other caretakers are provided with information. They learn how mutism may have developed child and how they can help to overcome the problems through changes in their reactions and practices. A description of treatment goals and treatment steps is provided in order to engage all in a collaborative effort. Guardians have an active role and are requested to participate in reinforcement of change and reinforcement of practice. Children are informed that they will be required to gradually talk to familiar people in the presence of others and then to talk to others. The use of rewards and punishments is introduced for motivation for change.
TechniquesA multimodal format based on research findings incorporates a number of different techniques:
1) anxiety reduction
2) graduated exposure to feared situations
3) behavior modification for efforts in graduated exposure
4) self-modeling of appropriate actions
5) auditory and video recordings used in settings in which the child is quiet
6) cognitive restructuring so that the child externalizes the condition
Depending on the extent and duration of the problem, all of these methods may be necessary or an abbreviated use of some techniques may prove useful.
Anxiety reduction Treatment can incorporate several methods for anxiety reduction. Medication therapy, discussed below, can reduce anxiety reactions through changes in chemical reactions within the brain. Anxiety reduction can be accomplished through the use of training in deep muscle relaxation. Training is done with the parent or other family member present to increase the child's confidence. The child is expected to listen only during these sessions. Muscle relaxation methods are taught and practiced, and children are then guided to use these with deep breathing efforts. Tapes of instruction are made for home use and children are expected to practice twice a day for several weeks so that they have the ability to calm themselves easily.
Graduated exposure and desensitization Graduated exposure refers to the step-by-step presentation of situations that produce anxiety. For mutism, this means the gradual introduction of people into situations in which the child is talking comfortably. Desensitization is the process of achieving comfort in the presence of formerly anxiety-arousing situations. Once a child has learned to relax, he or she is placed in situations in which he or she will talk comfortably, and gradually other persons are introduced into that situation while talk continues. For example, parents and the child play, draw, and talk in the therapist's office. Parents are directed to ask questions and to discuss the child's activities. At this time, the therapist is not present, so that the child gets comfortable talking in the setting. Next, a recording of the conversation is made while the therapist is absent, but the parents, child, and therapist listen to it together. Then, the parents and child continue to talk with the door open and the therapist just outside the door. Next, the therapist gradually moves into the room and gradually establishes eye contact with the child while the child continues to talk to the parents. Gradually, the therapist participates in the conversation. Once the child speaks with the therapist, the parents gradually pull back and eventually leave the room while the child talks to the therapist. Each of these steps is facilitated through the use of rewards when the child speaks under the new conditions. Movement to a new step is conducted only after the child has been successful and is comfortable with all previous steps.
Since the steps described to break the cycle of silence are difficult to achieve, several sessions are needed to proceed slowly through the steps. Once the child is speaking with the therapist, a plan for generalization to other people and other settings is implemented. Other people are added to the meetings and arrangements are made to include the child's teacher and other school personnel. Usually, the child is required to speak to the teacher when other children are not present. Soon afterwards, other children are added to the situation in gradually increasing numbers. Responding in class to teachers' questions and reacting to peers in conversation are the final goals. To promote generalization to situations outside of school, assignments are given to the parents to have child speak to peers and adults in and out of the home. Parents are asked to plan situations in which the child speaks to them while they gradually introduce other persons.
Graduated exposure has failed in some cases with children unable to budge even in the most comfortable of settings. At these times, extended sessions are required with the goal that the child must cooperate by talking briefly before being able to leave the clinical setting. Some of these sessions have lasted for hours, but they have been followed by success in most cases.
Behavior modification All of the steps in graduated exposure should be connected to some form of reinforcement program. Social praise and other forms of social reinforcement are earned along with concrete or activity rewards to motivate the child to overcome his or her high levels of anxiety experienced. The parents should be involved in providing the rewards, so that it is clear to the child that the family wishes to see more social behavior. Social rewards help the child who has been isolated learn that smiles and pleasant statements from others are good things that can be enjoyable.
Self-modeling and recordingsSelf-modeling refers to a procedure in which a person observes him/herself performing at the most effective level possible. Special video tapes can be constructed in which the child answers a set of questions presented by the parents or therapist. Another section of video tape is made of the teacher or other appropriate person to whom the child has not talked asking the questions. A specially-edited tape is then made which shows the person asking the questions followed by the child answering them, giving the impression that the child is having a conversation with the person.
Additionally, playing tapes of a child speaking, either audio or video, has been found to be helpful. This method allows other children to be aware that the child is able to speak, decreases any anxiety associated with the child being observed by others, and results in experiences which dispel fears that the child will receive negative feedback if heard or seen talking. It is recommended that this method be utilized when generalization of talking from the therapeutic setting to the school setting is the goal.
Externalizing the disorder Once they have begun to make progress, most children become enthusiastic and interested in improving. To help motivate continued gains once a child has begun to speak to the therapist, we have found it helpful to have the children consider the disorder as independent of them. They are asked to consider that mutism sends them messages to be constrained and quiet. We ask them to perceive the disorder as evil and nasty. We give negative attributions to the disorder and tell the child that it wants him to have a bad time. As therapy progresses we often keep track of who is winning by asking the child how homework tasks have been completed and whether the disorder is winning. This method has added an important motivational element to treatment and probably helps children gain control over the disorder and its impact on their reactions. In particular, oppositional children turn against the disorder in contrast to people who encourage talk.
Medication therapy Over the years several groups of psychotropic medications have been tried with limited success reported until the SSRI's (Selective Serotonin Reuptake Inhibitors) were utilized. The SSRIs work to increase the influence of serotonin in the brain. Serotonin is a chemical which has been shown to be at low levels in children and adults that are susceptible to anxiety reactions and anxiety disorders. When serotonin's influence is increased, people report that they can overcome anxiety reactions and worried thoughts. In the treatment of selective mutism, use of SSRIs, such as sertraline, fluoxetine, and an MAOI (monoamine oxidase inhibitor) such as phenelzine, have been successful in increasing the number of situations in which children will talk.
Our experience has shown that medication by itself leads to improvements, but not always to functional speech, which is the ability to speak in almost all settings in which it is appropriate and required. We have found that supplementing medication with behavior therapy results in more children achieving functional speech. We have also found that the use of behavior therapy with medication allows us to eventually eliminate medication as the children practice speaking in more settings. We are following many cases of children after the use of behavior therapy alone or behavior therapy with medication followed by medication withdrawal who are described by their subsequent teachers as being no different than other children in their social interactions.
Treatment effectiveness and the future
Although rare, selective mutism deserves careful attention because of its persistence and debilitating impact on young children. Behavioral therapy approaches, the use of medication, and their combination are receiving more attention in the treatment of selective mutism. With the publication of careful case studies and controlled studies that incorporate good scientific designs, mental health professionals now have the resources to formulate sound plans for the treatment of selective mutism. Although much scientific evaluation needs to be completed before it can be said that we have a definitive cure, the picture is much brighter than it was even 5 years ago.
References and Related Books and Resources
Web Resources
The Selective Mutism Group
www.selectivemutism.org
The Nature of Selective Mutism
Anstendig, KD (1999) Is selective mutism an anxiety disorder?
Journal of Anxiety Disorders, 13, 417-434.
Dummit, ES, Klein, RG, Tancer, N, Asche, B, et al. (1997) Systematic assessment of 50 children with selective mutism. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 653-660.
Treatment: Psychosocial Methods
Anstendig, K (1998) Selective mutism: A review of the treatment literature by modality from 1980-1996. Psychotherapy, 35, 381-391.
Blum, NJ, Kell, RS, Starr, HL, Lender, WL, Bradley-Klug, KL, Osborne, ML, & Dworick, PW (1998) Case study: Audio feedforward treatment of selective mutism. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 40-43.
Dow, SP, Sonies, BC, Scheib, D, Moss, SE et al. (1996) Practical guidelines for the assessment and treatment of selective mutism. Annual Progress in Child Psychiatry and Child Development, 452-472.
Schill, M, Kratochwill, TR, & Gardner, WI (1996) An assessment protocol for selective mutism: Analogue assessment using parents as facilitators. Journal of School Psychology, 34, 1-21.
Watson, S (1995) Successful treatment of selective mutism: Collaborative work in a secondary school setting. Child Language Teaching and Therapy, 11, 163-175.
Treatment: Medication
Dummit, ES, Klein, RG, Tancer, NK, Asche, B, et al. (1996) Fluxoetine treatment of children with selective mutism: An open trial. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 615-621.
Carlson, JS, Kratochwill, TR, Johnston, HF (1999) Sertraline treatment of 5 children diagnosed with selective mutism: A single-case research trial. Journal of Child and Adolescent Psychopharmacology, 9, 293-306.
Golwyn, DH & Sevlie, C (1999) Phenelzine treatment of selective mutism in four prepubertal children. Journal of Child and Adolescent Psychopharmacology, 9, 109-113.
