Mental Health Awareness: Selective Mutism
WHAT IS SELECTIVE MUTISM?
Selective mutism (SM) is an anxiety disorder in which a person who is normally capable of speech does not speak in specific situations or to specific people. Selective mutism usually co-exists with shyness or social anxiety. Children with selective mutism stay silent even when the consequences of their silence include shame, social ostracism or even punishment.
Children and adults with selective mutism are fully capable of speech and understanding language but fail to speak in certain situations, though speech is expected of them. The behaviour may be perceived as shyness or rudeness by others. A child with selective mutism may be completely silent at school for years but speak quite freely or even excessively at home. There is a hierarchical variation among people with this disorder: some people participate fully in activities and appear social but do not speak, others will speak only to peers but not to adults, others will speak to adults when asked questions requiring short answers but never to peers, and still others speak to no one and participate in few, if any, activities presented to them. In a severe form known as "progressive mutism", the disorder progresses until the person with this condition no longer speaks to anyone in any situation, even close family members.
Selective mutism is by definition characterized by the following:
- Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.
- The disturbance interferes with educational or occupational achievement or with social communication.
- The duration of the disturbance is at least 1 month (not limited to the first month of school).
- The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
- The disturbance is not better accounted for by a communication disorder (e.g., stuttering.) and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder.
Selective mutism may co-exist with or cause the child to appear to have attention deficit disorder. Many people with the inattentive form of ADHD show little or no interest in other people. People with inattentive ADHD may appear to be "space cadets" or "out in their own world", and may be slower to respond to social stimuli. Children with selective mutism, especially when they have severe social anxiety, may also display this behavior. In addition, many children with selective mutism are highly sensitive, and they may be distracted from the task at hand by sensory input or their anxiety.
The former name 'elective mutism' indicates a widespread misconception among psychologists that selective mute people choose to be silent in certain situations, while the truth is that they often wish to speak but cannot. To reflect the involuntary nature of this disorder, the name was changed to selective mutism in 1994.
Selective mutism is an umbrella term for the condition of otherwise well-developed children who cannot speak or communicate under certain settings. The exact causes that affect each child may be different and yet unknown. There have been attempts to categorize, but there are no definitive answers yet due to the under-diagnosis and small/biased sample sizes. Many people are not diagnosed until late in childhood only because they do not speak at school and therefore fail to accomplish assignments requiring public speaking. Their involuntary silence makes the condition harder to understand or test. Parents often are unaware of the condition since the children may be functioning well at home. Teachers and pediatricians also sometimes mistake it for severe shyness or common stage fright.
Selective mutism occurs in all racial and ethnic groups. The majority of reported cases are of white and interracial children. However this could be due to under-diagnosis and under-reporting in other ethnic groups.
Most children with selective mutism are hypothesized to have an inherited predisposition to anxiety. They often have inhibited temperaments, which is hypothesized to be the result of over-excitability of the area of the brain called the amygdala. This area receives indications of possible threats and sets off the fight or flight response. Given the very high overlap between social anxiety disorder and selective mutism (as high as 100% in some studies, it is possible that social anxiety disorder causes selective mutism.
Some children with selective mutism may have trouble proccessing sensory information. This would cause anxiety and a sense of being overwhelmed in unfamiliar situations, which may cause the child to "shut down" and not be able to speak (something that some autistic people also experience). Many children with Selective Mutism have some auditory processing difficulties.
About 20–30% of children with SM have speech or language disorders that add stress to situations in which the child is expected to speak.
Despite the change of name from "elective" to "selective", a common misconception remains that a selectively mute child is defiant or stubborn. In fact, children with SM have a lower rate of oppositional behavior than their peers in a school setting. Some previous studies on the subject of selective mutism have been dismissed as containing serious flaws in their design. According to a more recent systematic study it is believed that children who have selective mutism are not more likely than other children to have a history of early trauma or stressful life events. Another recent study by Dummit et al., in 1997 did not find any evidence of trauma in their sample of children. Recent evidence has shown that trauma doesn't explain why most children with selective mutism develop the condition. Many children who have Selective Mutism almost always speak confidently in some situations. Children who have experienced trauma however are known to suddenly stop speaking.
Parents will often notice that their preschool-aged child is shy is social situations, but they do not recognize the true extent of the mutism until the child starts school. Sometimes the mutism will be recognized if the child starts preschool and will not talk there. In other circumstances, the child's problem is not identified until beginning kindergarten. If a school SLP or teacher is the first professional to suspect mutism, they should refer the parents and child to a mental health practitioner. A preferred referral is to a child psychologist who can work with the SLP to design a behaviorally based treatment plan, the most effective approach to treating mutism. These professionals can also consider referring the child to a child psychiatrist for a medical evaluation.
Recent medical literature reports use of antidepressants to treat selective mutism in children. Although the reports are promising, they are limited in the number of patients treated and in the behavioral outcomes measured. In my experience, an antidepressant or an antianxiety medication is sometimes helpful in reducing associated anxiety symptoms, but has been of limited utility in targeting mute behaviors. At this time, parents and professionals should be cautious in their expectations that a medication can "cure" mutism. Rather, it is the responsibility of the psychotherapists and the parents to determine the appropriateness of medication for a young child who is mute.
As a psychotherapist, I establish a specific, systematic hierarchy of speaking situations for my patient. In individual therapy, we practice each step until the child is quite comfortable and spontaneous in that speaking situation. As the child demonstrates comfort in the therapy room with a specific communication behavior, I will recommend that school staff attempt to elicit similar behaviors at school. For example, I might start with children nodding and shaking their heads for yes and no. Then they may proceed to mouthing, but not vocalizing, words for me. Another step may be whispering words or writing them down. In transferring these behaviors from psychotherapy to the classroom, the SLP can help the child practice these in individual and small group treatment, and then shadow the child to help transition the behaviors into the classroom.
The SLP can also use techniques to help reduce the general anxiety of the child with selective mutism through direct intervention and collaboration with the classroom teacher. Routine and structure often help an anxious child. Clearly understanding activities and having a predictable schedule reduce the unknown. If a schedule is changed or a new activity occurs, a preview of this change can be helpful. Anxious children sometimes appear to be "slow to warm up." They might not jump right into a new activity, but first prefer to observe other children doing an activity until they are sure that they understand what to do. Once they engage in the activity, they may require some adult assistance at first, and then have the adult fade the assistance as the child becomes more confident in the skills. For example, in a kickball game, the child might want to first observe other students play, later start playing with adult assistance, and then independently join in.
Specific Treatment Issues
The SLP should be alert to various behaviors that may represent anxiety symptoms. Some children may be resistant to nonverbal activities, such as group activities in physical education class or recess. This may represent unfamiliarity with a new activity and anxiety about participating in something unknown. Some anxious children are resistant to making choices, unless they are quite familiar with a situation. Even as they show improvement in speaking, they may still show the anxiety symptoms of avoidance. If these behaviors occur, the SLP can consult with the psychotherapist and then help the teacher implement methods to involve the child in class activities without exacerbating the anxiety. One of my patients was anxious about any special celebration of her birthday in the classroom, and in therapy we composed a letter to the classroom teacher requesting a modification of the birthday activity so the child would be less anxious.
In working with children who are mute, I usually use terms such as "shy" and "nervous" to describe feelings when they are reluctant to speak, and "brave" when they extend themselves in therapy or in the classroom. Most of my patients understand these terms, and I find them helpful to use with teachers and parents.
Selective mutism is often at its height during the important years of reading development. Most children with selective mutism have adequate comprehension and reception in the classroom, but will not speak to name alphabet letters, produce phonics sounds, or read text. This presents a challenge to the teacher in assessment of the child's reading development and suitability for promotion from kindergarten through the primary grades. An SLP can help the teacher develop different methods of assessment of the child's reading abilities. Some children are amenable to a nonverbal assessment technique, such as pointing to letters, but others are initially reluctant to do that. Some children will allow their parents to videotape their reading performance at home, which can then be reviewed by school staff.
An effective treatment technique is to involve the child with peers in various activities. Most of my patients are well accepted by their classmates, even though they are mute. The classmates invite the children to their homes for play or parties and easily accept them, even though the child does not speak to them. The SLP can help identify which peers show a mutual interest in the child. The SLP can collaborate with the teacher to set up instructional situations in which the child is paired with a preferred peer. This peer can also be used in speech and language treatment sessions with the child. Parents can be advised of these developing friendships, so that they can arrange play visits with the peer's parents.
Typically, a child with selective mutism will begin speaking to the peer in the safety of the mute child's home. Next, the child will speak to the peer at the peer's house, if the other parents are not present in the room. Then the peer is often the first person to whom the child will speak at school. This typically occurs in a somewhat isolated setting, such as a quiet area of the playground during recess, or when the two of them are working alone in the building, such as in the library or on an assignment to the school office. The school SLP is a great resource for coordinating these peer events among the various members of the treatment team.
A variation shown by slightly older children with selective mutism is to talk in structured school activities, but then be mute in other circumstances. One of my patients answered teacher questions in class, but could not talk in unstructured situations, such as in the lunchroom or at recess. Rather, she gestured to her peers or wrote them notes. Another patient tried to dominate conversations by maintaining her chosen topic (she was an expert about a TV cartoon series). If an adult changed the topic, the child's anxiety increased and she became mute. In the first case, treatment involved bringing peers into the home and then slowly shaping speaking with peers to other settings. In the second case, therapy involved a shaping procedure of slowly introducing other topics to the conversation on which the patient was an "expert."
Because children with selective mutism often show other anxiety symptoms, another treatment goal in the schools is to promote more spontaneity in behavior. In individual therapy, I often use various media to help the child be more spontaneous and less constricted in actions. For example, we draw with markers, cut paper, use modeling compounds, and get messy with finger paints. The approach is to reduce the child's self-consciousness and inhibition. These media also afford the child opportunities to communicate in a nonverbal fashion. One patient of mine started communicating with me by drawing pictures of recent events at home and school. Over the next year, as she learned to read and write, she progressed from labeling the pictures to writing responses to me as we conversed in therapy. We used the creative media as a technique to move her along the communication hierarchy in therapy.
The SLP should know that the duration of mute symptoms is highly variable. I have had young patients show improvement in symptoms in several months, with no more than 12 sessions of therapy. I have had other patients whose symptoms have persisted for several years. I recommend that in consulting with teachers and parents, we caution them that it may take some time until the child is comfortable speaking spontaneously at school and in other social settings.
In this context, it is important to remember that the mutism is only one specific symptom of the social anxiety. Many times we can note improvement in other, nonverbal symptoms of anxiety. If we focus only on the mutism, we can become discouraged by the slow progress in the improvement of that symptom. However, if we take a broader view of the anxiety, we can often identify encouraging progress over a wider array of behaviors. The SLP can be of great help in counseling patience with other members of the team, including parents and teachers.
Children with selective mutism need psychotherapy to address their anxiety disorder in conjunction with speech and language treatment. If the mutism is first identified in the school setting, the SLP should counsel the parents for a referral to a child psychotherapist who is experienced with this disorder. The SLP can then serve as a key member of the treatment team for this child in two ways—by providing communication treatment and by facilitating interaction among the treatment team.
The SLP can consult with the teacher on different methods of instruction and assessment of the child with selective mutism and can provide focused communication treatment for the child in the school setting. The SLP can facilitate generalization of communication skills from psychotherapy to the school setting, which is usually the most challenging situation for a child with selective mutism. The SLP has a critical role in coordinating the efforts of an entire team. This integrated approach to therapy promises the best opportunity for the child's success.