Selective Mutism Treatment

A friend of mine, a kindergarten teacher, asked me for some suggestions how to approach a student with a selective mutism.

First of all we have to know that Selective Mutism, known also as elective mutism, usually happens during childhood, often before a child is 5 years old. A kid with selective mutism can speak but chooses not to speak in certain situations. Failure to speak is not due to a lack of knowledge or comfort with the spoken language, also not due to a communication disorder (e.g., stuttering) but, due to an anxiety, social phobia, excessive shyness, fear of social embarrassment, social isolation and withdrawal.

Selective mutism is described in the 2000 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR: pp.125-127).

A silent child after being diagnosed with a selective mutism should be seen and treated simultaneously by professionals: speech-language pathologist (SLP), psychologist or psychiatrist along with teachers and the family members.

It is important to gather all background history, a health report, hearing screening, oral-motor examination, educational review, parent/caregiver interview and a speech and language evaluation. Based on that knowledge we must individualize the best for the child treatment. A treatment, which might apply a combination of different strategies.

In Stimulus Fading Technique you involve the child in a relaxed situation with someone they talk to freely, and then very gradually introduce a new person into the room.

In Shaping Technique you use a structured approach to reinforce all efforts by the child to communicate, (e.g., gestures, mouthing or whispering) until audible speech is achieved.

In Self-Modeling Technique you let the child to watch videotapes of himself performing the desired behavior (e.g., communicating effectively at home) to facilitate self-confidence and carry over this behavior into the classroom or setting where mutism occurs. In addition the child can learn from a peer or adult therapist how to react in a calmer manner to the stressful situation. Research studies support the efficacy of using audio tapes or videotapes in treating selective mutism.

In Contingency combined with Stimulus Fading Strategy the desired behavior (e.g. speaking out loud) is elicited with a stimulus or prompt; then, the prompt is gradually faded by decreasing the number of prompts, eventually to zero.

In Behavior Shaping Technique combined with Positive Reinforcement the child is rewarded every time he exhibits behavior that is closer and closer to the desired behavior (e.g. speaking out loud). Positive Reinforces can be a token economy or reward system, e.g. a favorite book for perfect attendance at school, a movie for attending social events.

In Systematic Desensitization the child re-learns how not to be upset or anxious. Instead of feeling uncomfortable in a social situation, the child connects feelings of calm with the previously anxiety-provoking social situation. Instead of automatically reacting to the anxiety-provoking situation with autonomic nervous system activation, the behavioral response is reconditioned to that of relative autonomic nervous system deactivation.

Extinction: The undesired behavior (refusing to speak, hiding, refusing to go to school) is ignored, and the lack of attention to the behavior causes the behavior to cease.

In In-vitro Graded Exposure the child imagines the stressful situation starting with the least stressful aspects, learning how to deal with these, and then following up with more stress-provoking aspects. This could include the use of scripted play therapy using real-life stressful situations with targeted responses for learning and incorporation.

In In-vivo Exposure the situation becomes less tension-provoking with repeated graded exposures as the situation becomes less new and more predictable. Careful real-life exposure (from less-threatening to more-threatening) to anxiety-provoking situations with postexposure discussion may be helpful, as actual experience of real-life situations determines whether resolution of the abnormal emotional response has taken place.

Aversive Interventions such as forcing the child to speak out loud generally does not encourage the behavior to occur more often.

In Social Problem-Solving Strategy the child is encouraged to view the social interaction that causes anxiety as a problem to be solved; this technique can be especially helpful when combined with the use of positive reinforces and fading of prompts.

Cognitive-behavioral therapy may be extremely helpful to improve the level of the child's self-esteem.

The main Speech Language Pathologist’s role will be to target the problems that make the mute behavior worse. He will try to correct any communication disorders, exercise the voice to make it stronger and use role-play activities to help the child to gain confidence speaking to different listeners in a variety of settings. The SLP may create a behavioral treatment program focused on specific speech and language problems, and/or work in the child's classroom with teachers.

The main teacher’s role will be to encourage communication, first using non-verbal methods (e.g., signals or cards) and gradually adding goals that lead to speech. The teacher will form small, cooperative groups that are less intimidating to the child, gradually increasing number of the members.

The main parents’ role will be to support and cooperate with the team.