Selective Mutism


Selective, or elective, mutism is a disorder of childhood that is characterized by the total lack of speech in at least one situation, despite the ability to speak in other settings. It is usually first noticed when the child enters school. Specific features of this disorder are described in the Diagnostic and Statistical Manual of Mental Disorders as follows:

  • The child is able to communicate. Some children may have accompanying speech and language difficulties, but these problems are not the main reason for the mutism.

  • There is a persistent lack of speech in some places (e.g., school) but not in others (e.g., home).

  • The child's difficulties with communication make it difficult to form relationships.

  • The disorder significantly interferes with educational and occupational performance.

  • The behavior persists for at least 1 month.

  • The disturbance cannot be accounted for by a communication disorder (e.g., stuttering) or a pervasive developmental disorder (e.g., autism, schizophrenia).

    Other Problems

    A number of different psychological and personality features have been associated with selective mutism. Different studies identify different features. Even when a group of children with selective mutism in a particular study shows a tendency toward a particular feature, there are still children in the group who do not display that behavior. It is communication difficulty that is the hallmark of selective mutism.

    Assessment

    The speech-language pathologist works as part of a collaborative, multidisciplinary team consisting of the pediatrician, a psychologist or psychiatrist, the teacher(s), and the family. The speech-language pathologist will conduct a thorough parental interview, as most children who are selectively mute will not talk to the clinician. This interview seeks information on:

  • the child's symptom history, especially focusing on the onset of the behaviors. For example, if the behavior began abruptly after trauma to the head, the injury may be the underlying cause for the cessation of speech rather than selective mutism.

  • the degree to which the child is verbally and non-verbally inhibited. Parents may be asked to provide information about the child's relationships with friends or to describe how the child communicates in social situations outside of school (e.g., interacting with other children and adults on the playground or talking on the telephone).

  • other possible problems (e.g., schizophrenia, autism, pervasive developmental disorder) that could be causing the behaviors.

  • the child's speech and language development, as well as current use and comprehension of language. Does the child understand what people say to him or her? Can questions be understood and directions followed? Is the child able to find the words needed to express ideas? The parent is asked to describe the child's speech production (i.e. pronunciation of words, quality/tone/pitch of his voice, the fluency of his speech) to help rule out any other speech and language disabilities that could be causing or exacerbating the mutism.

  • any environmental influences (i.e., learning more than one language at a time or not having adequate language stimulation) that may affect the child's learning of language.

  • family history of psychiatric (e.g., social phobia, obsessive-compulsive disorder) and personality (e.g., extreme shyness) diagnoses that may be predisposing the child tomutism. The clinician reviews the child's medical history to rule out physical problems (e.g., neurological delay) underlying the mutism.

    The speech-language pathologist will also review educational history via academic reports, parent/teacher comments, and standardized testing. Do these reports indicate concern about the child's communication skills with peers or adults in the classroom? Are teachers concerned about the child's academic achievement? The clinician reviews the reports of any previous testing (e.g., psychological) to assess whether other diagnosed disabilities could be causing or exacerbating the mutism.

    The speech-language pathologist will then conduct a speech and language evaluation:

  • The clinician interviews the child to observe the quality of verbal and non-verbal communication. This is done through informal play activities (e.g., playing together with a dollhouse and using the dolls and accessories to stimulate dialogue and social interaction). If the child refuses to participate in these play activities, drawing is often used as a means to exploring non-verbal communication skills.

  • Comprehension of language is evaluated using standardized tests (e.g., the child is shown a set of four pictures and is told to point to one of the pictures).

  • The parent may be asked to do structured communication activities with the child (e.g., have the child retell the plot of a story or describe a picture) to create an informative audiotape. The parent may also be asked to provide an audiotape of the child's speech at home during regular conversation. These samples enable the speech-language pathologist to evaluate expressive language abilities (word knowledge, use of grammar, ability to sequence a set of ideas, social communication skills). The speech-language pathologist completes an oral-motor examination to evaluate the strength and coordination of the muscles in the child's lips, jaw, and tongue. Muscle weakness or incoordination may signify a neurological impairment that is causing or exacerbating the symptoms.

  • A screening test for hearing is also part of the evaluation.

    Treatment

    The speech-language pathologist may coordinate a behavior therapy program to increase verbalizations.

    Behavior therapy is based on the premise that the child who is selectively mute is using the behavior in response to anxiety in social situations or to gain attention. The focus of therapy is to reinforce speaking, or anything that approximates speaking, and not to reinforce the mute behavior. This may be done through stimulus fading, in which the speech-language pathologist sets simple goals (e.g., using a gesture to communicate) and gradually increases expectations until speech is achieved. Another behavior therapy technique called shaping reinforces mouth movements that approximate speech (e.g., whispering) until true speech is achieved. Using the self-modeling technique, the child watches videotapes of himself or herself performing the desired behavior (e.g., communicating effectively at home) to facilitate self-confidence and carry-over of this behavior into the classroom.

    The speech-language pathologist may also work with specific speech and language problems that are making the mute behavior worse. For example, some children with selective mutism are afraid to speak because they feel they may say the wrong thing. The speech-language pathologist may utilize role-playing activities to lessen the child's anxiety and increase confidence with speaking to different listeners in a variety of settings.

    Other children do not want to speak because they feel their voice "sounds funny." If necessary, the speech-language pathologist may work on speech pronunciation to increase the child's confidence and clarity of speech.

    Additionally, the speech-language pathologist will likely work in the child's classroom with teachers to encourage communication and lessen anxiety about speaking. For example, the speech-language pathologist may help the teacher implement the use of small, cooperative groups within the classroom that are less intimidating for the child with selective mutism. Then, the speech-language pathologist will work with the child within this group to facilitate more effective communication with peers, first using non-verbal communication methods, such as signals or cards, to contribute to small group discussions and gradually increasing expectations to include speech. The speech-language pathologist will work with the child, family, and teachers to generalize learned communication behaviors into other speaking situations.

    The speech-language pathologist continues to work as part of the school-based multidisciplinary team to treat the child with selective mutism. Other components of treatment may include:

  • Psychodynamic Therapy. The theory behind this approach is that the mutism is caused by some sort of internal conflict (e.g., an overly dependent parent-child relationship). The therapist, usually a psychologist or psychiatrist, focuses on identifying the conflict and resolving it.

  • Family Therapy. This approach to treatment identifies patterns of interaction in the child's family that reinforce the mute behavior, and then works to extinguish these patterns. Family members often help to design and implement the program. The treatment of choice will differ depending on the needs of the child and his or her family. The child's treatment may utilize a combination of strategies, again depending on individual needs.

    How Common Is It?

    Selective mutism is a rare disorder that is said to affect less than 1% of school-aged children. It is slightly more common in girls than in boys.

    Links

  • Selective Mutism Group

  • Social Anxiety Network

  • Family Village

  • Panic Anxiety Hub
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