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What is Selective Mutism (SM)?

Selective mutism (SM), formerly called elective mutism, is defined as a disorder of childhood characterized by an inability to speak in certain settings (e.g. at school, in public places) despite speaking in other settings (e.g. at home with family). SM is associated with anxiety and may be an extreme form of social phobia according to researchers and clinicians who are familiar with the disorder (Black & Uhde, 1995; Dow et al., 1995, Dummit et al., 1997, Kristensen, 2001; Leonard & Dow, 1995).

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, referred to by clinicians as the DSM- IV, (APA,1994) recognized that the social anxiety and avoidance characteristic of social phobia may be associated with SM, and thus, both diagnoses may be given. More than 90% of children with SM also meet the diagnostic criteria for social anxiety disorder, now termed social phobia (Black et al., 1996).

Diagnosis of other comorbid anxiety disorders are also commonly diagnosed with SM and social phobia (Biedel & Turner, 1998). The name change from "elective" to "selective mutism" in DSM-IV deemphasized the oppositional behavior connotation that a child elected not to speak and rather emphasized the characteristic of the disorder, that there are select environments in which speaking does not occur (APA, 1994). The term selective mutism is consistent with new etiological theories that focus on anxiety issues (Dow et al., 1995).

The current edition, DSM-IV-TR (APA, 2000) states that the following criteria must be met in order to qualify for a diagnosis of selective mutism:

An inability to speak in at least one specific social situation where speaking is expected (e.g., at school) despite speaking in other situations (e.g., at home); The disturbance has interfered with educational or occupational achievement or with social communication; The duration of the selective mutism is at least one month and is not limited to the first month of school; The inability to speak is not due to to a lack of knowledge of or discomfort with the primary language required in the social situation; and, The disturbance cannot better be 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.

Consistent with current research, SMG believes that Selective Mutism is best understood as a childhood social communication anxiety disorder. SM is much more than shyness and most likely on the spectrum of social phobia and related anxiety disorders. SM is NOT a child willfully refusing to speak.

How common is this problem, to be worthy of our attention?

DSM-IV-TR estimates that SM affects 1 in 1000 children referred for mental health treatment (APA, 2000). However, several researchers have suggested that the true prevalence of SM in the general population is largely underestimated (Bergman et al., 2002; Hayden, 1980; Hesselman, 1983; Kupietz & Schwartz, 1982; & Thompson, 1988). Recent studies show that SM is not as rare as it was previously believed to be but is comparable to other, widely known disorders of childhood. A study targeting a large sample of children in a Los Angeles, CA school district identified children who met the diagnostic criteria for SM and found a prevalence rate of 7.1 per 1,000 children (Bergman et al., 2002). A subsequent study in Israel found an almost identical prevalence rate (Elizur & Perednik, 2003). These numbers suggest that SM has a higher prevalence than autism (.5 per 1000), major depressive disorder (.4 to 3 per 1000), Tourette's disorder (.5 per 1000), obsessive-compulsive disorder (.5 to 1 in 1000) and other well-known disorders. In comparison to other studies, which only accounted for diagnosed cases of SM, provides evidence that a large number of individuals with SM are undiagnosed or misdiagnosed. Parents of children with SM who enter treatment often report that their child was misdiagnosed with autism or another pervasive developmental disorder, mental retardation or oppositional-defiant disorder. Most are told (if anything) by uniformed professionals that there is nothing wrong with their child, that their child is "just shy," or will grow out of this behavior. Thus, the lack of awareness among educators and treating professionals leads to delays in diagnosis and missed opportunities for treatment.

SM is slightly more common in females than in males. Although the duration of SM often lasts for several months, left untreated, it may sometimes persist longer and may continue for several years (APA, 2000). The average age of onset is 5 years, even though most parents report that their children's symptoms began years earlier (Leonard & Dow, 1995). In his treatment of children with SM, Thompson (2000) found that children who establish speech in previously mute settings before age eight typically become verbal in school and social settings within one year. Children who demonstrated longer-term mutism were likely to continue their silence into upper grades and into adulthood (Thompson, 2000). While reports of older children and adolescents with SM are scarce, based on our collective clinical experience, individuals who to enter into treatment later may suffer from depression and other disorders in addition to SM but can make treatment gains and overcome SM without it continuing into adulthood.

Why does a child develop SM/Etiology?

The understanding of SM as an anxiety disorder related to shyness, social anxiety and inhibited temperament has increased in popularity over the last decade. Reports of children with SM indicate that most are shy, inhibited and anxious. These reports combined with clinical experience suggest that SM may be the manifestation of an inhibited temperament, or inborn personality of mood (Dow et al., 1995). There is some evidence that there is a genetic link between children with SM and anxious parents or family members. Most commonly, social phobia, avoidant personality disorder, and parents with a history of SM themselves were more prevalent in families with a child with SM than those without (Black & Uhde, 1995; Chavira et al., 2005; Kristensen, 2001). In addition, most children with SM also have one or more other anxiety disorders, especially social phobia (Black & Uhde, 1995; Dummit et al., 1997). Other common comorbid anxiety disorders include separation anxiety disorder, generalized anxiety disorder and specific phobias (Dummit et al., 1997).

Behaviorally inhibited children may also have a decreased threshold of excitability in the almond-shaped area of the brain called the amygdala. The amygdala receives and processes signals of potential threat and sets off a series of reactions that will help individuals protect themselves. In anxious individuals, the amygdala seems to overreact and set off these responses even when the individual is not really in danger. In the case of SM, the anxiety responses are triggered by social interactions and settings where speaking is expected including school, the playground or social gatherings. Although there may be no logical reason for the fear, the feelings that the child with SM experiences are just as real as if an actual threat or danger were present.

Other factors may also contribute to the development of SM. A significant number of children with SM also have expressive language disorders and some come from bilingual family environments (Kristensen, 2000; Elizur & Perednik, 2003). While these factors do not cause SM, they can contribute to a child's anxiety with speaking. The child may become more self-conscious about his or her speaking skills and may have increased fear of being judged negatively by others.

A stressful environment may also be a risk factor in the development and maintenance of SM. Although earlier reports of SM suggested that a history of abuse and trauma may be associated with the development of SM, there is no evidence that there is a causal relationship between trauma and SM (Black & Uhde, 1995). However, if significant stressors are present, they may contribute to the SM by exacerbating the child's already present anxiety.

What are the signs and symptoms of SM?

Those with SM experience anxiety related to speaking and sometimes they may also be unable to make eye contact,

nod their heads, point or make other nonverbal forms of communication when in a social situation that provokes

anxiety. SM may be an extreme form of social phobia. Social anxiety and avoidance characteristic of social phobia may

be associated with SM, and thus, both diagnoses may be given. More than 90% of children with SM also meet the

diagnostic criteria for social anxiety disorder, now termed social phobia (Black et al., 1996). Diagnosis of other

comorbid anxiety disorders is also commonly diagnosed with SM and social phobia (Biedel & Turner, 1998). The

name change from 'elective' to 'selective mutism' in DSM-IV deemphasized the oppositional behavior connotation

that a child elected not to speak and rather emphasized the characteristic of the disorder, that there are select

environments in which speaking does not occur (APA, 1994). Thus a child's reluctance to speak and engage socially

should not be interpreted as an oppositional behavior but as avoidance due to anxiety. The term 'selective mutism is

consistent with new etiological theories that focus on anxiety issues (Dow et al., 1995).

The current edition of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, or DSM- IV-TR (APA, 2000), states that the following criteria must be met in order to qualify for a diagnosis of selective mutism:

(a) An inability to speak in at least one specific social situation where speaking is expected (e.g., at school)

despite speaking in other situations (e.g., at home);

(b) The disturbance has interfered with educational or occupational achievement or with social

communication;

(c)

The duration of the selective mutism is at least one month and is not limited to the first month of school;

(d)

The inability to speak is not due to a lack of knowledge of or discomfort with the primary language

required in the social situation; and,

(e) The disturbance cannot better be 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.

A diagnosis of SM can only be made by a treating professional qualified to diagnose mental illness. While many

parents and professionals unfamiliar with SM may identify many of the symptoms in their children, a formal

diagnosis should be obtained to confirm that SM is present and not better accounted for by other disorders that also

include the lack of speech as a presenting symptom.

Are there other associated behaviors or personality traits?

Associated features of SM may include profound shyness, little eye contact, social isolation, fear of social embarrassment, withdrawal, clinging behavior, compulsive traits, negativism and oppositional behavior when attempting to avoid feared social situations, and temper tantrums, particularly at home. Since children are unable to communicate verbally, they may opt for using nonlinguistic cues such as gestures, nodding or shaking the head to get their messages across. A child may pull or push objects and obstacles, and in some cases, communicate in monosyllabic, short or monotone utterances or in an altered voice (APA, 2000). Some of these behaviors may not be present at the onset of SM. At the onset of SM, children may often stand motionless and expressionless due to anxiety and then slowly progress from nonverbal and non-communicative stages to communicative and verbal stages in treatment (Shipon-Blum, 2001). Fundis et al. (1979) reported that 71 percent of the children in their studies displayed difficulty in performing motor activities and had bowel and bladder problems or, enuresis and encopresis. Some individual with social anxiety symptoms may also experience parureis, the fear of using public restrooms perhaps to fear of making sounds while urinating that others may hear (Stein & Walker, 2002).

When do I need to seek professional help for my child?

SMG recommends that treatment be sought as soon as it is suspected that a child may have selective mutism (SM). It is especially important to seek help when it is clear that a child is having difficulty engaging in social situations, seems out of step with his/her peers, and is experiencing adverse consequences such as having difficulty adjusting to school, difficulty with social relationships or co-occurring symptoms such as depression. Treatment is not indicated during the first month of school when a child is adjusting to entering preschool or Kindergarten for the first time, as this behavior is developmentally appropriate for young children who are not yet familiar with the school routine and being around other adults and children. If the selectively mute behavior continues beyond the first month of school, however, a treatment should be considered.

How does SM differ from shyness?

Shyness is a normal personality trait. It is marked by a voluntary tendency to withdraw from people, particularly unfamiliar people. Everyone has some degree of shyness; it may be experienced a lot, a little bit or somewhere in between. Shyness, like other inheritable traits, such as height and eye color, is largely influenced by genes (Stein & Walker, 2002). Shyness is not a psychiatric disorder like SM, social phobia and avoidant personality disorder which all characterize different forms of extreme inhibition that interferes with a person's daily functioning. People who are shy are able to function adequately in society. Shyness may fluctuate and change as a person matures and encounters new social challenges without treatment (Carducci, 1999). People with psychiatric disorders such as SM do not adapt well to social situations nor are they able to communicate effectively with others. They may have limited academic and occupational achievement and require treatment in order to overcome their symptoms and function at an adaptable level.

How is Selective Mutism treated?

Research-based treatments found effective for Selective Mutism

Some of the following information is excerpted from: Cohan, S.L., Chavira, D.A., and Stein, M.B. (2006). Practitioner Review: Psychosocial interventions for children with selective mutism: a critical evaluation of the literature from 19902005. Journal of Child Psychology and Psychiatry 47:11, 10851097.

Treatment for Selective Mutism can include psychotherapy and medication to address the anxiety that underlies the person’s inability to speak in certain situations. Some children with Selective Mutism also benefit from speech- language therapy, occupational therapy, sensory-integration therapy, and other interventions that may be recommended by the main treatment provider(s).

In psychotherapy, a psychologist or other professional will use some of the following approaches, depending on the individual child:

Behavioral and Cognitive-behavioral (CBT) strategies are the most widely supported psychological treatment for Selective Mutism.

Behavioral strategies: This refers to coming up with a step-by-step plan where the child gradually does more and more difficult speaking-type behaviors, as well as coming up with a system of positive reinforcement whenever the child is able to accomplish those behaviors.

There are several behavioral strategies. They are most effective to support the child to make and maintain gains in

speaking when they are used together:

Contingency management involves positive reinforcement of (or rewarding for) verbal behavior with initial reinforcement of nonverbal communication like pointing and whispering

Shaping reinforcement is provided for approximations of the target verbal behaviors (e.g., mouthing words, whispering, talking on the telephone) and later for normal speech. A reinforcement menu (what types of rewards the child wants to earn and for what behaviors) is first developed in collaboration with the child.

Stimulus fading interventions build on the success of contingency management and shaping by gradually increasing the number of people and places in which speech is rewarded. For example, the child may first be rewarded for speaking to a classmate to whom s/he already speaks outside of school. Gradually, other students are introduced into the group until the child is able to speak in the presence of a large group of peers. Stimulus fading can also be used in problematic situations that occur outside of school (e.g., talking to grandparents, ordering in fast food restaurants).

Systematic desensitization traditionally involves the use of relaxation skills along with gradual exposure to successively more anxiety-provoking situations. In this type of intervention a hierarchy of feared speaking events is constructed and therapy consists of a series of imaginal and in vivo (real-life) exposures to feared situations.

Social skills training may also be used to reduce anxiety and facilitate speech with peers and involves learning what to say to initiate conversations, how to take turns, making eye contact, and learning how to understand another person’s nonverbal behavior.

(self-)modeling involves making video and/or audiotapes that have been edited to depict the child speaking in settings in which he or she has previously remained mute. The tapes are played repeatedly throughout the intervention, with the expectation that the child will become accustomed to hearing him- or herself speaking in these settings and will begin to believe in his or her ability to do so.

Cognitive strategies: This involves identifying anxious thoughts that contribute to the mute behavior. Introducing

cognitive strategies is most useful for children age 7 and older, when they have developed the ability to become aware

of their thoughts. Techniques include recognizing body symptoms of anxiety, identifying and challenging maladaptive

beliefs, and developing a coping plan to deal with distress. For example, many selectively mute children have anxious

thoughts or worries that people will make fun of their voice or what they want to say. Cognitive therapy teaches the

child to understand that those thoughts are the product of worry (and are not real threats) and to coach themselves by

telling themselves positive thoughts instead. Cognitive strategies should be added to behavioral strategies at a point in

time determined by the treatment provider.

Other therapies commonly used alongside the behavioral or cognitive-behavioral treatment above, while not

necessarily researched or supported by research as yielding gains in children with SM, are aimed at increasing the

child’s self-esteem to strengthen the child emotionally by reinforcing areas of competence, belonging and acceptance

as he/she completes the difficult work involved in these behavioral and cognitive-behavioral therapies. These may

include learning new skills and/or encouraging participating in sports, music, arts, etc.

Medication

A medical doctor (psychiatrist, pediatrician) can prescribe medications that address the anxiety that underlies the

child’s inability to speak in certain situations. Medications are most effective when combined with behavioral and/or

other psychological strategies above, especially to help the child maintain gains in communication over time. In

particular, the SSRI (selective serotonin reuptake inhibitors) have the most evidence for being useful in youth with

anxiety conditions.

Speech-Language Therapy

The following is excerpted from Speech-Language Therapy and Selective Mutism. Contributed by: Evelyn R.

Klein, PhD, CCC-SLP, BRS-CL and Sharon Lee Armstrong, PhD. For the full article

Speech-language pathologists (SLPs) may contribute to the treatment benefits of children with selective mutism

(SM), as speech and/or language impairments can co-occur with SM. In addition, SLPs are trained in working with

pragmatic language that is greatly impacted by children with SM. For these children, simultaneous treatment using

both behavioral strategies to help children feel more comfortable to speak and linguistically-based activities to foster

language development are recommended. SLPs often follow a behavioral approach of setting goals with gradual

increases in expectations. For example, The Ritual Sound Approach® (RSA) that is a component of Social

Communication Anxiety Treatment (S-CAT) by Dr. Shipon-Blum (2010) has had good success in helping children

communicate with greater ease. The behavioral technique of shaping is used to help modify and shape specific

phonemes into blended sounds that represent real words. This approach starts with voiceless speech sounds that

require less vocal effort in that they don’t engage the vocal cords. Children feel air move in and out of their mouths as

they breathe, blow, and cough. Thus, voiceless speech sounds such as /h/ (similar to breathing), /k/ (similar to a

cough), /s/, /t/, /p/, etc. are used because they are less audible than vowels or voiced consonant sounds such as /z/,

/d/, /b/, /g/, etc. This behaviorally-based treatment helps the child think of sound-making from a mechanical

standpoint (e.g. put lips together lightly, build up air pressure in the mouth and puff out air to produce the sound of

/p/).

SLPs may also use augmented self-modeling, a technique that has promise for reducing anxiety when speaking

(Kehle, Bray, Byer-Alcorace, Theodore, & Kovac, 2011).The child watches videotaped segments of herself or himself

during a positive verbal interchange (often at home) and then visually (through playback) carries the communicative

interchange into another setting that is often more challenging. Using video software, the child can get a virtual

glimpse into communicating successfully in a setting that causes heightened anxiety. In many instances coordinating

voice and speech while thinking of what to say (linguistically) becomes difficult for children with SM due to anxiety.

Therefore, non-speech tasks may be used to help the children gain control of voicing. Once vocal control in non-

speech tasks is adequate then speech can be introduced slowly and systematically to allow for success. A typical

progression is as follows:

1. Communicate by pointing, gesturing, or nodding (use games, toys, and age-appropriate projects)

3.

Talk through a recording device that is played when out of the room and then when in the room (as comfort increases)

4. Talk to another person who speaks for the child (in front of others with increasing distance from the person’s ear)

5. Talk to others using sounds (may be blended to form words)

6. Talk to others using rehearsed or scripted language with and without visual prompts (develop charts to play guessing games include phone as possible)

7. Talks spontaneously using words or phrases (including phone)

8. Talks spontaneously using sentences (including phone)

Children with SM who present with a language delay may benefit from treatment that includes basic vocabulary

development, grammatical morpheme development, and work on sentence structure. For many children with SM, the

goal will be to enhance social-pragmatic communication with work on enhancing descriptive language (vocabulary

and describing), expository language (informing and explaining), narrative language (storytelling), and discourse for

social communication (discussing and interacting).

SLPs may first work on nonverbal skills of social engagement and later include communication skills in joint activity

routines. Speech articulation therapy may also be part of the treatment protocol for children who have speech

production errors, either sound substitutions, distortions, omissions, or additions.

It should be noted that some children with SM believe they cannot speak in some settings and so they may not

properly engage their respiration, voice, or articulation appropriately. Children with SM can get accustomed to not

speaking and thereby assume the self-image of the child who does not talk (Omdal, 2007). This self-fulfilling

prophecy is one that can persist without appropriate intervention. The earlier the intervention, the better!