20Q: Being Brave - How to Overcome Selective Mutism

From the Desk of Ann Kummer

Shy, as defined by Google, is “being reserved or having or showing nervousness or timidity in the company of other people.” Shyness, as defined by Wikipedia, is “the feeling of apprehension, lack of comfort, or awkwardness especially when a person is around other people.” Of course, most children are a little shy around strangers and many adults consider themselves to be shy or introverted. But when does it go from common shyness to selective mutism, which is a truly handicapping condition? What could possibly cause a child to be so anxious with strangers that he refuses to communicate at all? There are so many questions related to this very interesting and perplexing condition, which many of us encounter when working in a pediatric setting. Therefore, I am thrilled that Aimee Kotrba PhD, LP and her graduate student, Molly Schofield have submitted this 20Q article to answer these questions.

Here is a little information about the authors: Dr. Aimee Kotrba is a licensed clinical psychologist specializing in the expert assessment and treatment of childhood anxiety.  Currently, Dr. Kotrba owns and directs Thriving Minds Behavioral Health, with clinics in Brighton and Chelsea, Michigan, where she provides individual treatment, parent coaching, and school consultation for children with anxiety.  Dr. Kotrba is the author of Selective Mutism: An Assessment and Intervention Guide for Therapists, Educators, and Parents and Overcoming Selective Mutism: The Parent Field Guide. She is a nationally recognized speaker on the identification and treatment of anxiety and Selective Mutism for parents, professionals, and school personnel. 

Molly Schofield is a graduate student attending Eastern Michigan University to obtain a master’s degree in clinical behavioral psychology. She is doing her practicum at Thriving Minds and works under the supervision of Dr. Aimee Kotrba. Her clinical interests include anxiety and impulse disorders in children and adolescents. Her research interests include psychosocial outcome of pediatric patients with medical conditions.

In this 20Q article, these authors will answer questions about the history of selective mutism and what is known about its etiology. They will answer questions about communication concerns with selective mutism and this condition is evaluated and treated. This is a fascinating article!

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: Being Brave - How to Overcome Selective Mutism

What is selective mutism?

Selective Mutism is now considered a childhood anxiety disorder and is characterized by anxiety related to speech outside of the home setting (e.g. in public or in school). These children speak with ease and no anxiety with specific people, usually parents, siblings, and sometimes close friends, but are silenced by anxiety when in performance, academic, or social settings.

For the individual to be formally diagnosed with selective mutism, these behaviors must be present for more than a month, the lack of speech cannot be better explained by another disorder, and the lack of speech must cause an impairment in their daily functioning.Selective Mutism is now considered a childhood anxiety disorder and is characterized by anxiety related to speech outside of the home setting (e.g. in public or in school). These children speak with ease and no anxiety with specific people, usually parents, siblings, and sometimes close friends, but are silenced by anxiety when in performance, academic, or social settings.

Although selective mutism presents differently depending on the child, there are some commonalities amongst most cases. Children with selective mutism typically have a hard time answering questions verbally and sometimes nonverbally (e.g., nodding, pointing, writing). They are insightful, emotional, sensitive individuals. Sometimes they show unusual body language when anxious, poor eye contact, and a latency in responding to questions (both verbally and nonverbally).

2. What are the various classifications of selective mutism?

Children with mild selective mutism may speak to people they are comfortable with and may be silent only around new individuals. They may be able to respond to people when asked a direct question or in a simple yes/no manner, but likely will not initiate conversation or provide a lengthy response.

However, children on the more severe end of the spectrum may not talk at all in the school setting, or may not talk to family they do not see regularly. Some severe cases have difficulty with nonverbal communication as well, including gestures, making choices, and expressive writing tasks.

3. Where does selective mutism originate?

There seems to be a genetic component to selective mutism. It is not uncommon to see selective mutism in a child with family members who have a different anxiety diagnosis (including generalized anxiety, obsessive-compulsive disorder, or other anxiety disorders). It is commonly seen in twins or siblings. There is likely a portion of selective mutism that is genetic (“nature”) and a portion that is learned behavior (“nurture”).

Anxiety is not always a bad thing. Feelings of anxiety can keep us safe from harmful events and dangerous situations. Our muscles get tense and our heart rate increases in order to protect us. The amygdala is a part of the brain that is a key component in the body’s response to fear - it tells the body when to enter fight/flight/freeze mode. Our amygdala works like a fire alarm. The fire alarm is there to warn you of danger and that you need to leave the house because there is a fire. However, sometimes the fire alarm gets confused and goes off when it’s not supposed to. That would be a false alarm; when the amygdala sends the flight/flight/freeze alert in response to no actual harm or danger. This is what happens in an anxiety response.

When the amygdala sends a false alarm the child becomes scared or anxious when there is no actual real danger. The child then learns various ways to avoid situations that may create these false alarms. They may go to the parent or cry because they have learned this will help them avoid the anxiety-provoking situation. After repeated avoidance, the child may stop engaging in situations that could potentially be anxiety provoking.

4. How did the diagnosis of selective mutism develop?

Selective mutism has been recognized since the 1800s as “elective mutism.” At that time, it was thought to be a protective and volitional coping strategy caused by a previous traumatic event. Now we know that mutism or refusal to speak after trauma can be a symptom of post-traumatic stress disorder and is unrelated to selective mutism. It was not until the 1990s that it was termed selective mutism and was defined as a lack of speech that occurred in response to anxiety in specific situations or with specific individuals.

Children with selective mutism typically present with a genetic history of anxiety, as well as biological differences in their reaction to perceive threats (i.e., overactive amygdala).  When the child is put in particularly uncomfortable situations, people around them tend to “rescue” them or allow them to avoid speech. Therefore, the children get used to allowing others to communicate for them. This causes more of a problem when it extends into school. 

5. What sustains selective mutism?

When someone poses a question and the child does not answer, it can be uncomfortable to watch. The person asking the question may feel as if they have scared the child, or the caregiver may want to rectify the uncomfortable situation. This may result in caregivers, teachers, parents, novel adults, or peers rescuing the child from the anxiety. Rescuing can take the form of answering the question for them, so they no longer are expected to verbally respond, moving on from the questions without getting a response, or discontinuing asking questions. These “rescue” behaviors then encourage the child to avoid communicating.

6. Anxiety vs control?

It is common for other kids or adults to see the lack of communication as a choice. Some parents or teachers may think the child is being outwardly defiant. However, research suggests that these children are reacting to a high level of anxiety as opposed to oppositionality.

When individuals become anxious, they attempt to avoid that feeling, situation, or prompt in order to reduce the anxiety. Children with selective mutism develop strategies for avoiding speech or communication, including looking to parents to respond, avoiding eye contact, not attending social functions that may require speech, or using nonverbal or written methods to get needs met.

7. Is selective mutism more than just being shy?

It is very common to be described as shy, particularly as a child. However, shy children typically warm up at some point. It may take them longer than an outgoing child, but they will begin to feel comfortable in various new settings and with new people. Their shyness will not impair their daily functioning.

A child with selective mutism presents differently. These children have vastly different personalities regarding their settings. When they are comfortable or with a preferred communication partner such as their parents, they are outgoing and talkative. However, in a new setting or with an unfamiliar person, they may remain mute despite developing a level of comfort and enjoyment or rapport.

Furthermore, selective mutism causes functional impairments. Children with selective mutism may struggle to ask to use the bathroom in school, be unable to ask for help when hurt, or have difficulty verbalizing when they are confused about the directions for an assignment or task. These issues can lead to increased social and academic issues as the child ages, and can also continue into adolescence or young adulthood if not properly addressed with evidence-based treatment programs.

8. How does selective mutism differentiate from social phobia?

Social phobia is anxiety related to what is said or to being the center of attention, while selective mutism is a fear of speaking or communicating. Approximately 90% of children with selective mutism also meet criteria for social anxiety. The treatment goals are very similar in both cases. With social phobia as well as selective mutism the goal of treatment is to decrease anxiety in social situations and to increase the engagement in social activities. Ongoing research is aimed at understanding the specific difference between the two diagnoses, their causes, and their symptoms. Right now, it is evident that they are highly correlated.

9. What are the communication concerns with selective mutism?

There is a strong overlap between speech and language weaknesses and selective mutism. Some of these delays or weaknesses within communication can include the child’s ability to initiate or maintain a conversation, maintain a typical pitch, intensity, or volume to their voice, be fluent in their speech, speak clearly, or use correct grammar and vocabulary.

There are varying theories as to why this overlap occurs. The two issues could be completely independent of one another or these communication deficits may act as a precursor to selective mutism (e.g., the child may notice their communication deficit and avoid speaking). Another explanation may be that the communication deficit and the selective mutism occur together by chance, but the deficit causes the selective mutism symptoms to become more prominent than they originally would have been. The last explanation is that over time, a deficit in expressive communication develops because the child has not had the practice or frequent use of communication in social or academic environments.

10. When should you seek treatment?

Research has shown the best outcomes when intervention is started early (as early as 3 years of age). There has been success when implementing evidence-based intervention for selective mutism, and thus if a diagnosis is in question, professionals would suggest seeking treatment as early as possible. Unfortunately, there are various reasons why some children with selective mutism never obtain the appropriate treatment. Selective mutism can be misdiagnosed for autism, social phobia, or communication deficits. On average, there is approximately a 1-3-year delay between an issue being identified and treatment initiating, which can allow more time for the child to practice avoidance (as well as more time for others around the child to practice rescuing behaviors).

11. How do you break the avoidance cycle?

The cycle of avoidance maintains the lack of speech. The cycle begins with the opportunity to speak (someone asks a question or the child needs to say something). The child avoids the prompt, question, or situation, and someone rescues them. The child learns that if they wait long enough without engaging in conversation they will no longer be expected to talk. This avoidance makes the child feel relieved for the moment, reinforcing the avoidant behavior. Furthermore, the peers and adults who rescue the child are reinforced (upon seeing the child’s relief), and they are more likely to rescue quickly in the future.

12. What does the assessment process look like?

The first step of assessment is a diagnostic interview which determines the context around when the child speaks and does not speak. The clinician interviews the parents, teachers, or/and other caregivers. During the diagnostic interview the clinician needs to find out who the child talks to currently, what situations or settings encourage speech from the child, where the child speaks (settings or environments), and how the child communicates (verbally, nonverbally, etc.). This helps the clinician determine the starting point for treatment.

After the interview there are rating scales or questionnaires that can be given. Currently there is only one published rating scale that directly assesses selective mutism - the Selective Mutism Questionnaire (SMQ). It reliably gains information on communication in the home, at school, and in public. This rating scale is normed for children ages 3-11.

Other measures as a part of a diagnostic evaluation could include the Screen for Childhood Anxiety Related Emotional Disorders (SCARED) which will assess various anxiety symptoms in ages 8 to 18. The Social Phobia and Anxiety Inventory for Children (SPAI-C) assesses anxiety provoking situations for ages 8-14. The Multidimensional Anxiety Scale for Children (MASC) assesses major anxiety symptoms as well as the physical symptoms of an anxiety response for ages 8-19 years old. The Behavioral Assessment System for Children (BASC) is a more global questionnaire, and assesses various dimensions of child behavior including, internalizing behaviors like thoughts and feelings, as well as externalizing behaviors like acting out, emotional outbursts, or deviant behaviors for ages 4-18.

The third step to the assessment process are various observations. There are three settings in which observations would be most helpful - home, school, and in unfamiliar locations. It is most beneficial and will provide the most information if the clinician can observe in all three settings (when possible).

An at-home observation can be completed in one of two ways. The parents can videotape the child while they are relaxed and verbal. This may be best for a true observation of what the child comfortably speaking looks like. The other option is for the clinician to go to the home. This option allows the clinician to see the child’s most comfortable environment and observe the family dynamic. This option may cause some bumps in the road if the child is not comfortable speaking in front of the clinician.

The school observation typically occurs when the clinician visits the child’s school and observes interactions and context around speech. This is important to obtain information regarding whether they speak to peers or teachers, which peers or teachers, and what occurs when an opportunity to speak is placed upon the child.

An unfamiliar location observation is usually done in the clinic on their first visit. It begins with the child and a comfortable communication partner alone in a room while the clinician observes relaxed communication usually through video/audio recording. The clinician then sends an unfamiliar person into the room and observes any changes in speech created by the presence of a novel adult.

13. What does the intervention look like?

The intervention includes four steps - determining an intervention team, building rapport between the child and all individuals on the intervention team, educating the child on their anxiety, and creating a treatment plan.

When determining the intervention team, it is important to include all caregivers, including parents, grandparents, siblings, teachers, school administrators, peers, mental health professionals, and others. However, it is most important to think of the team as those who are actively carrying out the intervention. At minimum this should include the parents or primary caregivers, an appointed person from the school (keyworker), and the mental health professional implementing the treatment in the clinic and community. The keyworker is the appointed person from the school who will be conducting exposures (i.e. brave practices) in the school setting. This keyworker is typically a school psychologist, counselor, social worker, or speech/language pathologist who is the point of communication between teacher, parent, and outside mental health professional.

The next step is to build rapport with the client. Some rapport building activities include playing in a one-on-one setting, follow the child’s lead, avoiding asking questions or prompting for speech at first, and using PRIDE skills which will be described in a later section.

After rapport is built, the child learns about anxiety at a developmentally-appropriate level. This process is called psychoeducation and involves three steps: explaining anxiety, discussing what treatment will be like for them, and creating an anxiety scale. Psychoeducation is a component throughout all of treatment, continuing to learn about anxiety is necessary to understand how treatment will help them in the long term. In order to maintain motivation and compliance, the child typically benefits from understanding the avoidance cycle and how treatment can help them be brave.  

Creating a treatment plan is important especially when the treatment includes various people in various locations (home, school, public). This treatment plan is individualized to the child, and typically consists of shaping, stimulus fading, and/or contingency management. 

14. What are PRIDE Skills and when should they be used?

PRIDE skills are used to help the child warm up and become comfortable with the individuals around them before any demands for speech are placed. PRIDE stands for: Praise, reflect, imitate, describe and enthusiasm (Eyberg and Funderburk, 2011). The job of the individual implementing PRIDE skills is to reflect and describe what is happening with age-appropriate praise. While using PRIDE skills, do not give commands, ask questions, or criticize the child. PRIDE skills can be used as a warmup skill in the beginning of treatment, or to reengage the client in speech if they shut down during therapy.

15. How should adults prompt effectively for speech?

The intervention team’s job is to create opportunities for the child to speak without “rescuing”. When creating speaking opportunities, the child should be asked a forced-choice or multiple-choice question. After asking the question, the adult should wait at least five seconds, to allow the child to respond, and then should repeat the original question. If there is still no answer, the demand is not dropped but reduced to something more manageable. This could be changing an open-ended question to a forced-choice question, asking the child to make simple sounds to indicate their answer for the question, or moving to a more private area. It is very important to use age-appropriate (but matter-of-fact and calm) praise for verbal responses.

16. Who is involved in selective mutism treatment?

The child, parents, mental health professionals, and keyworkers are all involved in treatment. The child’s job is to be brave and try their best during all opportunities to speak. The parent’s job is to take advantage of all opportunities for the child to practice. It is important to not only facilitate speech with new communication partners but also to notice and stop all “rescuing” behaviors. It is okay to lessen the demand when necessary or take a break and come back to the question. However, the demand should not be entirely dropped.

The mental health professional’s job is to facilitate opportunities to speak in the community setting. Additionally, they provide training and support for parents.  

The keyworker's job is to create opportunities to speak in the school setting. The keyworker is expected to work with the child individually in the beginning of treatment. As the child becomes more comfortable, the keyworker may begin bringing in new communication partners, moving to new environments, and “pushing in” to the classroom setting.

17. How do you generalize speech to a new communication partner?

There are 3 methods to generalizing speech. For children who have a mild presentation, specific prompts and an effective reinforcement system may be sufficient to increase speech. However, it is more common that stimulus fading (generalizing existing speech to new people or locations) or shaping (reinforcing successive approximations of speech) are used therapeutically.

18. What is stimulus fading?

Stimulus fading is the most natural and easiest method to implement. Stimulus fading involves obtaining speech with the already established communication partner, and then slowly fading in a new person to this existing speech. When using stimulus fading to generalize speech to a new communication partner, the procedure starts with the child and the comfortable communication partner (usually a parent) alone in a room talking. Then, a new individual will enter the room slowly moving closer in approximation to the interaction. At first the new person does not talk or pay any attention to the interaction. After several minutes of just observing the new communication partner begins to comment on and reflect what the two are doing and saying. The new person slowly becomes more and more engaged with the child and parent interaction. Next, the new person begins to ask forced choice questions, such as “Do you want the red or the green marker?”.  If the child responds, the new communication partner can continue asking forced-choice and open-ended questions, and the parent can slowly withdraw and leave the room. The goal of the stimulus fading is to maintain speech after the parent or primary communication partner has left the room.

Additionally, a child’s existing speech can be faded from one comfortable environment to a new speaking environment. The child and communication partner would work to maintain communication while moving from the comfortable environment to a novel environment.

19. What is shaping?

If the child does not speak at all outside of the home, or speaks so quietly to parents that they cannot be overheard, shaping is the intervention that should be used. Shaping involves reinforcing approximations of speech until full speech is reached. Shaping is not a less effective intervention, but does generally take more time and is less “naturalistic.” Steps of shaping may include practice and reinforcement for blowing air, voiceless sounds, voiced sounds, short responses, longer responses, and initiating speech.

20. What should you avoid during treatment of selective mutism?

When implementing treatment for selective mutism there are a few key things to remember. It is okay to take things slow when beginning treatment but using strategies such as sign language, various assistive forms of technology, or accepting nonverbals as answers should not be encouraged (unless the child is very severe and even nonverbal methods of communication are absent). Secondly, interventionists should use effective prompts to speak and be aware of rescuing behaviors. Do not be critical or discourage. It is important to maintain praise, rewards, and positive interactions throughout treatment to motivate the child to engage. It is normal to be nervous and anxious, but it is important that the child does not know that you feel anxious or frustrated. Always be sure you are moving at a pace that challenges the child without expecting too much from the child. Be realistic about expectations and push for manageable progress.

References

Eyberg.S. & Funderburk, B. (2011). Parent-Child Interaction Therapy Protocol. PCIT International, Inc.

Kotrba, A. (2015). Selective Mutism: An Assessment and Intervention Guide for Therapists, Educators & Parents. Eau Claire, WI: PESI Publishing & Media.