Functional analysis and treatment of selective mutism in children.

Abstract

Selective mutism refers to a persistent failure to speak in public situations, especially school, where speaking is expected. Researchers have linked selective mutism to social anxiety in many cases. Functional analysis of selective mutism generally involves interviews, questionnaires, behavioral observations, and daily logs. Assessors should look closely for conditions under which selective mutism commonly occurs, especially directives from others, lack of attention from others, high child anxiety, and lack of interpersonal skills. Treatments for selective mutism often involve exposure-based practices and parent- and teacher-based contingency management.

Keywords: Mutism; social anxiety; functional assessment; interviews; scales; questionnaires; behavioral observations; treatment; contingency management.

Introduction

Selective mutism refers to a persistent failure to speak in public situations where speaking is expected, despite speaking in other situations (American Psychiatric Association, 2000). Children with selective mutism commonly fail to speak in situations outside their home and especially in places such as school, restaurants, stores, and recreational settings. From a diagnostic perspective, selective mutism must last at least one month. This excludes children who are naturally reticent about speaking during the first month of school. Selective mutism is not diagnosed in cases where a child simply lacks knowledge or comfort with the language that is spoken in the public situation. A child whose parents speak only Spanish, for example, would likely not be diagnosed with selective mutism during his or her first year of school unless the child was already quite familiar with English. Furthermore, selective mutism is not due specifically to difficulties in communication such as stuttering or specifically to a developmental disorder, though these problems may co-occur. Many children with selective mutism do try to communicate in public situations via nonverbal means such as nodding, pointing, mouthing, or writing letters in the air (APA, 2000).

Failure to speak in public situations, especially school, can hinder a child's academic progress because teachers are less likely to call upon these children for answers and because many of these children cannot undergo intelligence and other testing (Bergman, Piacentini, & McCracken, 2002). In addition, some of these children are teased or disliked by their peers, which further affects their social-communication development. Speech and language development may be delayed as well (Krysanski, 2003; Kumpulainen, Rasanen, Raaska, & Somppi, 1998).

The prevalence of selective mutism is not well known because of the furtive nature of the disorder and lack of literature regarding this population. Prevalence estimates range from 0.2-2.0%, but the actual rate may be higher because many parents attribute the problem to simple shyness that the child will eventually outgrow (Bergman et al., 2002; Kopp & Gillberg, 1997; Kumpulainen et al., 1998). In addition, because many of these children speak freely at home, parents often delay seeking treatment. An overt speech or language problem does not seem evident to them.

Initial studies on selective mutism indicated the prevalence of selective mutism to be higher for girls than boys, but recent evidence suggests a more equal gender distribution (Andersson & Thomsen, 1998; Hayden, 1980; Remschmidt, Poller, Herpertz-Dahlmann, Hennighausen, & Gutenbrunner, 2001; Wilkens, 1985). Age of onset for the disorder is typically 3-6 years but the problem is usually not recognized until school entry or later (i.e., age 6-8 years) (Black & Uhde, 1992; Ford et al., 1998). Selective mutism appears to have a variable but sometimes chronic course that can persist for years (Krysanski, 2003). In one study of second-graders with selective mutism, most (53%) had been mute since kindergarten and a substantial portion (18%) had been mute since preschool (Kumpulainen et al., 1998).

The conceptualization of selective mutism has been controversial, with some researchers contending that the problem is primarily due to oppositional behavior (Paez & Hirsch, 1998). Most researchers in this area, however, have linked selective mutism to anxiety and shyness in general and to social anxiety in particular (Steinhausen & Juzi, 1996). Vecchio and Kearney (2005) compared 15 children with selective mutism, 15 children with anxiety disorders without selective mutism, and 15 children without selective mutism or anxiety disorders. Youths and their families were compared via structured diagnostic interview, parent and teacher measures of internalizing and externalizing behavior, and family environment. All children with selective mutism met criteria for social anxiety disorder. No differences were found between the selective mutism group and the anxiety disorders group with respect to parent- and teacher-reported internalizing behavior problems. However, both groups were significantly higher than controls. Finally, parents rated the families of control children as significantly more socially active than families of children with selective mutism or anxiety disorders.

Children with selective mutism are commonly described by researchers as shy, timid, sensitive, withdrawn, fearful, inhibited, reticent, clingy, compulsive, anxious, and depressed (Bergman et al., 2002; Ford et al., 1998; Kopp & Gillberg, 1997; Kristensen, 2001; Kumpulainen et al., 1998; Lesser-Katz, 1986; Steinhausen & Juzi, 1996). Developmental disorders and delays are also common to this population, in particular articulation and communication problems. In one study, 68.5% of children with selective mutism met criteria for a developmental disorder or delay (Kristensen, 2000).

Given the seriousness and understudied nature of selective mutism, researchers have begun to delineate assessment and treatment strategies for this population. Given the relatively behavioral nature of the disorders, such as number of words spoken in public situations, a behavioral assessment strategy for functional analysis has drawn considerable support (Schill, Kratochwill, & Gardner, 1996). In addition, given the relationship between selective mutism and social anxiety, and given that children with selective mutism tend to be quite young, a treatment approach that coalesces exposure-based practices with contingency management seems reasonable as well. The purposes of the remainder of this article will thus be to provide a succinct protocol for assessment and treatment of selective mutism based on these behavioral principles.

Functional assessment of selective mutism

Given the intricate and unique nature of selective mutism, a traditional assessment approach that relies heavily on formal testing is inadequate unless nonverbal tests can be given or if a child is willing to engage an examiner verbally in his or her home. Given the infeasibility of this approach, a behavioral assessment approach is usually recommended. Such an approach typically involves detailed discussions with parents and teachers and others who are knowledgeable of a child's status, though attempts may be made as well to speak to the child in some truncated fashion. The primary measures for this population include structured diagnostic interview, parent- and teacher-based instruments, and behavioral observations and daily logs. Information from these measures can be synthesized in an attempt to understand the antecedents of a particular child's failure to speak and the consequences that follow such behavior.

Interviews

Structured interviews for functional analysis have been used for this population, particularly the Anxiety Disorders Interview Schedule for DSM-IV-TR (child and parent versions) and Functional Diagnostic Profile adapted for selective mutism (Schill et al., 1996; Vecchio & Kearney, 2005). A related measure, the Children's Global Assessment Scale for Children-Non-Clinician Version has been used as well to measure general severity of disturbance in this population (Bergman et al., 2002).

The Anxiety Disorders Interview Schedule for DSM-IV-TR (Silverman & Albano, 1996) can be administered to parents and children to assess for a wide range of anxiety-related disorders, including selective mutism. The interview has excellent psychometric properties and is particularly useful for determining whether a particular child has selective mutism and whether such mutism is primarily related to social anxiety, oppositional behavior, or some other difficulty such as depression. In our study that utilized this measure, all parents and one-third of youths with selective mutism completed the interview process. Some youths with selective mutism may be able to participate in this type of assessment either by responding nonverbally in a clinic setting or by responding verbally or nonverbally during a home visit. The following key supplemental questions should be asked during this interview:

* What settings occasion a child's mutism (e.g., home, school, community settings, etc.)?

* How is the child's mutism manifested in each setting?

& How long has the mutism occurred in each setting?

* When mutism occurs in each situation, is the child alone or with others?

* With whom will the child speak freely or become mute?

* What are the specific antecedents and circumstances that surround each instance of a child's mutism?

* Can the child be enticed to speak audibly in these situations in any way?

* What compensatory behaviors does the child show to communicate with others?

* How do significant others respond to a child's mutism (e.g., ordering food or completing tasks for the child; allowing whispers in the ear or pointing; rearranging a setting to accommodate a child's mutism)?

The Functional Diagnostic Profile is designed to gather information about psychosocial and physical events that could contribute to a child's mutism; child characteristics (e.g., affect, cognition, personality, skills development); setting events; and consequences of behavior (Schill et al., 1996). For example, parents are asked if selective mutism is more likely to occur during periods of low stimulation or social attention or if the mutism is more likely following a specific adult request or directive. The measure also assesses whether a child with selective mutism fails to speak to decrease anxiety, to increase social or sensory feedback from others, because alternative speaking skills are inefficient or underdeveloped, or to avoid aversive directives from others. Each of these potential functions of selective mutism should be explored in depth for each public situation that the child remains mute.

Questionnaires

No behavioral questionnaires are available for selective mutism per se, though many measures of constructs related to selective mutism have been used for this population. The most common measures involve social anxiety and most notably the Social Anxiety Scale for Children-Revised, a 26-item instrument that focuses on fear of negative evaluation from peers, social avoidance and distress related to new situations, and generalized social avoidance and distress (La Greca & Stone, 1993). The Social Phobia and Anxiety Inventory for Children, which focuses on assertiveness, general conversation, physical and cognitive symptoms, avoidance, and public performance, may be useful as well (Beidel, Turner, & Fink, 1996). Other measures of general anxiety and depression can also be applied to children with selective mutism, though the child's compliance and understanding with respect to these measures must be considered closely.

Parent- and teacher-based questionnaires of behavior are also commonly used for this population, given each party's detailed knowledge of a child's behavior in general and refusal to speak in particular. The Child Behavior Checklist and Teacher Report Form are especially useful for examining a wide range of internalizing, externalizing, and mixed (social/thought/attention) problems relevant to a particular child (Achenbach & Rescorla, 2001). Special attention should be paid to the anxious/depressed and withdrawn/depressed scales in general and to the item "Refuses to talk" in particular.

Behavioral observations and daily logs

Behavioral observations are a key linchpin for assessing children with selective mutism. Such observations can and should be done in a clinical setting, at the child's home, over the telephone, in various public places, and at the child's school. No formal rating systems have been designed for this population, but clinicians should pay special attention to the following in each situation:

* Number of words spoken

* Volume level of spoken words (e.g., audible or inaudible)

* To whom a child is willing to speak

* Key antecedents (e.g., demands or social approaches from others; boredom)

* Key consequences (e.g., parent or teacher acquiescence; accommodation of a child's mutism)

* Child's social and communicative skills

* Child's level of anxiety as indicated by escape, withdrawal, or avoidance

* Child's compensatory behaviors (e.g., whispering, pointing, nodding, mouthing, crying, frowning, stomping, temper tantrum, pushing, or pulling)

Daily logs should follow this process as well so that clinicians have a good sense of fluctuations in a child's behavior and whether treatment procedures are effective. Our daily logs, for example, are relatively simple and completed by children, parents, and teachers. These parties complete daily records of child's level of anxiety on a 0-10 scale as well as key behaviors such as number of words spoken, whispered, and mouthed. Audibility of statements is also rated on a 0-10 scale (10=completely audible). In addition, each party records on a daily basis to whom the child spoke, whispered, or mouthed any particular word.

Synthesis of assessment information

Once these data are collected and a baseline is set, clinicians should examine common patterns of a child's mutism by synthesizing information from interviews, questionnaires, and observations. Selective mutism in children does tend to have a relatively stable course without large changes in symptomatology over brief periods of time. Therefore, ample opportunity exists to identify particular antecedent-consequence pathways for a particular child. An especially common pathway is for a child to demonstrate selective mutism and considerable social anxiety following some directive from others and prior to some reward for the mutism. Such rewards often come in the form of special attention, accommodation, and removal of an aversive stimulus such as a teacher directive. Contextual variables that impact this process must also be considered, of course. Given that selective mutism is most commonly associated with social anxiety and with accommodation from others, a combined exposure SLP- based and contingency management approach is often preferred. A brief outline of this treatment strategy is presented next.

Treatment of selective mutism

Treatment of selective mutism often involves exposure-based practices to increase a child's audible speech in public places as well as parent-based contingency management to enhance these exposures and to establish an expectancy that the child will speak in public situations.

Exposure-based practices

Given that social anxiety is often a core feature of selective mutism, in vivo exposure to various situations is utilized so that a child can practice speaking to others. This usually involves a gradual process including several main stages across different aspects of the child's environment:

* Child's home (with the therapist)

* Clinical setting

* Public situations such as restaurants and home-based situations such as answering the telephone

* School-related situations

To help a child speak with the therapist, home visits are sometimes conducted. If a child is willing to come to the clinic setting, however, this is preferred. Initial sessions often involve playing games and engaging in other recreational activities with the child to build rapport and decrease social anxiety. After a few sessions, the therapist may purposely make mistakes that the child will try to correct nonverbally. These nonverbal attempts are generally ignored or met with a statement that the therapist only understands spoken words. Compensatory behaviors such as mouthing or pointing may be allowed in some circumstances to aid communication and rapport-building. However, whispers in the ear or other barely audible speech are more acceptable.

During these initial exposure sessions, parents may be asked to audiotape or videotape their child at home as he or she engages in good speech. The audiotape or videotape is then played before the therapist and family members in a clinical setting as the child watches and as he or she is reinforced by the therapist for her speech and voice. In addition, early exposures may include telephone conversations between a child with selective mutism and a therapist if the child is willing to do so. Children may also be willing in these early stages to speak to the therapist through a door, from some distance such as 50 feet away, or via cell phone from the car on the way to the clinic setting. All of these are allowed and encouraged. Finally, in some cases, children may be asked to stay with a therapist for an extended period of time until at least one word is uttered.

With practice and exposure, most children with selective mutism eventually speak regularly to the therapist. Once this is accomplished, exposures are scheduled for various public situations such as restaurants, ice cream places, pet stores, malls, parks, and playgrounds. Children are expected to order their own food, ask questions, answer questions from others, and initiate short conversations under the supervision of the therapist and parents. A common scenario involves the therapist and family ordering ice cream under the rule that anyone who orders ice cream loud enough for the counter person to hear may receive ice cream and anyone who cannot do so receives no ice cream. A therapist can accompany the family to help prompt the child to speak and to model appropriate interactions with others.

Once a child can speak regularly and appropriately to others in public situations, he or she should be expected to speak to others near home. This may include answering the telephone or door as appropriate, talking to visiting relatives, and initiating telephone calls to the therapist or others. Often this exposure process to public and home-based places requires several weeks or months. Once a child can speak regularly and appropriately in public and home-based situations, school-based exposures can begin. These exposures are typically conducted last because school is often the most difficult place for a child to speak. A seamless transition from the previous exposures can be made by first requiring a child to speak to the therapist in an empty classroom. Once this is accomplished, a peer or teacher (whichever is easier for the child to tolerate) may be added to the room at a distance as the child speaks to the therapist or reads a story. Over time more peers may be added, and at a closer distance, to resemble normal classroom activity. Final exposures should involve speaking to others in an audible fashion, initiating contact with peers and teachers, answering questions in class, taking standardized tests that require verbal interaction, and reading stories or otherwise performing before others in class.

Contingency management

Parent-based contingency management is the other key element for treating children with selective mutism. Appropriate consequences are established for successfully (or unsuccessfully) engaging in and practicing therapeutic homework assignments. These assignments typically involve speaking audibly to others in some pre-established way. In addition, parents are asked to establish routines that encourage a child to encounter others and to speak to others appropriately. This may involve accepting a call from the therapist or family members, asking a child to say hello to someone in public, or taking a child to recreational activities that require some social interaction.

Parents are also encouraged to engage in short, specific commands to their children and to ignore inappropriate compensatory behaviors, especially as treatment progresses. Over time as a child with mutism begins to speak more comfortably in public situations, social reinforcers can supplement or replace tangible reinforcers. Parents are encouraged as well, even when a child successfully speaks in all public and school-related situations, to continue placing their child in interactive settings and restrict accommodations for unwillingness to speak. Teachers are also instructed to engage in appropriate contingency management procedures during and following treatment.

Final comments

The treatment of selective mutism in children can be an elongated process that often requires intensive intervention in various public settings. In addition, the nature of the problem demands a molecular, behavioral assessment approach that allows clinicians to determine the exact antecedents and consequences that maintain a child's mutism over time. We have presented here one possible treatment strategy that works well for the children with selective mutism in our specialized clinical setting, but caution readers that any universal approach is not necessarily effective for all children of this population. This may be particularly true for those with co-morbid conditions, extensive family dysfunction, or children whose primary language is not English (Vecchio & Kearney, in press).

References

Achenbach, T.M., & Rescorla, L.A. (2001). Manual for the ASEBA school-age forms & profiles. Burlington, VT: University of Vermont Research Center for Children, Youth, & Families.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington DC: Author.

Andersson, C.B., & Thomsen, P.H. (1998). Electively mute children: An analysis of 37 Danish cases. Nord Journal of Psychiatry, 52, 231-238.

Beidel, D.C., Turner, S.M., & Fink, C.M. (1996). Assessment of childhood social phobia: Construct, convergent, and discriminative validity of the Social Phobia and Anxiety Inventory for Children (SPAIC). Psychological Assessment, 8, 235-240.

Bergman, R.L., Piacentini, J., McCracken, J.T. (2002). Prevalence and description of selective mutism in a school-based study. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 938-946.

Black, B., & Uhde, T.W. (1992). Elective mutism as a variant of social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 1090-1094.

Ford, M.A., Sladeczeck, I.E., & Carlson, J. (1998). Selective mutism: Phenomenological characteristics. School Psychology Quarterly, 13, 192-227.

Hayden, T.L. (1980). Classification of elective mutism. Journal of the American Academy of Child and Psychiatry, 19, 118-133.

Kopp, S., & Gillberg, C. (1997). Selective mutism: A population-based study: A research note. Journal of Child Psychology and Psychiatry, 38, 257-262.

Kristensen, H. (2000). Selective mutism and comorbidity with developmental disorder/delay, anxiety disorder, and elimination disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 249-256.

Kristensen, H. (2001). Multiple informants' report of emotional and behavioural problems in a nationwide sample of selective mute children and controls. European Child and Adolescent Psychiatry, 10, 135-142.

Krysanski, V. (2003). A brief review of selective mutism literature. Journal of Psychology, 137, 29-40.

Kumpulainen, K. Rasanen, E., Raaska, H., & Somppi, V. (1998). Selective mutism among second-graders in elementary school. European Child and Adolescent Psychiatry, 7, 24-29.

La Greca, A.M., & Stone, W.L. (1993). Social Anxiety Scale for Children-Revised: Factor structure and concurrent validity. Journal of Clinical Child Psychology, 22, 17-27.

Lesser-Katz, M. (1988). The treatment of elective mutism as stranger reaction. Psychotherapy, 25, 305313.

Paez, P. & Hirsch, M. (1988). Oppositional defiant disorder and elective mutism. In Kestenbaum, C.J. & Williams, D.T. (Eds.), Handbook of clinical assessment of children and adolescents (pp. 800-811). New York: University Press.

Remschmidt, H., Poller, M., Herpertz-Dahlmann, B., Hennighausen, K., & Gutenbrunner, C. (2001). A follow-up study of 45 patients with elective mutism. European Archives of Psychiatry and Clinical Neuroscience, 251, 284-296.

Schill, M.T., Kratochwill, T.R., & Gardner, W.I. (1996). An assessment protocol for selective mutism: Analogue assessment using parents as facilitators. Journal of School Psychology, 34, 1-21.

Silverman, W.K., & Albano, A.M. (1996). The Anxiety Disorders Interview Schedule for Children for DSM-IV, child and parent versions. San Antonio, TX: Psychological Corporation.

Steinhausen, H., & Juzi, C. (1996). Elective mutism: An analysis of 100 cases. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 606-614.

Vecchio, J.L., & Kearney, C.A. (2005). Selective mutism in children: Comparison to youths with and without anxiety disorders. Journal of Psychopathology and Behavioral Assessment, 27, 31-37.

Vecchio, J., & Kearney, C.A. (in press). Assessment and treatment of a Hispanic youth with selective mutism. Clinical Case Studies.

Wilkins, R. (1985). A comparison of elective mutism and emotional disorders in children. British Journal of Psychiatry, 146, 198-203.

Author contact information:

Christopher A. Kearney

Department of Psychology

University of Nevada 

4505 Maryland Parkway

Las Vegas, NV 89154-5030

Phone: [phone]

e-mail: [e-mail]

Jennifer Vecchio

Department of Psychology

University of Nevada

4505 Maryland Parkway

Las Vegas, NV 89154-5030

Phone: [phone]

e-mail: [e-mail]