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Clinical perspectives on the treatment of selective mutism.

Abstract

Selective mutism is a childhood disorder characterized by a failure to speak in some but not all of the contexts where speaking is normally expected. It is commonly associated with co-occurring anxiety, both on the part of the child and on the part of one or more family members. The prevailing opinion on treatment recommends medication, cognitive-behavioral therapy (CBT) and family counseling. However, treatment efficacy research is extremely limited. Further, since selective mutism is often first identified during the preschool years, CBT must be modified to match a child's developmental level. This paper summarizes the nature and prevalence of selective mutism, techniques used to treat this disorder, and issues in need of research. The discussion of behavioral treatment techniques is based on the literature and on the author's clinical experience.

Keywords: Selective Mutism; Operant Conditioning, Cognitive Behavior Therapy, Communication Hierarchy, Talking Scale, Talking Map, Parent Counseling, Collaboration.

Introduction

Selective mutism is an intriguing childhood disorder that presents considerable treatment challenges. The core symptom is that a child persistently and systematically refrains from speaking in some settings where speaking is expected (e.g., school, community) but speaks fluently in other settings (e.g., home.) Often there are additional complicating factors, such as co-occurring anxiety symptoms or oppositional behaviors, as well as a familial history of anxiety. While a number of articles have been written about selective mutism, there is no universally accepted treatment regimen. Following a short summary describing the nature and incidence of selective mutism, this paper will address approaches to treatment based on the literature and on the author's clinical experience with this population. Also presented are recommendations for research.

Definition, Incidence, and Co-Occurring Conditions

According to the DSM-IV-TR (American Psychiatric Association, 2000) the onset of selective mutism usually occurs before the age of five years. However, sometimes it is not recognized as a specific problem until a child enters school, when the systematic and selective failure to talk becomes more noticeable. A clinical diagnosis of selective mutism is made on the basis of five criteria:

A. The child refrains from speaking in specific social situations (e.g., school) while speaking in others (e.g., home)

B. Failure to speak interferes with educational achievement or with social communication

C. Symptoms persist for at least one month (not including the first month of school)

D. The failure to speak can not be attributed to a lack of knowledge or comfort with the spoken language (as might be true for bilingual children who have immigrated from another culture).

E. The symptoms are not better accounted for by a communication disorder, a pervasive developmental disorder, or a psychotic disorder.

Prevalence estimates of selective mutism range from .03 to 2 percent; and it is more common among girls, with ratios ranging from 1.5 to 2.6 girls to 1 boy with the diagnosis (Garcia, Freeman, Francis, Miller, & Leonard, 2004). Current research indicates that children with selective mutism show more anxiety symptoms than do other children (Bergman, Piacenti, & McCracken, 2002; Cunningham, McHolm, Boyle, & Patel, 2004) and that anxiety symptoms co-occur with selective mutism at a rate of 74 to 100 percent (Garcia et al.; Kristensen, 2000; Vecchio & Kearney, 2005). Oppositional disorder may also co-occur, but there is some dispute in the literature about its co-occurrence rate. Garcia et al., and Vecchio and Kearney reported that the rate of occurrence is quite low. However, Cunningham et al. reported oppositional disorder to co-occur twice as often among children with selective mutism as among children in a control group. Based on the literature and on the author's clinical experience, the conceptualization of selective mutism as a symptom of anxiety is a helpful framework for planning intervention.

In most instances, selective mutism does not appear to be caused by a specific, traumatizing event (Dummit et al., 1997; Steinhausen & Juzi, 1996). It appears instead to emerge within the context of shyness and anxiety. Krohn, Weckstein, and Wright (1992) noted a general pattern of shyness or anxiety among parents and other family members of children diagnosed with selective mutism. In the author's clinical experience, almost every child with selective mutism has had at least one parent with a history of significant shyness or anxiety disorder. This familial pattern of shyness and anxiety can contribute to the development of selective mutism in several ways. Mineka and Zinbarg (2006) have noted that children of parents with anxiety disorders may be at risk for developing their own anxiety disorders due to genetic transmission of temperamental vulnerability, vicarious learning of specific fears, or the use of avoidant coping styles that are supported by their parents.

Treatment

Medication

Published reports describing the medical treatment of children with selective mutism are limited. Only three publications have reported the efficacy of medical intervention based on controlled research (Black & Uhde, 1994; Carlson, Kratochwill, & Johnston, 1999; Dummit, Klein, Tancer, Asche, & Martin, 1996). Other reports are based on individual case studies without controls (e.g., Golwyn & Sevlie, 1999; Golwyn & Weinstock, 1990; Lafferty & Constantino, 1998; Lehman, 2002; Wright, Cuccaro, Leonhardt, Kendall, & Anderson, 1995). The medications used were selective serotonin reuptake inhibitors (SSRI) and monoamine oxidase inhibitors (MAOIs).

The case study reports suggested that medication had a positive effect on the individual children whose behavior was reported. However, these studies are difficult to interpret due to the small numbers of participants and the lack of controls. Moreover, none of the authors indicated whether other children with selective mutism had failed to make progress while taking the medication. Therefore, while case studies suggest that medication can be effective, these reports are anecdotal. In the experience of this author, every anecdotal report of success with medication can be countered with an anecdotal report of a patient whose symptoms failed to improve, given the same medication.

The three controlled studies involved a total of 41 children. Dummit et al. (1996) treated 21 children with fluoxetine (an SSRI) for a 9-week open trial. As a group, the children showed improvements on rating scales of anxiety and social behaviors. Ratings by the treating psychiatrists indicated that 16 of the 21 children had improved on global measures. However, no details were given about the children's specific behaviors pre- or post-intervention. The authors noted that despite treatment response, complete remission of the mutism required more time than the 9-week trial. They did not specify how many (if any) of the children showed complete remission of the mutism or how long it took.

Black and Uhde (1994) reported a double-blind placebo-controlled study also using fluoxetine. Fifteen children who did not respond to 2 weeks of placebo control were randomly assigned to a placebo or fluoxetine condition for 12 weeks. The six children on fluoxetine showed improvement on several measures, compared with the nine children taking placebos. In total, 27 measures were collected from parents, teachers, and a treating psychiatrist blind to the treatment condition. None of the psychiatrist's post-treatment ratings showed significant differences, including those measuring mutism. Two of the 9 parent ratings and 1 of the 10 teacher ratings showed more improvement in the group receiving fluoxetine. Overall, the children receiving fluoxetine scored significantly better on only 3 of the 27 measures. The authors concluded that treatment effects were modest and most of the participants showed continued impairment at the end of the study.

Carlson et al. (1999) observed five children in a double-blind placebo-controlled trial using sertraline (also an SSRI) within a multiple-baseline single-case design. Each child's mute symptoms were measured for 2 weeks with no medication. Then the children were randomly assigned to a treatment schedule of varying length (2 to 6 weeks), followed by a medication phase of 8 to 12 weeks, so that each child was observed for a total of 16 weeks for symptoms of selective mutism. The target measure for all children was speaking, which was rated several times a week by both teachers and parents. Improvement in talking was observed in the children, but it did not always correspond to the onset of the medication phase. The authors noted that the children might have entered the treatment phase of the research at different stages in their use of non-vocal communicative behaviors (see the discussion of Initial Presentation below). This suggests that measures of mutism and anxiety must be broad enough to capture the child's status at the time of treatment, and sensitive enough to measure progress. For example, Carlson et al. suggested that a more thorough examination of nonverbal communicative behaviors might be necessary for measuring progress. They concluded that their study offered "optimistic but guarded impressions" of treatment efficacy (p.304).

In sum, the efficacy of medication in the treatment of selective mutism appears modest, at best. The most enthusiastic efficacy claims come from anecdotal case reports. In contrast, three systematic studies have shown some limited and modest success with the use of SSRIs. These group studies show no consistent and large effects of medication with all children. It is noteworthy that Carlson et al. (1999) and Dummit et al. (1996) both found an inverse correlation between age and improvement following medication. This does not necessarily mean that medication per se is more effective with younger children, but perhaps that any type of early intervention is more advantageous. Furthermore, Carlson et al. suggest that the course of improvement for children with selective mutism seems to have discernable stages, and studies on treatment intervention may need to document the child's use of non-vocal social-communication behaviors at the time when the treatment is introduced.

Following a review of interventions for a number of related conditions (e.g., selective mutism, anxiety disorders, obsessive-compulsive disorder), Nemeroff, Gipson, and Jensen (2004) concluded that medication appears to be effective for treating children with obsessive-compulsive disorders (OCD) but there is only limited evidence for its efficacy in treating children's anxiety disorders or selective mutism. Cognitive-behavioral therapy is the treatment of choice for social phobia.

Behavioral Treatment

As noted above, selective mutism is commonly viewed as a manifestation of social anxiety disorder. Consistent with other manifestations of social anxiety disorder, the recommended treatment for selective mutism is cognitive-behavioral therapy (CBT) (Garcia et al., 2004; Albano & Hayward, 2004). However, many children with selective mutism are first identified at the age of 4 or 5 years when they lack the cognitive insight, self-monitoring, and social awareness needed to participate in CBT. Consequently, intervention may begin with operant and classical conditioning to shape more expanded communication behaviors. CBT can be introduced later as children mature. In other words, the treatment of young children with selective mutism often extends over an age range that requires therapists to adjust their use of interventions (behavioral, CBT) to fit the socio-cognitive capacity of children at different developmental levels.

Co-Morbid Conditions and Individualizing Treatment

As indicated above, selective mutism often exists in conjunction with other co-occurring conditions. In younger children this may include toileting problems (Kristensen, 2000; Steinhausen & Juzi, 1996). Children may resist using toilets in public settings (e.g., school). Occasionally, some (in the absence of any other developmental disability) are even resistant to sitting on the toilet at home. For these children it may be necessary to address the toileting issue first. In fact, parents and teachers are usually more concerned about managing the toileting problems first, because they believe that the public embarrassment of toilet accidents may increase the child's stress or shyness. Moreover, many schools are reluctant to accept a child of this age in a regular classroom if the child is not toilet trained.

Some children with selective mutism also produce behaviors associated with oppositional disorder. In these cases, parents and teachers tend to believe that the child's selective mutism is a form of passiveaggressive opposition. Oppositional behaviors may include deliberate refusal to comply with parent directives and temper tantrums when a preferred activities are not allowed. However, clinical experience suggests that these oppositional behaviors are often an expression of a child's attempts to cope with underlying anxiety since the behaviors often occur in direct proportion to the amount of pressure exerted by adults to encourage talking and socialization. Dummit et al. (1997) reported that a formal diagnosis of oppositional defiant disorder was rare among children with selective mutism and that it occurred in only 1 of the 50 children they studied. They proposed that that oppositional behaviors function to avoid anxiety-producing events, rather than as a primary disorder per se. Similarly, Wright and Cuccaro (1994) proposed that oppositional behavior emerges through the interaction of parent demands and child anxiety. Yeganeh, Beidel, Turner, Pina & Silverman (2003) reported prominent oppositional symptoms among older children, speculating that the oppositional behaviors become more entrenched over time. Following a history of adult pressure and child resistance, oppositional problems can take on a life of their own and become a well-practiced routine requiring therapeutic intervention.

Limitations in socio-cognitive capacity (as described above) combined with the possible presence of co-occurring problems (e.g., toileting or oppositional behaviors) suggest that therapy for selective mutism must be highly individualized. Anstendig (1998) advised that, "Attempts to treat a large sample of selectively mute children using a highly specific method for intervention often yield inconclusive results" (p. 390). The treatment techniques discussed in the remainder of this paper are offered as a repertoire that has been found clinically successful with children who present with selective mutism. However, not all techniques are used with any one child. Different techniques are appropriate depending on a child's symptoms and on a child's developmental level at different points in the therapeutic process. An overarching assumption in the use of these techniques is that selective mutism generally reflects a type of anxiety disorder and that behavioral therapy is the treatment of choice for this disorder.

Initial Presentation

During the initial visit to a therapist, a child with selective mutism will typically refrain from talking to the therapist, be reluctant to establish eye contact, and cling to or hover near his or her parent. For these reasons, it may be best to begin with the least intrusive tasks. The initial evaluation may include a nonverbal assessment to estimate the child's cognitive abilities and to determine the extent of social interaction. Some children will respond by pointing to pictures or placing markers on a receptive vocabulary test or a matrix test. Other children will not make any choices. A frequent theme of selective mutism is that children have difficulty answering specific questions or making choices. Later in therapy, the children often articulate their fear of making mistakes. In the initial evaluation, a child may watch the clinician demonstrate a toy or an activity, but may not respond in a testing mode.

An important goal of the initial evaluation is to determine the frequency and types of nonverbal communication signals produced by the child. The therapist should look for eye contact when talking to the child. Some children will smile if the therapist does something silly, and some will shake or nod their heads. A principle for therapy is that any form of communication is good communication, and the clinician should be sensitive to the signals the child produces during the first meeting.

Occasionally a child will talk to the therapist during the initial meeting (but not to a teacher at school). Occasionally children may dominate a conversation by talking about a favorite cartoon series for example. These children appear to feel secure when they can control the conversational topic with their personal expertise. This reduces the apprehension that they will make a mistake or not know an answer.

Selective mutism is exquisite and highly functional in reducing threats perceived by a child. In this sense, it is an adaptive behavior that serves the child well (Anstendig, 1998). Children will present with variations in the boundaries for their mutism. Some children will never speak if there is someone present who is not a member of their immediate household. Some children will whisper in the parent's ear in front of the therapist. Some children have a distance established in their mind. For example, in a waiting area they may talk to a parent if nobody else is inside a perimeter of 10 feet, 15 feet, or whatever has been established in that child's scheme. Some children will talk to their parents in public if the people around them are unknown and are not attending to the child. Many children show, and later report in therapy, that they do not like to be the center of social attention.

Conditioning Techniques

As indicated above, operant conditioning can be extremely helpful when working with the youngest children. For example, the clinician can reward successive approximations of communication, moving gradually toward fluent speech. Initially, any communication is good communication and should be rewarded. Even though many children with selective mutism dislike being the center of social attention, they tend to respond positively to a warm, supportive approach from the therapist. After assessing the child's initial level of communication in the therapy room, the therapist should arrange opportunities to motivate and shape communicative behaviors. The individual steps need to be quite modest, as these children are extremely anxious and resistant to making big changes, particularly at first.

Some children will start therapy by hiding under a table or behind furniture in the therapy room. If the therapist ignores the hiding (avoidance) and waits patiently, the child will usually try to initiate some form of contact/communication. The child may make noises or extend a toy into the visual range of the therapist. At this point, the therapist can respond in a positive manner to the child's communicative act (e.g., by commenting on the child's presence or by making a remark about the toy). This starts the process of reinforcing any act of communication.

Therapists and teachers who have had previous successful experiences with otherwise-typical shy children sometimes assume that they will be able to use their expertise to quickly encourage a child with selective mutism to talk. This assumption is likely to be false. The symptoms of children with selective mutism are often more entrenched than those of otherwise-typical shy children. The strategies that work successfully to warm up an otherwise-typical shy child are often not effective when applied to children with selective mutism. Therapists should plan to work with a child for a series of sessions, and should determine a sequence of steps to work through with the child. Initially, the therapists should determine if a child will use non-vocal modes of communication (e.g., nod/shake their head, gesture, point, write, draw). If the child will do any of these, the therapist can use activities that call for frequent practice and successful use of these forms of communication.

Children with selective mutism should be encouraged to bring favorite toys or other objects to therapy; and they often do so spontaneously. Even when a child does not talk, he or she often quickly establishes rapport with a supportive therapist who refrains from placing excessive demands on them. In this context, the child may be willing to show the therapist the toys or objects they use outside of therapy; and these things can serve as the topic of communication. Even adolescents with selective mutism are often willing to share personal artifacts with a therapist. At this age, the objects may include such things as favorite videos or pictures of their family and pets, or sports apparel they like to wear.

Within the context of play and communication therapy, the therapist may also use classical conditioning techniques to help the child be more relaxed and spontaneous in the atmosphere of a new and semi-public setting. This occurs when familiar and preferred objects from home are paired with communication activities involving the therapist.

A major goal of therapy is for the child to use successively more conventional forms of communication in therapy and other contexts in which initially resist talking. Figure 1 illustrates a series of successive approximations established for a child who was treated by the author. The program was coordinated with the child's teachers so that after the communication behaviors emerged in therapy the teachers evoked them at school. Although the child was quite anxious, she was responsive to the therapist's suggestions regarding classroom carry-over. Specifically, the therapist told the child that as she learned to perform target behaviors in therapy with him, he would inform her teacher. Then, the teacher would ask the child to perform the behaviors in class. As shown on Figure 1, the child started with a hierarchy of nonverbal communicative acts including eye contact, nodding/shaking her head, and pointing to choices. During later sessions, the therapist introduced noise makers (e.g., small horns and other party favors) to encourage creativity and variety of expression. Still later, the child began to engage in conversations with the therapist by producing her utterances in written form. This was followed by journal interactions with the teacher in class. Many children with selective mutism seem to enjoy journal interactions with their teachers; and teachers benefit by learning more about the child's personal interests and reactions to classroom events. After learning to engage in journal interactions, the child began to mouth and eventually to whisper single-word clues during therapy while playing picture search games. She then practiced whispering stock phrases during a board game (Guess Who?). This led to whispered answers and conversation in therapy and at school. Later, the child successfully used a microphone to amplify her whispering when giving a reading at a school recital. When whispering was well established, she and the therapist practiced phonating single words from a book. Eventually, she learned to say stock phrases during games, then to read passages in a book, and finally to converse with full phonation. Each child will require a set of approximations tailored to their skills and needs, but Figure 1 presents a typical therapy sequence.

At about seven years of age, children have more self-awareness and cognitive understanding of who they are and how they fit into a social context. At this time, the therapist can begin to use strategies associated with CBT. One helpful technique is the use of a talking scale. The scale itself consists of a hierarchy of speaking situations identified by the therapist in collaboration with the child. Figure 2 illustrates a talking scale that was created for a particular child (Child A) with selective mutism. This child reported that she could not imagine anything worse than being interviewed on television or radio, which defines the highest level of difficulty on her scale. A talking scale is a dynamic instrument that changes over sessions. The child or therapist can pencil in additions or changes during a therapy session if the child expresses different views or reports changes in her experiences. For example, the therapist's name may drop downward on the scale as the child becomes more comfortable interacting with the therapist. Often the therapist will introduce a no-talk line on the scale, to designate concretely the situations in which the child is willing to talk and those in which the child is not yet ready to talk . This helps young children to conceptualize talking situations along a continuum of comfort, rather than as two discrete categories-talk, no talk. As the child experiences success in talking in different situations, the no-talk line starts to move upward. A variation of this procedure involves use two lines across the scale: a whisper line and a no talk line. This could be used for a child who talks in some situations, whisper in others, and does not talk at all in still others. As therapy continues, whispering and full phonation are introduced during increasingly more challenging situations, and both lines move upward correspondingly.

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Talking scales help children conceptualize the nuances of their communication and give them a concrete method of discussing their communication with the therapist. It helps them better visualize where they talk and to whom they talk. Some children will even do a variation of this in which they draw a talking map, which shows their neighborhood, including their home, the homes of friends, and their school with a circle around areas where they currently feel comfortable talking. At first it might be only inside their home, then in the area around their home, then a friend's home or a neighborhood park. Across sessions they can see the talking circle expand, usually getting closer to school. Some children will show a time variation on their map. For example, they will meet friends on the school playground and talk with them if school is not in session, but will not talk with them at recess during school hours.

Self-perception is an important component of therapy and it can be addressed in several ways. The therapist may introduce it by asking a child to choose words to describe their feelings when they have to communicate. For example, a therapist might begin by asking a child to choose one of three "S words": shy, scared, stubborn. (Few children pick stubborn, but it is included because that is often a concern of parents and teachers. The children have dealt with people who think that they are oppositional, so it is a useful concept to introduce into therapy for the sake of discussion.) The author's clinical experience suggests that it may be useful to use the terms shy and brave with children to talk about when they are reluctant to speak and when they speak in a new situation, respectively. It can also be helpful to make process comments to the child about his or her performance during a therapy activity. For example, some children grimace when they become anxious during an activity. The therapist can point this out, explaining that it is a cue that something is difficult for the child. That provides a conversation point for understanding how the child is feeling and what alternatives are available to manage the situation.

Children can be encouraged to bring videos from home in which they are talking fluently to family members. Sometimes videos are made to provide a reading or speech sample for school so that teachers can evaluate the child's progress. Many children will sit with the therapist and watch the video together, and the therapist can comment about brave or easy talking. This is also a vehicle to recognize with the child that she is capable of talking in certain situations (refer to the talking scale), and that the therapist hears and appreciates the child's talking. The video might serve as one step in successive approximations. The child can then be encouraged to call the therapist's phone and leave a voicemail message. If that is successful, the child can be asked to call the therapist and talk live on the telephone. Some children will talk to a therapist or teacher on the telephone, but not face to face. They report that they become anxious when their conversation partner can look at them.

Some children may bring a friend or sibling to therapy session. The friend should be someone with whom the child is quite fluent in other situations. This offers the opportunity to pair a successful communicative situation with a new location. The children can do an activity with the therapist, and the visitor can serve as a model in talking freely with the therapist. Sometimes the child with selective mutism will start talking with her friend and the therapist can discretely enter the conversation.

Relaxation training has been used with limited success. Based on the author's clinical experience, it appears most effective with older children who can specify the situations in which they feel symptoms of anxiety. These children can learn to use relaxation techniques (e.g., deep breathing, imagery) in target situation (e.g., when giving a report in class). However, relaxation techniques are more difficult to use with younger children who have limited capacity for self-reflection. Younger children seem to respond much better when provided with (1) opportunities to practice specific communication behaviors during therapy and (2) encouraging communicative environments at home and school.

The use of alternative or augmentative communication (AAC) methods (e.g., sign language, electronic talkers) is not recommended based on the author's clinical experience. Most children with selective mutism speak fluently in comfortable situations and do not need alternative methods for communication. Rather, they need support for generalizing their use of perfectly adequate communication signals to an expanded range of contexts. Furthermore, the author's clinical experience has shown that children with selective mutism who were provided with the opportunity to use an AAC (e.g., manual sign) were not particularly interested in doing so.

Parent Counseling

Treatment of children with selective mutism must be accompanied by parent counseling. Parents need support for understanding their child and managing their child's behavior at home. Most parents of children who have behavioral and emotional difficulties are worried about their children. With selective mutism, this worry may be exacerbated by a history of anxiety disorder within the family. These parents may project their own experiences and apprehensions onto the lives of their children. Parents sometimes recount their own negative social experiences and dread the possibility of their children experiencing similar stress. Parents of anxious children may support their children's avoidant responses for coping with stress. Some parents have difficulty trusting that their children can manage more independence, such as weaning from nursing, sleeping alone, going away from their parents to visit relatives, staying with a sitter, or going to school. Parents recount stories of pulling their children in closer if a potential threat appears, even if the threat is not specifically focused on the child (e.g., a national calamity, a crime report in a metropolitan area). As has been suggested by Mineka & Zinbarg (2006), these parents may transmit vicarious learning of anxious behaviors and avoidant coping styles to their children.

Sometimes in an attempt to correct the shyness and mutism, parents of children with selective mutism will try home remedies that exacerbate the problem. For example, a common maneuver of parents with young children who have various communication disorders is to use a "quiz mode" to get the child to speak. The parents will pepper their children with questions, either to get their children to expand their speech repertoire, or in the case of selective mutism, to speak in front of extended family or other persons outside the household. Since many of these children are anxious about being in the spotlight, and are anxious about giving a wrong answer, this pattern of questioning may lead the child to engage in higher levels of avoidant coping behavior (mutism) rather than to talk.

Anxious parents can be overly concerned with the passage of time. For many anxious people, time is the enemy. An anxious person never has enough time to get everything done, is concerned about either external or self-imposed deadlines, and is often impatient for improvement because their current situation is so distressing. Enemy time often stalks parents of children with selective mutism. The parents feel pressure to encourage their child to speak to extended family members, who are perceived to be critical of how the parents are managing the child's problem. Parents may also be concerned that the child will not be promoted to the next level in school or not recognized as a successful student. If a child with selective mutism has a co-morbid condition such as not using the toilet, his or her parents may be further concerned that the child will have humiliating episodes of toileting accidents at school.

In their drive to make their children be as "normal" as possible, parents may try to make their children do things that a socially anxious child is not ready to try. Examples of such activities may include getting a dental exam or a hair cut; sitting on Santa's lap at the mall; participating in a school recital or ceremony; having the child's picture taken for a school photo. These are all situations that prove difficult for young children with social anxiety and selective mutism. It is common for these children to resist, and their parents often view the child's resistance and avoidance as a failure of the child to achieve a social milestone.

Therapists can support parents by helping them with activities to facilitate more confidence and independence in their children. This support should follow the principles of reassure, focus, and bind. The therapist can reassure anxious parents by letting them know that they are no longer alone in attempting to solve their child's problem. They now have the help of a therapist who can lend expertise to the process. Reassurance should be offered continuously throughout the course of the child's therapy as parents cope with challenges requiring them to be patient with the rate of their child's progress. It is also important for the therapist to help parents focus on relevant aspects of the child's problem. For example, many parents may not know that selective mutism is part of a more general problem with anxiety and that oppositional behaviors may function as avoidant behavior when anxiety is exacerbated. Parents may also need support in focusing on ways to create comfortable communicative contexts that can reduce the symptoms of anxiety. Finally, the therapist needs to bind energy generated by the parents' own anxiety to positive activities that they can do with their child. Well-intentioned but ineffectual strategies should be redirected towards more effective tasks. It is not a good idea for a therapist to counsel an anxious parent not to do things with their children. Therapist should bind the parents' energy to positive actions in the home.

Positive parent activities should include the arrangement of appropriate social opportunities for their children. Many children with selective mutism start talking to persons outside their immediate family when those outsiders spend time in the safe environment of the child's home. The parent can arrange opportunities for playmates (e.g., cousins, family friends, neighbors, classmates) to visit the child's home. Children with selective mutism are usually well accepted by their peers when they start school, even if they do not talk at school. Parents can learn the names of their child's favorite classmates by asking their child directly or by talking to the child's teacher. Then, parents can arrange play dates with these peers. A child with selective mutism will often first talk with another child if the other child is visiting his or her home. The next step may be for the child with selective mutism to visit the other child's home. Children with selective mutism may begin to talk in this context if adults are not present in the room.

Children with selective mutism show considerable variation in their willingness to talk with different extended family members. They tend to talk more freely with those extended family members who visit the house more often than with those who visit infrequently. When parents report that their children are not talking to grandparents, this is often accompanied by tension created by the feeling that the grandparents are unhappy or concerned. Parents may be worried about the grandparents passing judgment on their childrearing ability. Therapists can support parents by advising them to arrange more low-keyed contact time with extended family members. This would include coaching extended family members to help them understand that any communication is good communication, and that more advanced communication signals are likely to emerge with time in a paced and step-wise manner.

In most situations, peers accept children with selective mutism and include them in activities at school. They invite them to birthday parties and visits to their home. However, parents of children with selective mutism often have conflicting responses to peer relationships. On the one hand, they fear that their children will be isolated by peers and have no friends, because they do not speak. On the other hand, they are apprehensive about allowing their child to visit another child's home where he or she will experience greater autonomy and be accountable to another adult. This tension between the conflicting fears should be recognized and discussed in the context of parent counseling. Parents may also express other worries about autonomy besides visiting peers or using the school bathroom. For example, they may worry that their child will not be able to negotiate the lunch line at school or the school bus ride. A therapist can help the parent and the school by devising simple techniques that will enable the child to successfully deal with these challenges. The therapist can achieve considerable success in modifying the atmosphere at home by helping the parents learn how to model confidence in the child's ability to negotiate these new social challenges, even if the child is not yet ready to speak.

A therapist can help families expand their children's independence by encouraging them to allow their children to participate in social and recreational activities that interest the children (e.g., scouts, individual lessons in music or sports, team sports, etc.). Many children are intrinsically interested in trying these activities, especially if they can join with a favorite friend. Based on the author's clinical experience, scouts and individual lessons (e.g., swimming, horseback riding) offer highly successful contexts. However, children should not be forced into these activities if they are not interested; and when children do show an interest, parents should monitor the situation to be sure that the coach or teacher is setting goals that are realistic for the child.

It is important for the therapist to help parents understand three expectations of the overall therapy process. First, therapy may require a considerable length of time for the child to achieve the goal of speaking fluently in social settings, particularly at school. Second, patience is required with the rate of the child's progress and with the sequence of steps in the hierarchy of communication goals. Progress will be tracked, and parents will need to collaborate with the therapist in setting and reviewing goals. It is also important periodically to monitor whether parents are comfortable continuing with therapy. Third, there are various manifestations of anxiety, including avoidance, selective mutism, and opposition. Parent must learn how anxiety can be manifested in these various ways, and have a plan of positive behavioral support for managing anxiety.

Finally, some parents have significant difficulties with their own anxiety that extend beyond a level of apprehension typical of most parents. When this is the case, it should be discussed; and a decision should be made as to whether a parent's anxiety is best addressed during counseling sessions with the child's therapist or whether s/he could benefit from the support of an independent therapist. Each option has merits. One determining factor in making this decision relates to the source of a parent's anxiety. Is it primarily focused on the child's difficulties or is it more widespread? Another factor relates to the parent's ability to function. Can the parent negotiate everyday tasks despite the anxiety or does the anxiety interfere with routine aspects of daily living?

Teachers

Teachers will see the difficulties of selective mutism in full flower, because symptoms are often first manifested when a child enters school. Some of the teachers' concerns are similar to parents' concerns: Will the child be accepted by peers, and can the child be independent in activities during lunch and toileting? Teachers also have concerns specific to their role: Can a child with selective mutism learn? How will the child learn if she cannot communicate in the classroom? How can the teacher evaluate the child's performance if the child will not make oral responses? Should the child be promoted even if he or she is not talking?

Since a teacher is in daily contact with the child, he or she should be invited to collaborate with the therapist in developing a plan to support the child's progress in the classroom. The therapist can help the teacher in this process by providing information about the nature of selective mutism as a manifestation of social anxiety. The therapist should stress that the child is not being deliberately oppositional or passive-aggressive, but rather that she is trying to avoid distress caused by anxiety. The teacher may need support in understanding that, for children with selective mutism, any communication is good communication, and that progress is measured by increasingly more mature communicative acts, even if the child is not talking fluently in the classroom. Initially, the teacher may need verbal reassurance that the child will be accepted by peers. However, this will soon become obvious as the teacher observes the child's acceptance directly in the classroom. The teacher can also be reassured that the typical child with selective mutism learns at an average pace, even if they do not talk, and that the therapist can help the teacher to develop methods of assessing the child's skills. This may include working with the child and parents to use home videos to obtain reading and recitation samples.

The therapist and teacher can collaborate to identify a hierarchy of communication events, and the teacher can be encouraged to reinforce any small improvement in communication. The therapist can offer suggestions for ways to support communicative successes at school. For example, the child with mutism can be paired with a friend in a learning dyad or on school errands (e.g., taking a message to the office or to the library). Sometimes these semi-private interludes offer opportunities for a child with selective mutism to talk to his/her friend on the school premises when out of the earshot of adults. This is particularly effective when pairing the child with a friend who has a history of hearing the child talk, perhaps during visits to the child's home.

The teacher should be counseled not to try to trick or coerce the child into talking, as this is likely to be ineffective. Furthermore, the teacher should be asked to monitor the behavior of classmates who may be tempted to answer for the child. Based on clinical experience, it is preferable to let the child use whatever communication behaviors are currently available in repertoire rather than to allow him or her to dependent upon a friend to talk for them. The therapist can be in regular contact with the teacher, so that the teacher is up-to-date on what behaviors the child is practicing in therapy (e.g., nodding/shaking, pointing to choices, writing answers). The teacher can also be informed about activities that are likely to be stressful for the child, and how those activities could be modified to reduce the stress. For example, some children do not like to be the focus of attention on their birthdays. The therapist should anticipate the child's birthday and try to determine a plan with the child that can be communicated to the teacher. The author collaborated with one child in writing a joint letter to the teacher, requesting permission to forgo a birthday celebration. Some therapists might see this as an example of the child avoiding a social situation. Others would see it as an example of the child using an appropriate communication technique to make a reasonable request.

Collaboration with a school speech-language pathologist (SLP) can also be valuable (Schum, 2002). SLPs are communication experts who can support the child's program in a variety of ways. For example, an SLP could be asked to observe the child in the classroom and document communication attempts which may be difficult for the teacher to notice while teaching the entire class. An SLP may also be able to work with a child directly to encourage and reinforce communication behavior. This may take place during individual sessions at first. Later, the sessions may be expanded to include a small group. Children with selective mutism qualify for speech and language intervention since selective mutism is a pragmatic deficit that interferes with academic progress. The specialized training of SLPs provides them with the tools needed to collaborate with teachers in the development of a communication hierarchy and in working through the hierarchy systematically. Collaboration with a school psychologist and a school counselor may also help to support a child's intervention program.

Treatment Efficacy and Therapy Schedules

The author's clinical experience suggests that young children with selective mutism generally respond well to behavioral therapy and show progress. However, no controlled studies have been conducted to assess this empirically. Clinical experience also suggests that intervention is more effective with younger children than with older children (Wright et al., 1995). This author has received referrals of older children with selective mutism and no previous treatment. These children provided greater challenges for treatment. Part of the challenge could be attributed to many more years of practicing avoidant behaviors when the children were anxious. When patterns are more practiced and entrenched, it is more difficult to effect change.

There is no clear picture of how quickly children with selective mutism can progress from no talking to more fluent talking in selected contexts, particularly school. There are also different definitions of success, and different variations in the complexity of the problem. Clinical experience suggests that the time required to achieve fluency across contexts may be quite variable across children. In the experience of this author, one kindergarten child started talking in school after 6 biweekly sessions across a 3-month period. The longest therapy course involved a kindergartener who attained fluency in school only after 5 to 6 years of biweekly therapy.

There is no consensus about a therapy schedules. While weekly therapy may be ideal, it is often difficult to maintain. Few families can personally afford to pay at that pace, and few third-party payers will authorize it. Furthermore, most busy families and therapists find it difficult to maintain a weekly schedule. Clinical experience suggests that it is easier to schedule and to obtain payment authorization for biweekly sessions, totaling 20-25 sessions per year. Beyond the constraints of scheduling and payment, it is unclear how fast young children can consolidate their learning from therapy. With younger children, an effective use of time may be for the therapist to introduce communication activities in therapy, and then to ask the parents and school staff to practice these activities during the weeks between treatment sessions. As the child becomes older and develops more insight, the therapist can work more directly on cognitive-behavioral techniques to manage their responses and to develop insight into their shyness and anxiety.

The Need for Clinical Research

While good research exists in defining the demographics of selective mutism, there is little information about its cause. The meager information on cause is typically negative. For example, we know that most instances of selective mutism are not associated with specific trauma. Research on temperament, early manifestations of anxious behavior, and familial precursors would be helpful. This might allow clinicians to work with families to identify high-risk children before they develop the symptoms of selective mutism so that strategies might be implemented to mitigate the risk.

More research is needed regarding efficacy of medication intervention for treatment of selective mutism. While behavioral progress is often seen over years, medication efficacy has only been measured over weeks. Research should focus on more extended periods, varied with and without behavioral therapy, and carefully controlled with homogeneous sets of children matched for age and severity/range of symptoms.

Controlled research is needed to assess the relative impact of different behavioral interventions. While CBT and operant conditioning are recommended based on clinical experience, these methods should be assessed scientifically and compared with other procedures for managing children's anxiety disorders. It would be particularly interesting to compare the treatment of selective mutism as a manifestation of anxiety with treatments based on a view of selective mutism as a symptom of oppositional disorder.

Finally, carefully controlled studies are needed to compare the outcome of children who do and those who do not receive treatment for selective mutism. It is difficult to design a prospective study that is ethical as well as meaningful. Because selective mutism can produce such deleterious effects in social functioning and school participation, clinicians are obligated to recommend treatment to children who are identified with this disorder. However, well-designed retrospective studies may help to shed light on the frequency of spontaneous remission among children with selective mutism who never received treatment. Such studies must document carefully the reasons why participants never received treatment. There may be a self-selecting factor among families that creates this situation. For example, perhaps the level of parental anxiety affects who is comfortable seeking treatment for their child, who is pressed to seek treatment for their child, or who is confident that their child will learn to cope as the parents have done. Other factors that need to be considered are whether teachers advised parents that their child's behavior appeared to reflect more than mere shyness, whether selective mutism was accurately diagnosed, and whether expert therapists were available to the parents who desired help for their child.

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Author contact information:

Robert L. Schum, PhD

Clinical Psychologist

Department of Pediatrics

Medical College of Wisconsin

8701 Watertown Plank Road

Milwaukee, WI 53226

e-mail: rschum@mcw.edu

Phone: (414) 266-6397
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