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Selective Mutism: Speaking about Silence and Behavioral Approaches to Treatment

By February 4, 2014Blog

What is Selective Mutism?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5)- Fifth Edition notes that selective mutism is “consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school), despite speaking in other situations.”  For instance, children with selective mutism may talk with their immediate family members, but might not speak with extended relatives or at school. The DSM-5 further specifies that this disturbance, which results in impairments educationally/occupationally and/or socially, persists for at least one month, and is not better accounted for by lack of knowledge or comfort with the spoken language.  Some children with selective mutism also have a communication disorder and often meet criteria for social anxiety disorder as well. However, for other children with selective mutism they do not experience social anxiety, and are comfortable in social situations where speech is not required (i.e. playing with peers on playground).

Many children with selective mutism often have engaging and enriching social relationships with their peers without verbal communication. Some children with selective mutism may not talk to their friend at school, but will talk with them in their own home. Other children will continue to experience difficulty talking regardless of the setting, but will convey their enjoyment in their interactions with others non-verbally. Frequently, peers speak for these children, such as answering for them when the child with selective mutism is called on in class, and they offer empathic reasons for why their friend may not be talking (i.e. “he’s just shy”). Parents also often speak for their child when he/she does not respond to questions, or in an effort to have their needs met (i.e. making decisions for them, placing orders in restaurants, etc.).  These efforts may temporarily alleviate the child’s anxiety, but ultimately do not allow the child to learn the skills required to cope with uncomfortable and challenging situations.

As a parent what can I do?

Parents play an integral role in treatment and clinicians spend a large portion of time providing psycho-education to parents about ways that they can help increase their child’s speech and lessen anxiety. Parents may unknowingly accommodate their child’s anxious and avoidant behavior, and clinicians utilizing a behavioral or cognitive behavioral approach to treatment provide support to parents as they learn alternate ways of helping their child through distressing situations.

 

A behavioral treatment program for selective mutism, guided by a skilled clinician often includes the following components:

Stimulus fading
For example, the child is in a comfortable situation with someone they talk to freely (i.e. mother or father), and then gradually a new person (i.e. therapist or teacher) is introduced into the setting. The familiar person (i.e. parent) over the course of treatment is then gradually faded out so that the child is able to talk to the new person (i.e. therapist, teacher) in the absence of the familiar person (parent).

Shaping
A step-wise approach is used to reinforce efforts by the child to communicate. For instance, if the child is not speaking at all treatment efforts will reinforce the child as he/she more closely approximates audible speech. Additionally, treatment frequently focuses on increasing the number of utterances in speech, moving from one word responses, to speaking in sentences and eventually reciprocal conversations.

Exposure
Behavioral approaches often include exposures or practice situations in which children are gradually exposed to increasingly difficult situations as their skill level and confidence builds. Exposure is believed to work in part through habituation, as anxiety lessens through repeated exposure to a particular stimulus/situation. Typically an anxiety hierarchy is created with the child and parents, and beginning with the easiest step or exposure the child works their way up the ladder, talking in situations that are increasingly more difficult for the child.

Exposures might include talking to new people, talking in new environments, and increasing the volume of the child’s voice. Additionally, exposures may include allowing a new person to see them talk using technological means or be in the room while they are speaking with a familiar person. Technology is often a helpful tool with exposures. For instance, a child who is not yet speaking with his therapist may agree to allow the therapist to first watch a video of him speaking comfortably at home. Technology can also be used for exposures that address the volume of a child’s speech or utterances in speech.

Both labeledpraise and incentive schedules can be used to reinforce a child’s effort and progress towards talking goals. With labeled praise adults provide praise that clearly identifies the desired behavior. For instance, “thank you for using your words,” or “I love when you answer my questions.”  This is in contrast to non-specific praise in which one might say “good job,” omitting the specific behavior they are praising. Small rewards can be used as incentives as children work through anxiety provoking situations. For instance, a child may earn a point each time they speak in session, and use points to cash in for a reward on their behavior plan.

Children also often also benefit from Cognitive Behavioral approaches, including learning relaxation skills and cognitive restructuring. Relaxation might include deep breathing/diaphragmatic breathing and progressive muscle relaxation. With cognitive restructuring children are taught how to identify self-defeating thoughts and reframe these negative cognitions.

Andrea McLaughlin, Ph.D. is a licensed psychologist providing Cognitive Behavioral Therapy (CBT) for children, adolescents and young adults in her private practice in Park Slope, Brooklyn. She has more than 10 years of clinical experience working with children and their families. Dr. McLaughlin specializes in the treatment and assessment of anxiety disorders. Additionally, special areas of interest and expertise include working with youth with selective mutism, anxiety and depressive disorders, tics/tourettes and ADHD. Parents are often encouraged to participate in treatment so that they can learn skills to best help their children succeed and manage difficulties outside of sessions She can be contacted at andream@brooklynletters.com or 919-619-1061.

Rita Crisafi

Author Rita Crisafi

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