Author: Kelly Stewart (Psychology Intern under Colby’s Supervision)
Selective mutism is when a person is able to speak but chooses not to, or can’t for reasons other than being unable to speak or having the language capacity to do so.
Selective mutism is by definition characterized by the following:
- 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.
- The disturbance interferes with educational or occupational achievement or with social communication.
- The duration of the disturbance is at least 1 month (not limited to the first month of school).
- The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
- The disturbance is not better accounted for by a communication disorder (e.g., stuttering) and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder.
Selective mutism is very commonly found with individuals who suffer from social anxiety disorder. In fact, there is such a high incidence of correlation between the two that the Diagnostic and Statistical Manual (DSM) 5th edition, may classify selective mutism as a subcategory of social anxiety disorder.
Contrary to popular belief, people suffering from selective mutism do not necessarily improve with age. Effective treatment is necessary for a child to develop properly. Without treatment, selective mutism can contribute to chronic depression, further anxiety, and other social and emotional problems.
Consequently, treatment at an early age is important. If not addressed, selective mutism tends to be self-reinforcing. Those around such a person may eventually expect him or her not to speak and therefore stop attempting to initiate verbal contact with the sufferer. Alternately, they may pressure the child to talk, making him or her have even higher anxiety levels in situations where speech is expected. Because of these problems, a change of environment (such as changing schools) may make a difference, and treatment in teenage or adult years can be more difficult because the sufferer, and those around him or her, have become accustomed to being mute.
The exact treatment depends on the sufferer’s age, other mental illnesses he or she may have, and a number of other factors. For instance, stimulus fading is typically used with younger children, because older children and teenagers recognize the situation as an attempt to make them speak. Older sufferers and people with depression are more likely to need medication.
The child is brought into the classroom or the environment where s/he will not speak and is videotaped answering a series of questions. First, his/her teacher, or adult representative of those to which the child will not speak asks the child questions. The child likely does not answer the questions at this time. A parent or someone to whom the child will converse verbally then comes in the room and the teacher goes out. The comfortable adult asks the child the same questions, this time eliciting a verbal response. This video is then edited so that the it looks like the child is answering the questions posed by the teacher. This video is then shown the child repeatedly. The child is asked to view the video and every time s/he sees him/herself answering the teacher verbally they are to stop the video to receive a positive reinforcement (e.g. praise).
The video can also be shown to the child’s class in order to set an expectation in the classroom by th child’s peers that s/he speaks. The classmates now know the sound of the child’s voice and believe they have seen the child conversing with the teacher.
Mystery motivation is often seen paired with the self-modeling technique. An envelope is placed in the child’s classroom in a visible place. On the envelope, the child’s name is written along with a question mark. Inside is a prize determined with the child’s parent in order for it to be something the child would want to have. The child is told that when s/he asks for the envelope appropriately and loudly enough for the teacher and his/her peers to hear, s/he may then receive the mystery motivator. The class is also told in this case about the expectation that the child ask for the envelope loudly enough that the class can hear.
The subject is brought into a controlled environment with someone with whom they are at ease and can communicate. Gradually, another person is introduced into the situation. One example of stimulus fading is the sliding-in technique, where a new person is slowly brought into the talking group. This can take a long time for the first one or two faded-in people but may become faster as the child gets more comfortable with the technique.
An example of this would be a child playing a board game with a family member in his/her classroom at school. Gradually, the teacher is brought in to play as well. When the child adjusts to his/her presence, then a peer is brought in to be a part of the game. Each person is only brought in if the child continues to engage verbally and positively.
The subject communicates indirectly with a person he or she is afraid to speak to through such means as email, instant messaging (text, audio, and/or video), online chat, voice or video recordings, and speaking or whispering to an intermediary in the presence of the target person. This can make the subject more comfortable with the idea of communicating with this person.
The subject is slowly encouraged to speak. He or she is reinforced first for interacting nonverbally, then for saying certain sounds (such as the sound that each letter of the alphabet makes), then for whispering, and finally saying a word or more.
Spacing is important to integrate, especially with self-modeling. Repeated and spaced out use of interventions is shown to be the most helpful long-term for learning. Viewing videotapes of self-modeling should be shown over a spaced out period of time of approximately 6 weeks.
Many practitioners believe that there is evidence indicating that antidepressants may be helpful in treating children and adults with selective mutism and even that medicine is essential to effective treatment. The medication is used to decrease anxiety levels to speed the process of therapy. Use of medication may end after nine to twelve months, once the person has learned skills to cope with anxiety and has become more comfortable in social situations. Medication is more often used for older children, teenagers, and adults whose anxiety has led to depression and other problems.
Medication, when used, should never be considered the entire treatment for a person with selective mutism. While on medication, the person should be in therapy to help them learn how to handle anxiety and prepare him or her for life without medication.
Anti-depressants have been used in addition to self-modeling and mystery motivation in order to aid in the learning process.
There are a variety of treatment strategies that can be usefully employed with selective mutism. The choice of which should be used may be based therefore on the age of the client and the extent of the problem.
- Selective Mutism Group: Child Anxiety Network
- Selective Mutism Foundation