How is selective mutism treated

What often happens is teachers tell parents the child is not talking or interacting with the other children. In other situations, parents will notice, early on, that their child is not speaking to most individuals outside the home.

Why do so few teachers, therapists and physicians understand Selective Mutism? Studies of Selective Mutism are scarce. Most research results are based on subjective findings based on a limited number of children. In addition, textbook descriptions are often nonexistent, or information is limited, and in many situations, the information is inaccurate and misleading. As a result, few people truly understand Selective Mutism. Professionals and teachers will often tell a parent, the child is just shy, or they will outgrow their silence.

Others interpret the mutism as a means of being oppositional and defiant, manipulative or controlling. Some professionals erroneously view Selective Mutism as a variant of autism or an indication of severe learning disabilities. For most children who are truly affected by Selective Mutism, this is completely wrong and inappropriate!

Mutism not only persists in these children, but is negatively reinforced. These children may develop oppositional behaviors out of a combination of frustration, their own inability to make sense of their mutism, and others pressuring them to speak.

As a result of the scarcity and often inaccuracy of information in the published literature, children with Selective Mutism may be misdiagnosed and mismanaged. In many circumstances, parents will wait and hope their child outgrows their mutism and may even by advised to do so by well-meaning, but uninformed professionals.

However, without proper recognition and treatment, most of these children do NOT outgrow Selective Mutism and end up going through years without speaking, interacting normally, or developing appropriate social skills. In fact, many individuals who suffer from Selective Mutism and social anxiety who do not get proper treatment to develop necessary coping skills may develop the negative ramifications of untreated anxiety see below.

Our findings indicate that the earlier a child is treated for Selective Mutism, the quicker the response to treatment, and the better the overall prognosis.

In other words, Selective Mutism can become a difficult habit to break! Anxiety disorders are the most common mental illnesses among children and adolescents. Our main objective is to diagnose children early, so they can receive proper treatment at an early age, develop proper coping skills, and overcome their anxiety. If parents suspect their child has Selective Mutism, what should they do? However, please note that having experience with Selective Mutism does not guarantee that the treatment approach and understanding is correct.

In fact, a clinician with less experience, yet who has an excellent understanding of Selective Mutism may be an ideal choice for your child. What are the key questions to ask a potential therapist or physician? Do your homework! You will have a much better idea what to look for if you understand Selective Mutism.

Educate yourself as much as possible before seeing any professional. Parents should read as much information as they can about Selective Mutism. The Selective Mutism Association website has countless pages of information and it is updated on a regular basis.

Simply lowering anxiety is NOT enough to enable the child to begin engaging socially, learn to progress to verbal communication and feel comfortable in an environment.

Skills must be taught. Treatment approaches based on discipline and forcing a child to speak are inappropriate and will only heighten anxiety and negatively reinforce mute behavior. How is a child evaluated for Selective Mutism? Children suffering from Selective Mutism SM change their level of social communication based on the setting as well as the expectations from others within a setting.

As a result, social comfort and communication will change from setting to setting and person to person. For some children, they appear very comfortable and mutism is the most noted symptom. This usually means they are able to engage nonverbally with others via astute nonverbal skills professional mimes!

These children are stuck in the nonverbal stage of communication Stage 1 and suffer from a subtype of SM called Speech Phobia. Although mutism is the most noted symptom of SM, the inability to speak merely touches on the surface of our children.

A complete understanding of the child is necessary to develop an appropriate treatment plan for home and in the real world, as well as in school by developing accommodations and interventions, e. IEP or Plan. According to Dr. To help a child suffering in silence, an understanding of which stage the child is in during particular social encounters must be developed.

Treatment is then developed via the whole child approach under the direction of the treatment professional, the child, parents, and school personnel working together. Shipon-Blum emphasizes that although anxiety lowering is key, it is often not enough, especially as children age. Over time, many children with Selective Mutism no longer feel anxious, but their mutism and lack of proper social engagement continue to exist in select settings.

Children with SM need strategies and interventions to progress from nonverbal to spoken communication. This is the Transitional Stage of Communication, an aspect missing from most treatment plans. In other words, how do you help a child progress from nonverbal to verbal communication?

Strategies and interventions are developed based on where the child is on the Social Communication Bridge in a particular setting and are meant to be a desensitizing method as well as a vehicle to unlearn conditioned behavior. Time in the therapy office is simply not enough. The office setting is used to help prepare the child for the school and real world environments by developing strategies to help the child unlearn his or her conditioned behavior.

Then, in the real world and within the school setting, the strategies and interventions are implemented. Children with SM need to understand, feel in control, and have choice in their treatment age dependent.

Strategy charts are used to help develop social comfort and progress into speech. By lowering anxiety, increasing self-esteem, and increasing communication and social confidence within a variety of real world settings, the child suffering in silence will develop necessary coping skills to enable for proper social, emotional, and academic functioning.

A trained professional familiar with Selective Mutism will have a parental interview. Emphasis will be on social interaction and developmental history, other manifestations of anxiety, behavioral characteristics shy temperament , home life description family stress, divorce, death, etc. From the results of the initial interview, the professional will often see the child. Children with Selective Mutism may or may not speak to the diagnosing professional.

Whether or not a child speaks to the evaluating physician does not really matter. An astute professional should be able to assess interpersonal communication skills and build rapport quite easily and, if given at least one session and possibly viewing videotapes from home, can rule in or out Selective Mutism as a diagnosis.

A complete physical exam including hearing , standardized testing, psycho-educational testing as well as a thorough developmental screening are often recommended if the diagnosis is not clear. What are the diagnostic criteria for Selective Mutism? Associated features of Selective Mutism may include excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling or oppositional behavior, particularly at home.

There may be severe impairment in social and school functioning. Teasing or goading by peers is common. Although children with this disorder generally have normal language skills, there may occasionally be an associated Communication Disorder e. Mental Retardation, hospitalization or extreme psychosocial stressors may be associated with the disorder. In addition, in clinical settings children with Selective Mutism are almost always given an additional diagnosis of Anxiety Disorder, especially Social Phobia is common.

As mentioned earlier, children with Selective Mutism manifest many behavioral characteristics other than mutism. In addition, children with autism, PDD-NOS, Aspergers and other developmental disorders can manifest mutism that is selective in location.

How is Selective Mutism treated? The main goals of treatment should be to lower anxiety, increase self-esteem and increase social confidence and communication.

Emphasis should never be on getting a child to talk. All expectations for verbalization should be removed. Treatment approaches should be individualized, but the majority of children are treated using a combination of:. It is important to realize that with proper diagnosis and treatment, the prognosis for overcoming Selective Mutism is excellent! Author: Dr. Many of these findings are based on research from treatment at the SMart Center of hundreds of children with Selective Mutism.

Temperamental Inhibition : Timid, cautious in new and unfamiliar situations, restrained, usually evident from infancy on. In line with the practitioner review recommendation by Cohan et al. The behavioral interventions consisted of stimulus fading in the form of gradual increased exposure, as well as contingency management use of positive reinforcement for speaking behavior to be applied in a joyful play activity inspired by the Selective Mutism Resource Manual [ 30 ].

Due to the feasibility of the study, the maximum length of treatment was set to 6 months. The treatment was discontinued if the child started to speak freely before reaching the maximum length of treatment 6 months. Using this school-based CBT, we found a highly favorable treatment outcome in a pilot efficacy study of seven preschool children with longstanding SM [ 32 ].

All but one child spoke freely in all preschool settings after a mean of 17 weeks treatment sd 5, range 8—24 weeks. At follow-up 1 year after end of treatment, this child had SM in partial remission; the others did not have SM.

Using the SM questionnaires, two children showed a transient drop of scores related to their transition into school, while treatment gains were upheld in the others. Bilingual children comprised the majority in this study, suggesting that bilingualism may not be a central negative outcome predictor. We also found a significant treatment effect in an RCT study of 24 children with SM, 3—9 years of age, with no change in wait-list controls, using this school-based CBT applied by local therapists at community health clinics all over Southern Norway [ 31 ].

A time by age interaction favored younger subjects. After 3 months, the children in the waitlist group received the same treatment. In this effectiveness study, there was a significant increase of speech after mean 23 weeks of treatment sd 3, range 12—24 weeks , with continued progress measured 1 year after the end of treatment using the teacher-rated SSQ and diagnostic status as primary outcome measures [ 33 ].

There was one treatment drop-out after 3 months in this effectiveness study, but all children had complete outcome data. While older age and more severe SM at baseline had a significant negative effect upon outcome, we found no significant effect of gender or familial SM.

As SM is defined as an anxiety disorder, the literature on pediatric anxiety disorders is relevant for the present study. Pediatric anxiety disorders can be effectively treated in the short term, and predictors of remission were found to be younger age, nonminority status, lower baseline anxiety severity, absence of other internalizing disorders, and absence of social phobia [ 34 ].

The overrepresentation of bilinguals, and the high proportion of comorbid anxiety disorders, especially social phobia in children with SM [ 7 ], makes the literature on pediatric anxiety disorders particularly relevant for SM outcome studies and could suggest a poorer outcome.

Data are limited on the long-term outcomes of pediatric anxiety disorders. Over the years, a subjective perception of well-being has been recognized as an important complement to clinical symptomatology and functional impairment in CAMHS. For children with SM, findings on quality of life, as well as the use of children as informants are missing in the outcome literature.

A systematic review on how childhood mental disorders affect quality of life in general conclude with a significant reduction compared to healthy controls across several disorders, and that studies for large diagnostic groups for instance anxiety disorders , are largely lacking [ 37 ].

The aim of the present study was to expand the literature on the anxiety disorder SM in two ways: by providing prospective long-term outcome data in a relatively large number of children with SM who completed the same school-based CBT and by including data on child rated quality of life and their own speaking behavior.

Based on the existing literature on pediatric anxiety disorders, where factors such as bilingualism, and comorbid anxiety disorders, especially social phobia are found to be negative predictors of treatment outcome [ 34 ] one could hypothesize a poor long-term outcome in children with SM, where these factors are overrepresented [ 7 ].

However, based on the favorable results in our previous follow-up studies conducted 1 year after end of treatment [ 32 , 33 ], we hypothesized that treatment gains would be maintained in the present 5-year follow-up study.

This is a prospective long term follow-up study conducted at mean 5 years after the end of our school-based CBT especially adapted for children with SM. Data include the present follow-up T5 , as well as from baseline T1 , after 3 T2 and 6 T3 months of treatment, and 1 year after end of treatment T4. The sample consists of 30 of the total 32 children who completed a school-based CBT for SM in Norway, seven children from our pilot study [ 32 ] and 24 children from our RCT [ 31 ] and one child not included in the RCT who received the same treatment by one of the therapists in the study.

Mean age at inclusion was 6 years range 3—9 years and mean age at follow-up was 11 years range 8—14 , including 20 girls, and 9 bilingual children. The two non-participating families did not reply to our follow-up invitation, and both children had SM and social phobia when assessed at the 1-year follow-up study [ 33 ]. Our rationale for the operationalizing of SM as not talking to teachers was that a detailed description is missing in the diagnostic criteria.

By giving a description of how we defined SM we could allow for study replication. The final inclusion was confirmation of the SM diagnosis after a parental diagnostic interview and a child assessment to rule out severe intellectual problems.

At baseline, nonverbal IQ and receptive language were within the average range [ 31 , 32 ]. None had specific CBT training, but used our detailed manual describing defocused communication and weekly behavioral school-based interventions for a maximum of 6 months mean 21 weeks, sd 5, range 8—24 under supervision from the first or last author, with no further treatment adherence measures.

See Table 1 for an overview of measures and informants at T1 through to T5. Overview of informants and measures throughout the study, at baseline T1 , after 3 months of treatment T2 end of treatment; 6 months T3 , 1 year after end of treatment T4 and after 5 years T5. The SM module relates to the speaking behavior of the child in different social situations.

We chose to use three categories of SM:. Full remission: children who no longer fulfilled diagnostic criteria for SM, as they spoke freely at school. Partial remission: children who spoke freely in some, but not all settings at school. To assess diagnostic comorbidity, we used the revised version of the schedule for affective disorders and schizophrenia for school-aged children: present and lifetime version K-SADS-PL [ 40 ].

The second author, an experienced child psychiatrist, conducted the interviews, blind to diagnostic status.

The parents were also asked whether they had been in contact with CAMHS or the school psychology services during the follow-up period. It is a quantitative measure with no cut-off score, includes 10 questions modified from the SMQ see below with acceptable internal consistency. As in the SMQ, 0 indicates that speaking behavior never occurs, and 1, 2, and 3 refer to seldom, often and always speaking, respectively.

The SMQ includes 32 questions scored from 0 to 3, where 0 indicates that speaking behavior never occurs, and 1, 2 and 3 refer to seldom, often and always speaking, respectively. Seventeen of the SMQ questions are used to compute three subscale mean scores; at school six items , at home six items and in public five items with the same 0—3 scoring range, computed as the mean of the relevant items. The SMQ total factor score was computed from the sum of three subscales divided by three.

ILC consists of seven items. Six items address subjective well-being at school, in the family, with peers, when alone, and perception of physical and mental health with a final global item of life quality. A review on the published studies on the Norwegian version of the ILC concluded that although there is limited documentation for the psychometric properties of the Norwegian ILC, the existing four studies are of good quality, including satisfactory norms and measures of validity and reliability [ 43 ].

Mean LQ 0—28 score Mean ILC subscale scores, using the 1—5 ratings on the individual subscales normative data not available. The ILC problem score PR computed by dichotomizing each of the seven subscales, such that ratings of 1 or 2 indicates no problem 0 , and ratings of 3, 4 or 5 indicates that a problem is present 1 on the subscale. A mean ILC problem score can then be calculated range 0—7 , where a score of 1.

Normative Norwegian data are also available for the percentage of problems per subscale presented as a comparison in Fig. Standardized SM questionnaires for children are not available. A mean score range range 1—5 and a problem score PR where ratings of 1 or 2 indicates no problem, and ratings of 3, 4 or 5 indicates that a problem with speaking is present , was computed. Child ratings were available from 28 of the participating 30 children.

Written informed consent was provided by the parents and children from age 11 years. A linear mixed model for repeated measurements using a random intercept for each subject was applied to investigate the SM questionnaires scores from baseline T1 , 3 months T2 , 6 months T3 , 1 year after end of treatment T4 and 5-year follow-up T5.

Post hoc analysis of mean differences between the five time points T1—T5 were tested using Bonferroni corrections. An independent samples t test was conducted to calculate the difference in Quality of life scores between the children in the present study and Norwegian schoolchildren. When investigating the different individual courses of development, most of the children showed continuous progress, but three children changed status negatively.

One school-age child had a relapse of SM after having SM in partial remission at the 1-year follow-up. Two children one preschool- and one school-age child who at the 5 year follow-up did not speak in all school situations were diagnosed with SM in partial remission, after having been fluent speakers at the 1-year follow-up.

Among the eleven children with SM in the family, two children had SM and four children were diagnosed with SM in partial remission. Among these seven children, only two did not also have SM, or SM in partial remission.

Separation anxiety disorder was found in one child without SM or social phobia and one child with SM in partial remission, while specific phobias and enuresis nocturna were found in children without SM or social phobia.

When asked about significant negative life events, as assessed by K-SADS, and whether there had been contact with CAMHS or school psychology services during the 5-year follow-up, no negative life events were reported. Apart from one child, who had been medicated with SSRIs, and still had SM at follow-up, none had received other kinds of treatment for SM or other anxiety disorders.

Most parents reported that they had used what they learned during the treatment period defocused communication and graded exposure tasks when they found it appropriate during the follow-up period. Table 2 presents mean scores over time. SSQ results further indicated a more pronounced increase in speech in younger children. Findings based on teacher and parent questionnaires throughout the study, at baseline T1 , after 3 months of treatment T2 end of treatment; 6 months T3 , 1 year after end of treatment T4 and after 5 years T5.

Mean scores on the parent rated SMQ total score and the teacher-rated SSQ over time, at baseline T1 , after 3 months of treatment T2 end of treatment; 6 months T3 , 1 year after end of treatment T4 and after 5 years T5.

Mean ILC subscale scores are presented in Table 3. The percentage of problems on the ILC subscales is in general comparable to data from Norwegian schoolchildren. The mean score on the item measuring difficulties with speaking was 2. To our knowledge, this is the first prospective follow-up study conducted 5 years after the end of a cognitive behavioral treatment for children with SM in a reasonably large sample in the context of SM studies.

As hypothesized, treatment gains were largely maintained at follow-up T5. As shown in Fig. We have no obvious explanation for the less steep improvement from T2 to T3. However, our large early effect may be in line with a review of CBT studies for anxiety disorders in youth. The authors say that in the case of most childhood anxiety disorders, treatment responders can expect to be free of their primary diagnosis with a course of treatment that usually last between 12 and 16 weeks [ 45 ].

We know of no other prospective long-term outcome studies in children with SM to compare with directly. However, our results are good compared to the important CAMELS study on children with anxiety disorders reporting a mean relapse in about half of acute responders when assessed at mean 6 years after randomization. This is a tentative definition of the increased occasional use of language in some of the treated children in need of further replication to be a valid description of treatment outcome.

In the first long-term follow-up study based on a larger sample of SM patients, Remschmidt et al. The negative change could result from several internal or external factors; however, it was not a result of transition into school, as found in our pilot study, because these three children were all school-aged children.

Due to a possibly less entrenched mutism in younger subjects, our finding of a younger age at inclusion to predict more improvement seems plausible. This is also in line with the earliest SM literature suggesting that an early intervention may have been particularly important for those who improved with treatment [ 8 , 46 ], in studies of the effect of medication in children with SM [ 7 , 15 ], as well as findings from treatment of children with anxiety disorders in general [ 34 ].

As the effect of age at inclusion was not examined in the Bergman study [ 26 ], we cannot directly compare our findings on age. Consequently, we cannot rule out that our intervention is more suitable for younger children with SM. One speculation is that for older children with SM, the cognitive component of CBT in the form of active cognitive restructuring could be particularly important, something that was not included in our study.

In line with our previous findings [ 33 ], and the study with the longest follow-up time [ 22 ], baseline severity of SM, as measured by the parent rated SMQ total score, was a significant negative predictor upon long-term outcome. Although bilingual children with SM are reported to be overrepresented in several clinical studies [ 9 , 47 ], and bilingualism is considered a vulnerability factor for SM [ 9 ], the present study did not find that bilingualism had a negative impact upon treatment outcome, in line with our previous findings [ 32 , 33 ].

In general, girls have comprised the majority in recent clinical samples treated for SM [ 28 , 33 ]. However, a more even gender ratio is also found [ 27 , 33 ] but whether gender has a predictive value upon treatment outcome, has, as far as we know not been studied. The present long-term-study could not find that gender had a significant impact upon treatment outcome, in line with our findings 1 year after end of treatment [ 33 ]. For details of how Priory can provide you with assistance regarding mental health and wellbeing, please call or click here to submit an enquiry form.

For professionals looking to make a referral, please click here. For more information about the mental health services that Priory offer, download our brochure. Selective Mutism Treatment You don't have to struggle with a mental health condition - help is available. Selective Mutism Treatment. Additional Information. Contact Priory Today. Enquire Now. What is selective mutism? Factors that may influence the development of selective mutism include: Being a child learning a second language, as confidence in their speech may be reduced Presence of a speech and language impairment Anxiety either personally or a family history of anxiety Family history of shyness or selective mutism Reinforcement of mutism by increased attention and affection Selective mutism can occur alongside autistic spectrum disorder, but there is no evidence to suggest that one causes the other.

What are the signs and symptoms of selective mutism? What causes selective mutism? Tips for parents. If you think that your child may be showing signs of selective mutism, and if you are waiting to receive professional support, the following tips may help you to manage this condition: Reassure your child that they can speak normally, and will eventually be able to do so in situations that they find difficult, when they feel more comfortable Avoid placing pressure on them to talk; this will only serve to raise anxiety Give your child praise if they communicate in any way, in the situation that they find difficult e.

Praise them away from the situation so they do not feel embarrassed during it Do not avoid social situations but try to make them as comfortable and enjoyable for the young person as possible, so their fear of the situation begins to gradually reduce Ask others who will be coming into contact with your child not to draw attention to them not speaking.

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