Selective mutism

Selective mutism treatment is used to help clients who are not speaking most of the time, but are comfortable speaking in selected situations, and have displayed this behavior for at least 1 month. 

A sign of an anxiety disorder, Selective Mutism typically starts to display between ages 3 to 6, when a child enters school.

The disorder can cause a child not to verbally communicate in certain social settings, such as school. This is not because he or she has a communication disorder such as an expressive language delay. 

Without selective mutism treatment, the client could experience social and academic impacts. Children and adults with the disorder do not functionally or consistently communicate through speech during important interactions with others. 

As part of a team of specialists, speech-language pathologists play a valuable role in Selective Mutism treatment.  

Let’s dive into Selective Mutism treatment approaches, assessment, intervention, and unique considerations to make when working with a client.

Signs and causes of selective mutism

When it comes to speech therapy for an individual with Selective Mutism, early intervention is critical for achieving the best outcomes.  

In order to start Selective Mutism treatment early, SLPs, parents, and other professionals should be aware of what signs to look for.

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Signs of Selective Mutism can include any of the following:

• Consistently not speaking in certain environments or situations (i.e., at school)
• The above, but speaking in other situations
• Showing the signs for at least 1 month (not including the first month of a new environment like starting school)
• Demonstrating sufficient receptive language skills for comprehending general spoken information from others (comprehension does not seem to be impacting their speech output)
• Signs of avoiding certain situations that require social communication (ex: reading out loud, parties)
• Showing emotional/behavioral reactions when in a difficult speaking environment
• Lack of verbal communication is not secondary to the presence of another diagnosis such as Autism

Selective Mutism is considered rare, and more research is needed on its prevalence. Based on current information, the prevalence of Selective Mutism appears to be between 0.2% and 1.6% of individuals. It is unclear whether the disorder affects more males or females. 

There isn’t a specific known cause of Selective Mutism. Psychological, genetic, family/environmental, and neurological factors can affect whether an individual demonstrates signs of Selective Mutism.    

Assessment

SLPs may complete an assessment for possible Selective Mutism as part of a comprehensive, interdisciplinary evaluation from a team of professionals.

Here are the typical components of the SLP’s assessment of Selective Mutism:

• Case history
  • Obtain this from parents/caregivers and teachers
  • Ask about any specific environments or people that seem to result in the individual having trouble speaking.
  • Family history
  • Child’s history of speech and language development
  • Encourage caregivers and teachers to show any relevant videos that display the client’s communication skills across different environments
  • Assessment and standardized tests measuring expressive and receptive language skills, and speech articulation skills
    • Some individuals may not participate in standardized testing. Caregiver and teacher interviewing will be important in this situation, to gain sufficient information about the client’s speech and language skills
  • Assessment of social communication skills
    • Standardized and non-standardized measures can be used
    • Note the client’s understanding and use of nonverbal communication, such as facial expressions, eye contact, joint attention, and proximity to others
  • Assessment and standardized tests measuring expressive and receptive language skills, and speech articulation skills
    • Some individuals may not participate in standardized testing. Caregiver and teacher interviewing will be important in this situation, to gain sufficient information about the client’s speech and language skills 
  • Assessment of social communication skills
    • Standardized and non-standardized measures can be used
    • Note the client’s understanding and use of nonverbal communication, such as facial expressions, eye contact, joint attention, and proximity to others

Intervention for Selective Mutism

A goal of Speech Therapy intervention for an individual with Selective Mutism is to increase their successful speech output in situations that have been identified as provoking anxiety.  

 A variety of treatment techniques can be used.

Behavioral strategies 

According to the American Speech-Language and Hearing Association (ASHA), a combination of behavioral and cognitive-behavioral strategies is supported by research for Selective Mutism treatment.

The goal of therapy is to reduce the client’s anxiety and increase their verbal communication across settings. The therapist might provide verbal praise or tangible reinforcements to reinforce the client’s speaking in certain situations. 

Stimulus fading

In this approach, the client is increasingly exposed to whatever stimulus provokes anxiety or a reduction in successful speech output. 

For example, consider the case of a child who has difficulty reading out loud in front of his or her entire class. The child would practice reading in front of someone he or she is more comfortable speaking in front of, like his or her parents. Then, one child would be added to the room. Then another, and so on. 

Relaxation techniques (systematic desensitization), exposure-based practice, and contingency management are other Selective Mutism treatment approaches. Augmentative Alternative Communication (AAC) may be used in some cases, and SLPs should probe for the need for this.