SELECTIVE MUTISM

Presented by:

Shaista Butt

Definition

Selective mutism, formally known as elective mutism, is a disorder of childhood characterized by the persistent lack of speech in at least one social situation (school), despite the ability to speak in other situations (home).

Children with selective mutism will have difficulty speaking, reading aloud, and singing aloud in front of people outside of their family or their “comfort zone”. (Silver, 1989).

Age of Onset

It is most prevalent between the ages of 3 and 5; onset usually occurs when the child first enters an educational framework in which speech is expected,

but sometimes onset is gradual – the child decreases speech output until he eventually stops speaking (Silver, 1989).

Signs and SymptomsBesides lack of speech, other behaviors displayed by selectively mute people include:

• shyness, • social anxiety, fear of social

embarrassment, and/or social isolation and withdrawal;

• use of gestures to get message across;

• difficulty maintaining eye contact, blank expression and reluctance to smile; (Silver, 1989).

• difficulty eating , or speaking in front of audience;

• stiff and awkward movements; • difficulty expressing feelings,

even to family members; • tendency to worry more than

most people of the same age, and sensitivity to noise and crowds (Silver, 1989).

DSM V Criteria• Consistent failure to speak in specific social situations

in which there is an expectation for speaking (e.g. in classroom), despite speaking in other situations (e.g. with mom in classroom).

• Disturbance interferes with educational/occupational achievement or social communication.

• Disturbance must last for at least one month. • Failure to speak is not due to lack of knowledge of or

comfort with the language in use.• Disturbance is not better explained by communication

disorder (ex. Stuttering) (APA,2013)

Co morbidity

Selective mutism is co-morbid with a number of disorders including: – social anxiety disorder / social phobia,– expressive language disorder, – self-regulation – ability to adjust arousal and emotion in

appropriate manner, – developmental speech delay,– enuresis – bedwetting or daytime holding of urine for

prolonged intervals, – separation anxiety disorder, depression, – motor developmental disorders and oppositional defiance

disorder (Steinhausen, & Juzi, 1996).

Prevalence and Epidemiology

Most research has found that the incidence of SM is around 0.07% that is seven children in every 1,000, and it is 3 times that number in children from bilingual homes.

Twice as many girls than boys have Selective Mutism (Steinhausen, & Juzi, 1996).

Etiology and Pathogenesis Selective mutism is caused by the interaction between

nature and nurture. One can conceptualize this as various factors fitting into one of three groups, namely, predisposing factors, precipitating factors, and maintaining factors:

– Predisposing factors could include: anxiety of child, shyness, timidity, and hyper-sensitivity; speech impairment of child usually expressive language; bilingualism, negative self image related to speech (e.g. doesn’t like sound of voice), neuro- developmental delay, and often sensory processing disorder.

– Precipitating factors (triggers) could include: school or kindergarten admission, frequent geographical moves, family belonging to linguistic minority, negative reactions to child talking – bullying, shouting etc.

– Maintaining factors could include: social isolation of families, misdiagnosis, lack of early and appropriate intervention. Lack of understanding by teachers, families, psychologists; reinforcement of the mutism by increased attention or affection; heightened anxiety levels caused by pressure to speak; ability to convey messages non-verbally, over acceptance of mutism (Silver, 1989).

Combination of predisposing factors and triggers can bring about the onset of SM. (Blake &Moss, 1967).

Treatment Often children with SM benefit from social skills

training and behavioral interventions. Medication can sometimes be effective as an additional therapy.

• Behavioral treatment:

The speech-language pathologist may coordinate a behavioral treatment program to increase verbalizations. Behavioral treatment is based on the premise that the child who is selectively mute is using the behavior in response to anxiety in social situations. The focus of the speech language pathologist’s intervention is to reinforce communication with a gradual progression from non-verbal to verbal (Steinhausen, & Juzi, 1996).

• Stimulus fading:

In stimulus fading, the speech-language pathologist sets simple goals (e.g., using a gesture to communicate) and gradually increases expectations until speech is achieved.

For example, child and parent may visit the child’s classroom after school. The child is then encouraged to talk to parent. A teacher may gradually be introduced at a degree that she does not stop the verbalization of child. The teacher enters the room; goes near parent and child, parents introduce the teacher to child and relay information between child and teacher. Once the teacher is introduced the role of parent is gradually faded (Silver, 1989).

• Shaping:

Shaping involves rewarding approximations of target speaking behavior.

For example, the child may be reinforced for mouth movements accompanied by approximation of speech (e.g., whispering) until true speech is achieved. Shaping is often necessary in order to achieve positive outcome for selectively mute child (Blake &Moss, 1967).

• Self-modeling:

Another technique sometimes used, when the child is willing, is the self-modeling technique where the child watches videotapes of himself or herself performing the desired behavior (e.g., communicating effectively at home) to facilitate self-confidence and carry-over of this behavior into the classroom (Cunningham, McHolm, & Melanie, 2005).

• Role playing:

The speech-language pathologist may also work with specific speech and language problems that are worsening the mute behavior.

For example, some children with SM are afraid to speak because they feel they may say wrong thing. The pathologist may use role-playing activities to lessen the child's anxiety and increase confidence with speaking to different listeners in a variety of settings. Other children with SM may not want to speak because they feel their voice “sounds funny”. The pathologist may work on speech pronunciation to increase the clarity of speech (Cunningham, McHolm, & Melanie, 2005).

• Reinforcement contingency:

It involves rewarding the child for speech behavior.

For example, allow and support parent and child to visit school before school starts possibly multiple times. Allow use of a verbal intermediary (parent, friend, doll, puppet, and recording device) that makes the child more comfortable in speaking/communicating. Reinforce verbal AND non-verbal communication attempts positively; be careful not to overdo the praise (Cunningham & Melanie, 2005).

• Play therapy:

Play therapy aims to create an environment in which the child feels free to express feelings, manage conflicts and gives insight into and control over problems (Blake &Moss, 1967).

• Relaxation training:

Individual exercises to help child release tension. (i.e. “squeeze lemons” to feel tension and then relaxation in hands/arms) are taught as well as group relaxation exercises are also emphasized (Blake &Moss, 1967).

• Stages of Speech Emergence in School (least to most)1. Complete mutism at school

2. Participates non-verbally

3. Speaks to parent at school (usually when teachers or students are absent)

4. Peers see child speaking (but don’t hear)

5. Peers overhear child speaking

6. Speaks to Peer through Parent or Sibling

7. Speaks softly or whispers to one peer

8. Speaks to one peer w/normal volume

9. Speaks softly or whispers to several peers

10. Speaks in normal voice to several peers

11. Speaks softly or whispers to teacher

12. Speaks in normal voice to teacher

13. Normal Speech in School (Steinhausen, & Juzi, 1996).

ReferencesAmerican Psychiatric Association (2000). Diagnostic and

Statistical Manual of Mental Disorders (4th ed, text revision). Washington, DC: American Psychiatric Association.

Blake, P., & Moss, T. (1967). The development of socialization skills in an electively mute child. Behavior Research and Therapy, 5, 349-356.

Cunningham, E., McHolm, A., & Melanie, A. (2005). Helping your child with selective mutism (3rd ed.). New York: Harbinger Publications, Inc.