Selective Mutism and Communication Anxiety in Children
By Shari A. Gross, M.A., CCC-SLP, Director of Child Achievement Center
Originally Published in Advance for Speech-Language Pathologists and Audiologists, February 11, 2002. All rights reserved.
Selective mutism is a challenge that often is highly frustrating for children, parents and professionals. In the public school setting, often at the preschool and elementary levels, speech-language pathologists may encounter children presenting with selective mutism due to their complete lack of communication in school. Other children may demonstrate some verbalizations but still have a significant reluctance to speak.
Although selective mutism was assumed to be primarily a behavioral disorder in the past, a multitude of recent research, such as that conducted at the UCLA Child & Adolescent Anxiety Program, in Los Angeles, CA, has demonstrated that selective mutism is a childhood manifestation of social anxiety disorder.
According to the DSM-IV-TR, the Text Revision to the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000), a diagnosis of selective mutism is indicated by a persistent failure to talk in one or more social settings, including school, despite speaking in other social situations.
Unfortunately, in practice some school personnel, physicians and psychologists frequently have equated this lack of speech with a behaviorally-based refusal to speak. However, many professionals contend that, in the large majority of cases, children with selective mutism are not refusing to speak at all but rather are extremely anxious about verbalizing.
They are anxious to the point that "they actually exhibit a physical reaction and Iiterally cannot talk," stated Elisa Shipon Blum, DO, executive/medical director of the Childhood Anxiety Network and clinical professor of psychology and family medicine at Philadelphia College of Osteopathic Medicine in Pennsylvania.
Furthermore, some children with selective mutism are not only totally silent in school, but they may lack typical facial expressions because they are overwhelmed with fear and unable to participate in any way. Other children with this diagnosis may be able to participate in activities while remaining silent. Some anxious children may speak only when required, but do not volunteer to speak and do not initiate interaction.
Sometimes children with selective mutism may have receptive or expressive language disorders, articulation disorders or leaming disabilities. They may be bilingual or come from bilingual homes. It is crucial that school personnel realize that in many cases these children have fully developed to age expectations in all respects and may in fact be particularly bright, even though this may only be apparent in the home or other very comfortable settings.
Because selective mutism is anxiety-based, it is important to recognize that the condition stands apart from any other characteristic of a child's learning and language skills. Some children who are selectively mute benefit from treatment with selective serotonin reuptake inhibitors (SSRI). These medications are monitored by knowledgeable physicians and psychologists.
Other children gradually overcome selective mutism with step-by-step treatment plans but without the aid of mediciltions. However, if left untreated, selective mutism can lead to underachievement in school, poor social skill development, low self-esteem, social withdrawal and possibly psychiatric complications.
How can the speech-language pathologist help these children? The first step to helping children with selective mutism is to view them with a completely open mind. Although similarities may exist between cases, each child who is selectively mute is unique.
Although the child must be observed in the classroom, it is imperative that the parents be questioned about their child's behavior and speech-language use at home and in other comfortable settings. This information must be fully acknowledged and accepted by all professionals working with the child.
By definition, parents will report that their child is verbal and animated at home and often loud and boisterous. Ideally, observing the child at home or viewing a videotape of the child at home, provided by the parents, offers tremendous insight into the potential abilities and/or possible weaknesses of the child.
After the speech-language pathologist has received enough information to begin approximating the child's level of function, a therapy eligibility plan can be formulated and presented to the parents so the child can begin to be seen by the clinician. The child's eligibility could be based on the need for improvement in pragmatics, with goals written accordingly. Individual goals can include nonverbal interaction with the speech-language pathologist, teacher and peers; one-word answering of the teacher and then peers; eventual one-word initiation, such as a greeting, to members of Ihe school community; or speaking in simple sentences to the speech-language pathologist in the context of a board game.
If it is possible and the parents agree, a full child study team evaluation may not be appropriate at the onset because test scores can be skewed if the child is fully mute. What is most important is for the child to begin to feel comfortable communicating in school, even if that communication is nonverbal at first. Even the slightest successes from the child - including looking at the speech-language pathologist or coming to a speech room- should be calmly but fully praised by the therapist. Each individual step is often a huge leap because the child who is selectively mute often feels that "the words just won't come out," even though they want them to.
Techniques that have been successful in getting preschool and primary grade children with selective mutism to feel comfortable initially and interact both nonverbally and verbally are, by design, fun and motivating.
One technique is arts and crafts. After proceeding well into a project, the child has to communicate a choice, such as color, or a part, like a hat or a scarf for a snowman. Many children also react well to playing with playhouse-type figures or puppets and will allow their figure or puppet to interact with the therapist's figures before they themselves directly interact with the clinician.
Children with selective mutism also can play on a computer alongside the speech-language pathologist, with the clinician operating the mouse. In this way they are not forced to maintain eye contact at first, which can provoke anxiety. The speech-language pathologist might play a game while the child watches but should later encourage the child to communicate choices about the game, nonverbally at first with gestures and then verbally as the child demonstrates strong interest.
When children with selective mutism begin to display comfort and increased communication, they can benefit from participating in a social skills group with well-matched peers. Regardless of the specific activity offered, accepting the child fully, communicating a positive affect toward the child, and rewarding all communication attempts by providing logical outcomes are the first steps the speech-language pathologist can take to lessen the child's anxiety and build communication confidence in the school setting.
Shari A. Gross is a speech-language pathologist and certified elementary educator in private practice in Manalapan, NJ, and served as a member of the Professional Advisory Board and the Executive Committee of the Selective Mutism Group, Child Anxiety Network. In addition to serving as director of Child Achievement Center, she was the director of speech-language pathology at the Selective Mutism Anxiety Center. She can be reached at 732-617-8255.