2. Has the mutism lasted at least one month? Brief refusal to speak is not uncommon in children.
3. Does the child speak well at home with people she knows well? Most children with selective mutism speak well at home with family members, which belies a communication disorder.
4. Is failure to speak significantly interfering with the child’s academic or social development? Selective mutism must involve a significant interference in daily functioning.
5. What circumstances surround each episode of mutism? In particular, is the mutism associated with the desire to increase social attention or stimulation from others, decrease anxiety, or avoid or withdraw from adult commands or requests? A full understanding of selective mutism must include a review of triggers like these.
6. Can the child be encouraged to speak audibly in any way in certain public settings? Children with selective mutism who can speak to some extent in public situations may have a better prognosis than those who do not.9
7. How do others respond to, or compensate for, the child’s mutism? Do they complete tasks for the child? Order food for her? Allow whispers or communication via writing? Excessive accommodations enable a child with selective mutism to maintain the behavior.
8. Does the child appear anxious or depressed in situations involving mutism? Mutism is often linked to poor affect and social anxiety.
Still suspect selective mutism? Make a referral
If after asking these 8 questions you still suspect selective mutism, you will need to make a referral to a child psychologist or other mental health professional who specializes in behavioral strategies to treat selective mutism. The psychologist will meet with the child and utilize more formal methods of assessment.
The psychologist may use the Anxiety Disorders Interview Schedule for DSM-IV-TR (child and parent versions), a structured interview that emphasizes anxiety-based disorders and includes a section for selective mutism based on DSM-IV-TR criteria.16 Another helpful tool is the Functional Diagnostic Profile for Selective Mutism, which helps to assess contextual factors that surround refusal to speak.17 The challenge, of course, in conducting these interviews is that many children will not answer the psychologist’s questions verbally, but may communicate via nonverbal gestures, writing, or other creative ways such as drawing letters in the air.
Parent and teacher logs provide valuable insight
Ongoing behavioral observations or daily logbooks completed by parents and teachers are also important in treating a child with selective mutism. If parents aren’t doing so already at the suggestion of the therapist, ask them to keep a logbook and encourage them to ask the child’s teachers to keep one, as well. This log should include the number and volume of words spoken, to whom the child has spoken, where the child spoke, how others reacted (ie, Did they pay extra attention to the child?), and the child’s compensatory behaviors such as whispering, pointing, crying, nodding, or frowning.18 Parents and teachers should also note the antecedents to mutism, including demands (or requests) from others, or the presence of unfamiliar people.
A focus on systematic desensitization
Much of the literature regarding the treatment of selective mutism consists of case reports and small-scale studies.19 The paucity of data is, in part, a reflection of the rarity of the problem as well as a historical lack of consensus among researchers about the nature and diagnostic criteria for selective mutism.
The studies we do have on selective mutism indicate that behavior modification can be effective for these patients. Behavioral treatment primarily involves child- and parent-based practices.20
Child-based practices include management of physical sensations of anxiety often via relaxation training and breathing retraining. Neither technique requires verbal input from a child. In addition, the therapist will have the child practice audible words in progressively more difficult settings via systematic desensitization. These settings often include the following, in order: the child’s home (with the therapist), the therapist’s office, community settings such as a mall or a restaurant, and finally, school.
In these settings, the therapist might, for example, encourage the patient to:
- speak on the telephone or answer the door at home.
- stay at the therapist’s office until at least one word is audibly spoken. (One approach that the therapist may use to increase rapport and provide opportunities to prompt speech is to play games with the child.)
- order her own food at a local restaurant.
- read a story aloud to classmates at school.