Kids with selective mutism are most often diagnosed between the ages of 3 and 8 years old. Identifying selective mutism and intervening at an early age provides the child with more opportunities for successful treatment and it can help them avoid a long and challenging future of potential academic, social, and emotional repercussions. Early intervention is key, and beginning interventions at the time that the symptoms appear has been shown to be the most effective timing for treatment success. Beginning treatment early can minimize the amount of time that the child is experiencing reinforcements and accommodations for their mutism.
Many times, when a child appears anxious outside of the home and at school, a caregivers initial reaction will be to accommodate their child and meet them at their level. This could include things like a parent speaking for their child when ordering at a restaurant, which allows the child to avoid the interaction that makes them anxious. It also could include a teacher refraining from calling on the kid in class, or allowing them to skip a presentation, because of their anxiety. When caregivers support the child in avoiding the experience that they are anxious about, they aren’t encouraged to face their fears. As a result, their anxious behaviors, like mutism, are rewarded. They get what they want, they don’t have to interact with others, and their anxious behaviors are reinforced in this cycle. Many treatments for selective mutism, and other anxiety disorders, encourage “brave behaviors” and the use of an approach model. In these treatments, clinicians and caregivers use skills to help the child approach situations that make them anxious, which in turn will teach the child that it’s not so bad after all. In this model, brave behaviors are rewarded instead of anxious ones, making them less likely to return.
If a child is left without intervention for longer, and adults are accommodating anxious behaviors, it can be harder to break them out of their conditioned, mutism responses to feelings of anxiety.
The first step to getting effective support is to pursue a thorough evaluation with a mental health professional. With an evidence-based evaluation, your clinician can help you to identify the specific challenges your child is struggling with, determine if a diagnosis is appropriate, and recommend the best treatment pathway for your individual family and child. Each kid is different, and an individual evaluation and approach will help you and your clinician feel confident that the proscribed approach will be a good fit for you.
Through the evaluation, your clinician will be assessing if the potential mutism is a result of anxiety or if it is a result of a language ability challenge, hearing difficulties, a communication disorder, or any other developmental challenges. By pinpointing where the mutism is coming from, providers will be able to tell what challenges to address. The evaluation will also assess how long the child has been struggling, and in which ways their anxiety and mutism is impacting their ability to engage at school and in other situations.
Evidence-Based Treatments for Selective Mutism
Parent-Child Interaction Therapy- Selective Mutism (PCIT-SM)
PCIT-SM is a family-based intervention that is based on a two-phase treatment model. The first phase is Child-Directed Interaction (CDI) which includes learning and building skills for positive relationships and reinforcement, and it serves as a base for the second phase of treatment. The second phase is Verbal-Directed Interaction (VDI), which introduces a framework for encouraging and facilitating speech for kids with SM. This phase helps caregivers build skills to use specific types of questions and prompts, respond to non-verbal communication appropriately, positively reinforce verbal responses, and increase their child’s brave behavior.
In this intervention, caregivers are live coached by a clinician and interact with their child as they engage in bravery practices. Bravery practices are exercises used to overcome the child’s fears and increase their ability to engage verbally.
Behavioral and Cognitive Behavioral Therapy
A behavioral approach to selective mutism is highly supported by research. Behavioral treatments will include gradual exposures to the anxiety-inducing stimuli, with less distressing situations being introduced first. Exposure helps the child learn how to tolerate and habituate the feeling of anxiety in their bodies. It will also include positive reinforcement strategies for verbal engagements to make them more likely in the future.
Cognitive strategies can be an effective tool for treatment of older kids, once they can reflect on their thoughts. Some strategies taught will be how to recognize the feeling of anxiety in the body, identifying and challenging negative thought patterns in anxious moments, and setting up a coping plan for their anxiety in advance.
Medication for Selective Mutism
Medication for selective mutism has been used in combination with therapy if the child has severe difficulties, if they have not been respondent to behavioral approaches, or if they have been struggling with selective mutism for a long time. The goal of medication for these kids is to help reduce high levels of distress so that they can better engage with behavioral therapy skills. Consult with your clinician and other providers before pursuing medication.
Strategies to Use at Home
- Give a labeled praise to your child when they engage verbally outside of the home to increase the likelihood of the behavior.
- When you notice your child speaking up in public, be sure to tell them that you are proud of them for using their voice and that you like hearing what they have to say! The more positive responses they get to their verbalizations, the more likely they will be to speak.
- When you notice your child speaking up in public, be sure to tell them that you are proud of them for using their voice and that you like hearing what they have to say! The more positive responses they get to their verbalizations, the more likely they will be to speak.
- Use “forced choice” questions to help your child warm-up to speaking outside of the home.
- A forced choice question presents a child with two options to pick from for their answer. This can be helpful in removing the stress from the moment, since they do not have to come up with their own response.
- For example, you can ask: “Would you like a chocolate shake or a vanilla shake?” instead of, “What flavor ice cream would you like?”
- Practice “Brave Talking” with your child at home and in public
- Help your child prepare for social interactions by walking them through the potential interactions. Explaining possible questions and potential answers in social situations can help decrease anxiety because you provide a roadmap for the interaction.
- For example, you can show your child what to do when they need to use the bathroom at school, and then roleplay the part of the teacher!
- Encourage your child to use their voice and their social skills outside of the home but start small and have realistic expectations.
- Instead of expecting your child to participate in large group parties or in front of the whole class right away, start small by creating opportunities for your child to interact with others one-on-one. For example, you can set up a meeting with the teacher before school starts so they can meet each other individually. Or you can arrange a playdate with a close friend in the park to help them start small outside of the home.
Want to learn more?
- Watch our FREE selective mutism webinar
- Read How to Recognize Selective Mutism
- Read Client Spotlight: An Effective Selective Mutism Treatment Experience
- Contact us
Sources:
Camposano, L. (2011). Silent suffering: Children with selective mutism. The Professional Counselor, 1(1), 46–56. https://doi.org/10.15241/lc.1.1.46
Stanley, C., Dabney, L., & Gorski, L. (2023, September 14). What is selective mutism: Selective mutism and anxiety disorders. Selective Mutism Anxiety & Related Disorders Treatment Center | SMart Center. https://selectivemutismcenter.org/whatisselectivemutism/
Wall, D. (2021, June 19). Selective mutism: Fact sheet - ABCT - association for behavioral and cognitive therapies. ABCT. https://www.abct.org/fact-sheets/selective-mutism/
Wong P. (2010). Selective mutism: a review of etiology, comorbidities, and treatment. Psychiatry (Edgmont (Pa. : Township)), 7(3), 23–31.