Given the complex and relatively rare nature of Selective Mutism, many professionals have limited understanding of the nature and treatment approaches for SM. The Selective Mutism Group (SMG) is and internationally recognised authority on Selective Mutism. SMG advocates for evidence-based treatment strategies that are consistent with current understanding that SM should be treated as an anxiety disorder. Anxiety disorders are the number one mental illness among children and adolescents yet they represent one of the least understood mental health problems in this population (Costello et al., 1996; Zahn-Waxler et al., 2000).
The Selective Mutism Groups (SMG) position statement on treatment is:
Most cases of SM are not referred for treatment due to the lack of understanding of SM, thus, many children and adolescents can go years without speaking and, because their mutism is ingrained, it becomes much harder to overcome. SMG encourages parents of children who appear to have SM to seek diagnosis and treatment as soon as possible.
The following list illustrates the necessary components that the ideal treatment for SM should address:
- Selective Mutism (SM) should be viewed and treated as an anxiety disorder. Children with SM manifest their anxiety by displaying an inability to speak in one or more select social settings. Children and adolescents with SM are likely to have changes in their anxiety level and level of functioning from one setting to another. Thus, the child’s inability to speak effectively in one setting despite the ability to do so in a setting that is comfortable to the child should not be mistaken for a deliberate refusal to speak. Punishment or withholding of privileges for not speaking and communicating effectively in social settings is inappropriate.
- Treatment of SM should focus on reduction of anxiety through multimodal treatment strategies. These may include, but are not limited to, cognitive-behavioral therapy, family therapy, play therapy, and school-based and community-based behavioral interventions. Treatment should assist the child in decreasing anxiety and teaching coping skills to use when confronted with anxious situations. A treatment plan should include approaches that gradually desensitize and allow for decreased anxiety in social settings where speaking does not occur, and a progression from nonverbal to verbal communication.
- Treatment should not focus on “getting a child to speak” nor should emphasis be placed on speaking goals. Children generally progress through a hierarchy of feared situations from using nonverbal communication such as nodding, pointing or writing to gradual approximations toward speaking such as whispering or initiating communication nonverbally. Placing emphasis on speaking alone will put unnecessary pressure on a child and will often increase anxiety, leading to a lack of progress or regression. A focus on speaking also neglects to address other manifestations of anxiety that are likely present and may remain problematic after a child begins speaking.
- Treatment should address not only selective mutism but individual characteristics of the child (including strengths and weaknesses), comorbid problems, and exacerbating factors. These may include but are not limited to social phobia, separation anxiety, generalized anxiety, obsessive-compulsive disorder, learning difficulties, speech/language disorders, and developmental delay. A diagnosis of SM should be confirmed by assessment by a treating professional. A thorough assessment of Selective Mutism should also rule-out other disorders that may better account for the mutism such as autism-spectrum disorders, communication disorders and psychotic disorders.
- A team approach is crucial to the child’s overall success. The child, their family, their teacher and other significant persons involved in the child’s life should be involved in the treatment plan. Education of parents, school staff members and other significant persons is crucial to enable treatment strategies to be appropriately implemented across various social settings. This may be accomplished through direct involvement in family or school-based therapies or through regular consultation with or the provision of educational training seminars with all who are involved.
- Treatment should involve helping the child to increase awareness of his or her anxiety in a manner that is developmentally appropriate. For example, preschool-aged children may be taught to recognize feelings including happy, sad, mad and scared and communicate whether they have a lot or a little of the feeling shown. They can also be taught to use progressive muscle relaxation and deep breathing techniques by telling them to squeeze lemons in their hands and release to make lemonade (make fists and relax them), turn their body from Jello to ice (tense and relax muscles) and to fill their tummies with air and slowly release it as if it were a big balloon (breathe slowly and deeply). Older children and teens may be able to rate their feelings in various situations using a subjective unit of distress scale (SUDS) such as rating the feeling from 0 (not having this feeling at all) to 10 (experiencing the highest intensity of the feeling), creating a hierarchy of feared situations from easiest to most difficult, and apply anxiety reduction techniques through gradual exposure to the feared situations. Goals for desensitization and exposure should be in extremely small increments (often beginning with nonverbal communication goals before verbal goals) so that children may experience experiences of success rather than failure. The child progresses at his or her own pace, and may need to revert back to a more intermediate step before progressing to the next goal which may be difficult. The child or adolescent should be actively involved in the treatment plan. At no point is it appropriate to trick a child into speaking or attempt an exposure without preparing the child in advance. Exposure techniques should not be undertaken without the child’s willingness to participate. A treating professional who is familiar with treating children and adolescents will have knowledge of developmentally appropriate strategies to use with an anxious child and ways to work with a resistant child or adolescent.
- Medication may or may not be needed. If medication is prescribed, it should be used in combination with a multimodal, team treatment approach as described herein. Medication is not a “quick fix” or “cure all” for SM or anxiety. Medication is used to lower anxiety enough to allow the child to participate in the treatment process and to treat comorbid depression which is common in older children and adolescents. Antidepressant medications such as Prozac and Paxil have been used in the treatment of SM but are not sufficient to treat SM when used alone. When medication is used, dosages should start very low and increases should be made very gradually and only when monitored regularly by the prescribing physician. Side effects should also be closely monitored when a child is using medication. Any behavior or mood changes or other new symptoms should be reported to the prescribing physician.
- Nutritional therapy supplements and herbal remedies should be used with extreme caution. While these may be helpful in some cases, they should only be used under the supervision of a highly trained professional due to the potential harmful side effects associated with these treatments, equal to or greater than those associated with prescription medication. Claims made about these unregulated and less researched products should be scrutinized as more research is needed to validate the benefits of these supplements on growing children.
- Due to the nature of SM, treatment should include interventions and goals within the school and community settings, not just the treating professional’s office. Within the school, there is likely a need for education of school staff, consultation and close collaboration regarding treatment goals, and possibly, accommodations in the classroom to increase the child’s comfort and participation. These components are necessary to help the child generalize treatment gains to all settings, not just with the treating professional. School and community goals, like all other treatment goals, should be planned and implemented by the treatment team, led by a trained professional. Generally, attempting to apply all of these strategies to “treat” one’s own child is not advised.
- Generally, it is not advised to place children with SM in self-contained or special education classrooms based solely on their selective mutism diagnosis, nor are educational environments with limited opportunities for social interaction advised. Most children with SM can perform academic work with minimal or no accommodations in the regular classroom. All children suspected of having SM or diagnosed with SM should receive an evaluation to rule-out other symptoms and behaviors that may be experienced in addition to SM. Following this evaluation, appropriate educational planning should take place, and in some cases, developing a 504 plan or Individualized Education Program (IEP) may be indicated. While not all children with SM will qualify for special education services and an IEP, most children diagnosed with SM will qualify for 504 plan accommodations since selective mutism affects the major life activity of speaking. Parents and treating professionals should become familiar with the special education and educational laws and exercise their rights as needed to support their child.