Understanding and Treating Selective Mutism
We need to rethink the idea that kids who don't speak are being stubborn.
Posted Oct 13, 2016
Children with selective mutism do not speak at school or in other public places where others might hear them, or they speak only in a barely audible whisper. These children speak freely and easily, however, when they're at home with family members. This condition used to be called "elective mutism," reflecting the thinking that these children were deliberately not speaking, perhaps being stubborn or simply trying to get attention. Current theories argue that the problem is not elected. Rather, it's as if these children's voice boxes are frozen with fear, preventing them from communicating with words.
Olivia became concerned about her daughter, Jenny, when she was in preschool. She never said a single word to her teachers or the other children. One day she fell on the playground and cut her knee deeply, but she didn't tell the teacher what it happened. When someone noticed and directed her to the nurse’s office, she became hysterical.
Later, when Olivia came to pick up her daughter after learning what had happened, Jenny admitted she was afraid to talk to her teacher and she definitely didn't want to talk to the nurse. When Olivia took her daughter to the pediatrician—both to check her knee and ask about her not speaking at school—the doctor said, "She's just shy. She'll grow out of it." Olivia wasn't convinced, but she didn't know what else to do.
Jenny did not speak the entire year at her preschool, although she was quite talkative at home. Olivia hoped and prayed her daughter would start to talk at school and kindergarten—even just a few words—but it didn't happen. Fortunately, her kindergarten teacher recognized Jenny as being extremely anxious, and they were referred to me for evaluation and treatment.
At first, Jenny wasn't comfortable talking with me. But we worked with puppets, and she was able to make them move their heads to indicate "yes" or "no" responses to my questions. I taught Jenny some basic breathing techniques—children usually learn this quite easily—by having her imagine a balloon expanding and contracting in her belly. I taught her progressive muscle relaxation by having her pretend to squeeze a lemon in her hand and then release it, and so on. We drew pictures of ladders to show how she could overcome her fear of speaking by climbing the ladder, one wrong at a time.
After some preliminary work of educating Jenny and her family about the process, we constructed a hierarchy of situations she was to complete. We also devised a reward system in which she would earn stickers for completing the items on her hierarchy. In addition, Jenny would be able to buy a stuffed bear she had been wanting after a specified amount of progress had been made. The hierarchy we used is below. After Jenny worked her way through it, we developed another one using more challenging tasks, such as asking aloud in class, "May I get a drink of water please?"
Jenny’s Behavioral Hierarchy:
- Whisper aloud to Mom or Dad so that Jill (same age neighbor) can hear
- Talk aloud to Jill with Mom or Dad present
- Talk aloud to Jill without Mom or Dad present
- Talk aloud to Mom or Dad in front of Jill's mother
- Say one sentence to Jill's mother
- Say a few words to an unfamiliar adult, such as a bank teller who gives her a piece of candy (for example, "thank you")
- Say hello to an adult, such as the mail carrier
- Say hello to teacher at school—no children present
- Say hi to a classmate
- Talk to a teacher in presence of one other child
In addition to working with Jenny behaviorally on her hierarchy, I also met with the family to teach them to stop reinforcing Jenny for not speaking. Jenny's siblings had become quite skilled at knowing what Jenny wanted or needed when they were in public and she wouldn't speak. This commonly happens when a child has selective mutism, and unless these dynamics are addressed, little progress can be made.
Fortunately, Jenny's family was cooperative when they realized they weren't doing Jenny a favor by "helping her" in the ways they had been. Meanwhile, Jenny worked diligently to complete the items on the hierarchy. Of course, her parents were there to encourage her and keep her on the right track. Once the pattern was broken, it didn't take much time to see progress.
If you suspect your child has selective mutism, here are some general suggestions to follow.
What you can do:
Selective mutism is best treated early. If your child has not spoken in the classroom by mid-year of kindergarten at the very latest, seek an evaluation from a mental health professional who is familiar with selective mutism.
Don't speak for your child or allow siblings to do so. Once a child learns he or she can communicate without speaking, it is much more difficult to break the cycle. In addition, over time the extra attention the child receives can be reinforcing and keep the problem going.
At the same time, do not "force" your child to speak or use any type of punishment to correct the problem. Instead, encourage your child to meet small speaking-related goals in a gradual fashion. A therapist may be needed to assist with this.
Not all cases go as smoothly as Jenny’s did. Some children may require medication as an adjunct to behavioral treatment. Don't be afraid to try medication if things are not going well using therapy alone.
Check out the Selective Mutism Group/Childhood Anxiety Network on the Internet. They have tips for parents and teachers, support groups, an "Ask the Doctor" program, book listings and reviews, and several forums.
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