Clinical Perspectives on the Treatment of Selective Mutism

Abstract Selective mutism is a childhood disorder characterized by a failure to speak in some but not all of the contexts where speaking is normally expected. It is commonly associated with co-occurring anxiety, both on the part of the child and on the part of one or more family members. The prevailing opinion on treatment recommends medication, cognitive-behavioral therapy (CBT) and family counseling. However, treatment efficacy research is extremely limited. Further, since selective mutism is often first identified during the preschool years, CBT must be modified to match a child's developmental level. This paper summarizes the nature and prevalence of selective mutism, techniques used to treat this disorder, and issues in need of research. The discussion of behavioral treatment techniques is based on the literature and on the author's clinical experience. Keywords: Selective Mutism; Operant Conditioning, Cognitive Behavior Therapy, Communication Hierarchy, Talking Scale, Talking Map, Parent Counseling, Collaboration. Introduction Selective mutism is an intriguing childhood disorder that presents considerable treatment challenges. The core symptom is that a child persistently and systematically refrains from speaking in some settings where speaking is expected (e.g., school, community) but speaks fluently in other settings (e.g., home.) Often there are additional complicating factors, such as co-occurring anxiety symptoms or oppositional behaviors, as well as a familial history of anxiety. While a number of articles have been written about selective mutism, there is no universally accepted treatment regimen. Following a short summary describing the nature and incidence of selective mutism, this paper will address approaches to treatment based on the literature and on the author's clinical experience with this population. Also presented are recommendations for research. Definition, Incidence, and Co-Occurring Conditions According to the DSM-IV-TR (American Psychiatric Association, 2000) the onset of selective mutism usually occurs before the age of five years. However, sometimes it is not recognized as a specific problem until a child enters school, when the systematic and selective failure to talk becomes more noticeable. A clinical diagnosis of selective mutism is made on the basis of five criteria: A. The child refrains from speaking in specific social situations (e.g., school) while speaking in others (e.g., home) B. Failure to speak interferes with educational achievement or with social communication C. Symptoms persist for at least one month (not including the first month of school) D. The failure to speak can not be attributed to a lack of knowledge or comfort with the spoken language (as might be true for bilingual children who have immigrated from another culture). E. The symptoms are not better accounted for by a communication disorder, a pervasive developmental disorder, or a psychotic disorder. Prevalence estimates of selective mutism range from .03 to 2 percent; and it is more common among girls, with ratios ranging from 1.5 to 2.6 girls to 1 boy with the diagnosis (Garcia, Freeman, Francis, Miller, & Leonard, 2004). Current research indicates that children with selective mutism show more anxiety symptoms than do other children (Bergman, Piacenti, & McCracken, 2002; Cunningham, McHolm, Boyle, & Patel, 2004) and that anxiety symptoms co-occur with selective mutism at a rate of 74 to 100 percent (Garcia et al.; Kristensen, 2000; Vecchio & Kearney, 2005). Oppositional disorder may also co-occur, but there is some dispute in the literature about its co-occurrence rate. Garcia et al., and Vecchio and Kearney reported that the rate of occurrence is quite low. However, Cunningham et al. reported oppositional disorder to co-occur twice as often among children with selective mutism as among children in a control group. …