Treatment Tips for Working with Selective Mutism in the School Setting
Selective mutism (SM) is an anxiety-based childhood disorder that prevents a child from speaking in specific situations—often this is anywhere outside the home, or to anyone other than immediate family members (American Psychiatric Association, 2013). One of the most common places that SM manifests is in the school setting. SM is currently thought to be the result of a variety of factors, including genetic, temperamental, environmental, and neurodevelopmental (see Muris & Ollendick, 2015, for an overview). Prevalence rates of SM range from .71% to 2% of school-age children and is currently estimated to be about 1 in 140 children (Bergman, Piacentini, & McCracken, 2002; Kumpulainen, Räsänen, Raaska, & Somppi, 1998). Children with SM are at significant disadvantage compared to peers in terms of social and academic functioning. Broadly, SM prevents the child from engaging in meaningful conversational exchanges with adults and peers and, thus, from learning vital social norms and skills (Johnson & Wintgrens, 2017) as well as vocabulary and language structure. Research indicates that children diagnosed with SM are more likely to present with underlying speech and/or language deficits (Manassis et al., 2003, 2007; McInnes, Fung, Manassis, Fiksenbaum, & Tannock, 2004). Academically, children experience limited or even nonexistent social interactions with peers and teachers, leading to limited involvement in school routines and activities and even delays in oral reading and word attack skills (Giddan, Ross, Sechler, & Becker, 1997). However, there is hope: research has also shown that children who receive appropriate treatment can and do make communicative gains and can be successful speakers in the school environment (Cohan, Chavira, & Stein, 2006; Giddan et al., 1997; Johnson & Wintgrens, 2017). It can be overwhelming to determine how to start supporting a child who has no or very limited communication within the school setting. Some general tips are provided below.
Establish a Key Worker
Though typically diagnosed by a psychiatrist or psychologist, selective mutism is a complex disorder that demands involvement from an interdisciplinary team of professionals in order to be treated successfully (Giddan et al., 1997). Within the school setting, these professionals might include a school counselor, school psychologist, social worker, speech-language pathologist, learning support teacher, paraprofessional, teacher, or other professional. Regardless of title, practitioners should be trained in specific, evidence-based strategies to use with the child with SM (i.e., Parent-Child Interaction Therapy Adapted for Selective Mutism [PCIT-SM]; Cotter, Todd, & Brestan-Knight, 2018; Mele & Kurtz, 2013) in order to facilitate appropriately scaffolded opportunities that build communication skills across people, places, and activities. It is critical to establish a “key worker” in the school setting—someone who is willing and able to be trained in skills and has the flexibility and availability to work with the child in a number of settings throughout the year to increase communication. This key worker will serve as the primary point person who will work with the child in a variety of environments, collaborate with other professionals (i.e., the speech-language pathologist to determine appropriate language goals and skills; the school counselor to integrate techniques to reduce anxiety; etc.), and communicate the child’s progress to the rest of the team on a regular basis.
Fade In New Communication Partners
Fading in new communication partners is a critical skill for the key worker to master. It requires the child to begin in an environment with someone (usually an adult) they can speak to comfortably—at first this may be a parent or sibling, and then may be the key worker. The familiar adult engages in scaffolding (see below), providing warm-up time and encouraging first behavioral and then verbal engagement. The new communication partner who is being faded in systematically moves closer to the point of interaction, slowly becoming involved in the activity, making neutral comments, and reflecting (repeating) the child’s utterances as the familiar adult works to keep them verbally responsive. As the child becomes comfortable with the new communication partner’s presence, the new partner can begin asking forced-choice and open-ended questions, interspersed with the familiar adult’s continued engagement. Once the child is consistently responsive to the new communication partner, the familiar adult can “fade out” by slowly moving away from the interaction until the child is communicating with the new partner independently. In this way, the child can work to transfer their communication skills to more people, both adults and peers.
Use Intentional Scaffolding
Opportunities for communication must be carefully and intentionally scaffolded in order to balance an appropriate level of challenge for the child with the need to keep success rates high in order to encourage a sense of self-efficacy about the child’s own communication skills and build momentum to keep moving forward. Sessions should always begin with a “warm-up” period in which there are no communicative demands placed on the child. The adult and child can interact with a preferred activity to build comfort and rapport, and the adult can engage in narration of what each of them are doing to demonstrate engagement and provide models of appropriate language to use in the situation. The goal should be to promote comfort and behavioral engagement from the child.
After a period of warming up, the adult can move to asking forced-choice questions (i.e., “Do you want a red marker, a blue marker, or something else?”), which have all the answer options embedded in the question, thus reducing the cognitive demand on the child to think of their own answer. When the child is successful at that level, the adult can move to using open-ended questions (i.e., “What color marker do you want now?”), thus providing the child with the chance to think of and use their own novel responses. From this point, the adult may choose to fade in new communication partners, transfer these skills to a new environment, or begin targeting higher level skills (i.e., having the child ask questions, make comments, advocate for themselves, initiate conversations with adults and peers, give compliments, share an opinion, negotiate appropriately, etc.) in the comfortable environment. Progress will vary from child to child and from day to day with each child. In some instances, it may take several sessions to move from one level of scaffolding to the next. In other instances, the child may be able to move through many levels of complexity within the same session or day. The adult should always have a plan of how to scaffold up (make the demands slightly more challenging) or scaffold down (make the demands slightly easier) tasks depending on the child’s response. The primary goal is to ensure the child has as many successful communicative interactions as possible, as this repeated practice is what creates new patterns of behavior.
Communicate with Team Members
Given the interdisciplinary nature of treatment of SM, treatment teams may comprise a large number of people who may have varying degrees of interaction with the child on a daily, weekly, or monthly basis. As such, frequent communication among team members is essential to ensure that everyone remains on the same page. The team should determine a communication plan that outlines who will communicate progress, through what method, and at what frequency. This may look different for different members of the team. For example, the key worker may communicate progress to the parent and teacher on a daily or weekly basis and to other consulting members of the team on a monthly basis. Communication ensures that everyone is aware of the child’s current goals and progress, and therefore allows all members to adjust their recommendations and interactions with the child in order to meet their needs appropriately.
Conclusion
Children with SM can and do make incredible progress when met with the right support. Helping these children to communicate effectively in their school environments can have a significant, positive impact on both their academic and social-emotional success, and ameliorate potential long-term effects that can come from lack of communication and social involvement (i.e., increased risk for additional anxiety disorders, depression, difficulties in work settings, difficulties with interpersonal relationships, etc.). As our awareness of this disorder and ability to identify it increases with more knowledge and research on the subject, so must our ability to provide treatment to these children effectively and with efficacious practices.
For More Information
For more information about each of these strategies and many more, please see my new book, Treating Selective Mutism as a Speech-Language Pathologist, available now from Plural Publishing.
Other helpful resources include:
● The Selective Mutism Association’s Webinars (https://www.selectivemutism.org/learn/webinars/) and Toolkit for Educators (https://www.selectivemutism.org/selective-mutism-a-toolkit-for-educators/)
● Child Mind Institute’s Teacher’s Guide to Selective Mutism: https://childmind.org/guide/teachers-guide-to-selective-mutism/
● The Selective Mutism Learning University, where families and professionals can become trained in PCIT-SM skills: https://www.kurtzpsychology.com/selective-mutism/sm-learning-university/
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Bergman, R. L., Piacentini, J., & McCracken, J. T. (2002). Prevalence and description of selective mutism in a school-based sample. Journal of the American Academy of Child and Adolescent Psychiatry, 41(8), 938–946.
Cohan, S. L., Chavira, D. A., & Stein, M. B. (2006). Practitioner review: Psychosocial interventions for children with selective mutism: A critical evaluation of the literature from 1990–2005. Journal of Child Psychology and Psychiatry, 47(11), 1085–1097.
Cotter, A., Todd, M., & Brestan-Knight, E. (2018). Parent–child interaction therapy for children with selective mutism (PCIT-SM). In Handbook of Parent-Child Interaction Therapy (pp. 113–128). Springer, Cham.
Giddan, J. J., Ross, G. J., Sechler, L. L., & Becker, B. R. (1997). Selective mutism in elementary school: Multidisciplinary interventions. Language, Speech, and Hearing Services in Schools, 28(2), 127–133.
Johnson, M., & Wintgens, A. (2017). The selective mutism resource manual. New York, NY: Routledge.
Kumpulainen, K., Räsänen, E., Raaska, H., & Somppi, V. (1998). Selective mutism among second-graders in elementary school. European Child and Adolescent Psychiatry, 7(1), 24–29.
Manassis, K., Fung, D., Tannock, R., Sloman, L., Fiksenbaum, L., & McInnes, A. (2003). Characterizing selective mutism: Is it more than social anxiety?. Depression and Anxiety, 18(3), 153–161.
Manassis, K., Tannock, R., Garland, E. J., Minde, K., McInnes, A., & Clark, S. (2007). The sounds of silence: Language, cognition, and anxiety in selective mutism. Journal of the American Academy of Child and Adolescent Psychiatry, 46(9), 1187–1195.
McInnes, A., Fung, D., Manassis, K., Fiksenbaum, L., & Tannock, R. (2004). Narrative skills in children with selective mutism: An exploratory study. American Journal of Speech-Language Pathology, 13(4), 304–315.
Mele, C. M., & Kurtz, S. M. S. (2013). Parent-child interactions in behavioral treatment of selective mutism: A case study. Poster presented at the meeting of the Anxiety Disorders Association of America, La Jolla, CA.
Muris, P., & Ollendick, T. H. (2015). Children who are anxious in silence: A review on selective mutism, the new anxiety disorder in DSM-5. Clinical Child and Family Psychology Review, 18(2), 151–169.