Selective Mutism: A Literature Review

Shannon M. Hageman

College of St. Mary

Selective Mutism: A Literature Review

Silence. Not word. Blank stares and nervous gulps. This is how my son responded to his preschool teacher on the very first day of class. And the second. All they way through second grade. He's fine, the pediatrician assured us. He's just really shy, he'll outgrow it, the preschool teacher encouraged. He's not right, the kindergarten teacher warned, he's handicapped.

Those words stung. How could my son be handicapped? He speaks all the time at home. He's the boss around home, yelling at his younger brothers and taking control, leading them in and out of mischief. He reads and writes and tells jokes and loves football. He engages in class activities, he plays at recess. He just does it silently. Is this a handicap? He's only handicapped in the classroom.

They drove by our house, counselors and teachers curious if I was telling the truth. They interviewed the babysitter, no one told us about the investigation. Did the school think I beat my son into silence?

We followed the pediatrician's advice. We offered rewards, we bribed our son to speak up at least once a day and we'd take him for ice cream. Speak up three times and he could have that new Avatar action figure he's wanted. It helped, a little. But his kindergarten teacher refused to cooperate. "There's more wrong here and until you can accept that, I can't help him," she said, insisting on his mental disability.

In first grade, his teacher recognized the silence as a previous student acted similar. She suggested we keep up with the pediatrician's suggestion, but also start and IEP for reading and speech therapy. Cooperation from the school opened a completely new world to us as we struggled to cope with out son's selective mutism (SM), a definition we found by doing our own research.

Now, six years later, our son is still quiet, but he responds when called on, he even volunteers. He's in football and wrestling and has a solid set of diverse friends. He never gets in trouble and maintains average grades, although he does require extra help in Math.

Our experience with SM brought me to this topic of literature review. I already knew the basics of diagnosis and symptoms. I wanted to know what happens next. Our situation was more of chance and child advocacy than of professional intervention and diagnosis, so I was curious about what happens long term. Should we still be considering options for collegian years? I wanted to know what causes SM. How does it affect education? What are the trends in treatment?

I researched the web and scholarly articles from the library. The material is pretty redundant and limited. I found websites like ChildMind.org and SelectiveMutism.org, which I found helpful with new advice and supports- something I will continue to refer after completing the review. Of the thirteen pieces of literature I reviewed, I kept eleven for reference. One article was too vague and another failed to appear credible, with no evidence or real research.

Overall, the literature seems to be pretty much in agreement with each other, with obvious room for more research.

Genetics, and Co-occurring Anxiety, and Parental Modeling are Common

Causes of Selective Mutism

While studies fail to prove any one specific cause of selective mutism, a common theme among research is that parental modeling, genetics, and co-occurring anxiety continue to be a common factor among children with SM (selective mutism). The parents tend to be over protective or they themselves are socially inverted and extremely shy, thus they model the behavior and reinforce the child's SM. Rarely have specialists found SM to be a solo symptom, almost always it co-occurs with some social phobia or anxiety. Because SM stems from anxiety, research also suggests that it is genetic and runs in the family.

Initially, experts thought SM was a separate problem. Children with SM frustrated parents and educators who assumed the child was manipulating and controlling his environment by refusing to talk (Hultquist, 1995, p. 101). Child abuse, depression, and attention seeking were all risk factors. However, further studies suggest the response is not controlled and the behavior is an aspect of social phobia. "The fact that this disorder is characterized by just one symptom allows for the inclusion of children with other possible co occurring disorders, such as social phobia, and the possibility for varied etiologies" (Hultquist, 1995, p. 101).

According to Dr. Cumba's research (2014), studies show SM and social anxiety disorders may have shared genetic factors. Separation anxiety and social phobia co occur with most of her SM patients. SM, however, continues beyond any 'warming up' period that often allows children to cope with the other anxieties such as extreme shyness or clinginess. In her research, Dr. Cumba shows that sometimes children with SM exhibit lower levels of anxiety (physiological arousal- sweaty palms, rapid heart, blushing) than those with social phobia or no diagnosis (2014). However, other studies show that "the requirement to speak will cause an intolerable rise in anxiety levels, to which the speech avoidant behavior is a response" (Perdenik & Shaughnessy, 2012, p. 368). That attribute coincides with phobias and a child cannot overcome the behavior without intervention. Ruth Perdenik treats patients who also have siblings or parents coping with SM. Once that child overcomes the fear barrier preventing him from being able to "speak in certain places or to certain people, a feeling of empowerment and confidence is engaged, not just in the child, but in his entire family, too" (Perdenik & Shaughnessy, 2012, p. 368). Classifying SM as an anxiety disorder suggests that the cause can be genetic since family history shows common traces of anxiety disorders.

While the genetic factor is a risk, family dynamics also contribute. Stress within the family can cause SM. Usually, the stress involves multiple traumas such as death or divorce in addition to existing language difficulties (Perednik & Shaughnessy, 2012, p. 367). "Modeling by socially anxious parents who may themselves be uncomfortable interacting with people they do not know well may be internalized by their children" (2012, p. 367). Sometimes, a parent of a child with SM is one who shuts down and refuses to express himself when uncomfortable. Family factors like "parental use of silence to promote hostility, pathological shyness or anxiety in parents, and the marital discord are associated with selective mutism" (Hultquist, 1995, p. 101).

Observational findings consistently show that anxious children tend to have parents- usually the mothers- who are more controlling of their children than parents of non-anxious children are. "Socially withdrawn children evoke the parental feelings, such as concern and frustration, and that these may be exacerbated when parents are anxious themselves (Edison, Evans, McHolm, 2011, p. 271). Research also shows that "parents of children with SM are more controlling, parents tend to take over for their anxious children, and this may be especially true when parents themselves are anxious, as though to reduce theirs and their child's distress" (Edison, Evans, McHolm, 2011, p. 288). Such studies then suggest that children not only need to learn coping strategies, but so do the family members involved.

Every child with SM contains a list of genetic and environmental causes, though no two lists will look alike. Because of the various causes, it is essential to consider carefully the diagnosis and treatment of children suspected to have selective mutism (Hultquist, 1995, p. 106).

Selective Mutism and Educational Influence

Since selectively mute children are vocal at home, they don't usually diagnose SM until early education years (pre-k through first grade usually). Therefore, teachers, schools, counselors, and speech/language pathologists play an important role in diagnosis and treatment of children with SM. One cause for misdiagnosis is the temptation is to assume that silence means the child delayed developmentally or that he has a language disorder. The immediate response then is to place the child in special education. Research emphasizes that children with selective mutism suffer from an anxiety disorder- meaning they use silence to respond to fear. Speech and Language pathologists play a key role in the therapy used with children with SM, however language disorders and developmental delays in speech are generally not the issue related to SM. In fact, many children with SM are developmentally on target, academically similar to their peers, and participate in group activities without any other social road blocks.

According to Dummit, "Many parents report that schools and professionals recommend speech therapy for mute children...although most children seen in our research program had normal or above average speech and verbal skills when carefully evaluated" (2013, www.selectivemutismfoundation.org). Placing a child in special education for the purpose of speech remediation is highly discouraged without proper and extensive formal testing. "However, because their language and academic skills are hard to evaluate due to the mutism and that the schools have no other help to offer, such children are frequently placed in speech and special education services, aimed at improving language or speech skills without needing or benefiting from them" (Dummit, 2013). Placing the child in a smaller, specialized classroom that encourages opportunities to speak could be advantageous, given that there are no other disruptive students isolated to that class, which would only further the anxiety issue (Dummit, 2013). "It is crucial that school personnel realize that in many cases these children have fully developed to age expectations in all respects and may in fact be particularly bright, although this may only be apparent in the home or other very comfortable setting" (Gross, 2014, www.advanceweb.com).

Early identification and intervention are important when treating SM. "The current practice in many school settings is just watching, waiting, and hoping these children will outgrow their shyness and selective silence" (Crundwell, 2006, p. 50). Since SM is a product of anxiety, children will not simply outgrow the disorder. Without the earliest intervention, secondary problems with socialization and learning can develop, such as lack of friends, failure to engage extra curricular activities, and becoming victims of bullying. Common assumptions about children with SM are that their silence makes them vulnerable and susceptible to abuse (Dummit, 2013).

Children in the school environment present psychological and personality features associated with their selective mutism. The child is so overwhelmed with fear, facial features become void and new features take over (Gross, 2014, www.advanceweb.com). Such features include "blushing, avoiding eye contact, fidgeting, becoming overly rigid, and showing social isolation and withdrawal when expected to interact and speak with others" (Crundwell, 2006, 51). If children with SM are continually forced to speak within the classroom setting, tantrums and oppositional behavior results (Crundwell, 2006, p. 51). This furthers misconceptions that refusal to speak is behaviorally based, rather than a reaction to extreme anxiety about vocalizing (Gross, 2014, www.advanceweb.com).

A common suggestion in literature about educating children with SM is to create gradually a comfort level that encourages vocalization. Bringing in a source from the selectively mute child's 'outside' peers- those who engage outside the school setting and whom the child is comfortable enough to converse. As that conversation becomes comfortable in a quiet place within the school setting, teachers can gradually bring additional people (speech pathologist, counselor, and teacher) to the conversation, ensuring the child knows speech in not forced (Crundwell, 2006, p. 52). The speech pathologist might start with a fun and motivating activity like arts and crafts or computer games. This allows the child to interact without making initial eye contact or verbalizing. Once the child with SM begins to show comfort and attempts that are more frequent at conversation, then they can benefit from participating in a social skills group with well matched peers (Gross, 2014, www.advanceweb.com). Rewarding and praising all communication will build confidence and lessen anxiety about speaking in school environments.

Some recent studies show contradictions, suggesting children with SM are not unsociable. Teachers need to keep in mind that children with SM are often "more assertive than submissive, less disruptive, and are likely to be enrolled in sports, recreational activities, and after school playtime with peers, building friendships" (Crundwell, 2006, p. 51). It is important for teachers to be aware of what behavior the child exhibits outside of the classroom, both in the comfort of his home and in other social settings (Crundwell, 2006, p.52). In order for the school to intervene, cooperation must come from teachers, parents, and supportive school staff if proper and effective treatment is to occur.

SM is an Anxiety Disorder Treated with Cognitive Behavioral Therapy (CBT) or Psycho-pharmacological Therapy

Literature consistently refers to four methods of treatment for children with SM: stimulus fading, shaping, modeling, and medication. Just as every child with SM is unique, so are the reasons for treatment. Research suggests that since SM is a learned behavior, it can be corrected with the use of stimulus fading, or gradually introducing a new person into an already comfortable speaking environment. Another behavioral therapy often used is shaping, or reinforcing all behavior efforts made by the child to communicate- even if its non verbal- until the child is comfortable to vocalize. More studies that are recent argue that augmented self-modeling encourages children to visualize themselves speaking successfully, via audio/visual recording, building his confidence and therefore removing some of the inhibiting anxiety. A more controversial and less used therapy involves medicating with selective serotonin reuptake inhibitors (SSRIs) or monoamine oxidase inhibitors (MAOIs) to reduce the anxiety and encourage speech. While all therapies show success, there are varying levels of improvement and side effects. Literature agrees that CBT is the preferred treatment for moderate and early-detected cases of SM.

The American Speech-Language and Hearing Association (ASHA) suggests cognitive behavioral therapies like shaping and stimulus fading because it allows children with SM to grow confident with various audiences and allows them to become familiar with the sound of their own voice in those settings (2014, www.asha.com). According to Cohen, CBT helps people realign their thinking by make situations once perceived as terrifying now seem less threatening. When the child retrains the mind to transmit those messages back to the amygdala, the panic levels lower significantly (2011, p. 29). "Conceptualizing selective mutism as an anxiety disorder implies that there is an adverse physiological arousal of the autoimmune nervous system [anxiety] in response to certain stimuli" (Shriver, Segool, Gortmaker, 2011, p. 390). Therefore, operant elements of shaping and stimulus fading prove to be effective behavior interventions for promoting speech. Depending on the child, a combination of uses may be necessary.

Deciding which behavior therapy is best for individual cases requires data from observations and interviews taking place in clinical and familiar settings. Observation in the key to creating the proper therapy treatment plan (Shriver, Segool, Gortmaker, 2011, p. 391). Keeping a log book about collections of data from both parents and school staff in a variety of settings is recommended to guide assessments and determine how to apply therapy- what stimulus to use, what reinforcement schedule, etc (Shriver, Segool, Gortmaker, 2011, p. 392). According to ASHA, observational data also needs to include data about expressive language ability, language comprehension, and verbal and non-verbal communication. In many cases, this might involve the parent bringing in video footage from the child in his home environment. In the event that a language problem does exist, then it is necessary to determine and focus on problems that are making the mute behavior worse (2014, www.asha.org).

When considering the data from observations, it is important to identify where the child is when he is and isn't silent, what activity he is engaged in, and whom he is interacting with and how he chooses to communicate, including non verbal cues (Shriver Segool, and Gortmaker, 2011, p. 395). Once the data collected is substantial, it is easier to establish opportunities for the child to communicate and apply those behavioral therapies.

Augmented self-modeling is another common therapy. "Self modeling has been portrayed in the literature as a particularly potent intervention for treating children with and young adults with selective mutism...It is the least restrictive and lest intrusive" (Kehle, Bray, Bryer, 2012, p. 99). During this type of intervention, the child is recorded producing the proper tone and volume of speech, behavior that is encouraged with a reward. After viewing the correct behavior repeatedly, children learn from their own behavior the that they can successfully communicate, easing the anxiety that causes the silence (Kehle, Bray, Bryer, 2012, p. 101). In moderate cases self-modeling produces success; however, in more sever cases medication may be necessary.

According to Cohen, research suggests that anxiety associated with SM is caused by an imbalance of neurotransmitters in the brain's amygdala, affecting how we perceive a given situation as being particularly threatening (2011, p. 28). In order for cognitive behavior therapy to work, children may first need a SSRI like fluoxetine to ease the anxiety and allow for speaking. In Cohen's research, the speech success occurred within 4 weeks of medication with children speaking in front of the class at average levels (2011, p.29). At the same time, research suggests against using medication as there are adverse side effects often associated and learned behavior may require continued use of the medication (Kehle, Bray, Bryer, 2012, p. 98).

Summary and Conclusion

Considering the literature reviewed about Selective Mutism, it remains clear that this is still a rather new disorder with continuing research. All material suggest the same basic criteria: the child doesn't speak in some situations, usually school or some place where they are expected to talk, and they do speak in other places, usually the comfort of their own home. Children with SM remain silent in those situations for more than a month and they are otherwise proficient with their spoken language. While I was hoping to find a better correlation between SM and learning disabilities, it seems that the research in inconclusive. Most children with SM are developmentally average; however, assessments are not always accurate because of the challenges of getting the child to speak.

My inquiry questions about treatments were thoroughly answered. While behavior therapy such as stimulus fading and shaping were common, self-modeling and medication are also used. I'd agree that more research is needed about medicating. I have reservations that the medication might serve as more of an immediate fix with fast results, but long term behavior changes are less conclusive. The research has led me to question what happens when the treatments stop. Do children gradually return to the original behavior? Can something trigger a relapse? What happens if the child has to change schools after showing extended improvement?

My inquiry about causes led to new discoveries within my personal experiences with SM. In our situation, the topic of cause never came up for deep investigation. The literature shows that parents have modeled the behavior, suggests that SM stems from social anxiety, and that anxiety can be genetic. I was startled a bit by that research as I became more aware of my own anxiety, as well as my husband's and the possible ways our child internalized that behavior.

I still have questions about SM and the impact on adult life and changes in therapy. Literature seems to suggest it's a new but growing area of study. I hope to learn more in the future.

References

American Speech-Language-Hearing Association, (2014). Selective Mutism. Retrieved from www.asha.org/public/speech/disorders/selectivemutism/#3

Cohen, M. (2011). VITAL SIGNS. Discover, 32(3)28-29.

Crundwell, R.A. (2006). Identifying & Teaching Children with Selective Mutism. Teaching Exceptional Children 38(3), 48-54.

Cumba, Raqauel (2014, March 19). Research Update: What Do We Actually Know? [power point slides]. Retrieved from www.childmind.org/en/posts/articles/2014-3-24-research-update-what-do-we-know.video.

Dummit, E.S. (2013). Selective Mutism: Common Myths. Retrieved from www.selectivemutismfoundation.org/myths.html

Edison,S.C., Evans, M., McHolm, A.E., Cunningham, C.E., Nowawski, M.E., Boyle, M., & Schmidt, L.A. (2001). An Investigation of Control Among Parents of Selectively Mute, Anxious, and Non-anxious Children. Child Psychiatry and human Development, 42(3), 270-290.

Gross, S.A. (2014). Selective Mutism and Communication Anxiety in Children. Retrieved from http://speech-language-pathology-audiology.advanceweb.com/Editorial/Content.

Hultquist, A.M. (1995). Selective Mutism: Causes and Interventions. Journal of Emotional and Behavioral Disorders 3(2),100-107.

Kehle, T.J., Bray, M.A., Bryer-Alcorace, G. F., Theodore, L.A., & Kovac, L.M. (2012). Augmented Self-Modeling as an Inervention for Selective Mutism. Psychology In Schools, 49(1), 93-103.

Perednik, R., & Shaughnessy, M. F. (2012). An Interview with Ruth Perednik: Treating Selective Mutism. North American Journal OF Psychology, 14(2), 365-370.

Shriver, M.D., Segool, N. & Gortmaker, V. (2011). Behavior Observations linking Assessment to Treatment for Selective Mutsim Edcation of Children (West Virginia University Press). 34(3), 389-410.

Selective Mutism: Literature Review	12

Title of Paper

Ryan Carruthers

2014-05-06

Blank