As it turns out, my first experience with Selective Mutism (SM) was my first day on the job during my Clinical Fellowship Year in a private school for children with severe communication difficulties. To many bystanders, it seemed logical for the Speech-Language Pathologist to treat children with this diagnosis because, well, SLPs help people who have trouble speaking, right?
This presented a conundrum for me. By definition, children with SM, consistently fail to speak in one or more social situations, which begged the question:
“If this child can speak in some social situations (i.e. with his parents at home), then I’m not treating an inability to speak…What is my role here?”
Questions like this circled my mind as I embarked on a journey to learn more about this complex disorder.
What I later realized was that my way of thinking about the problem was through the lens of physical speech output rather than within the broader scope of communication. My job was not to help this child learn how to phonate, articulate and make sentences, as I was so used to doing as a grad student. My job was to help this child face the pragmatic challenges of communication. To help him communicate in small, incremental steps in an increasing number settings with a greater amount of communication partners.
The specifics of my role became more clear as I more closely examined how SM is defined. According to the 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition:
- SM is characterized by an ongoing failure to speak in specific social situations despite speaking in other situations.
- Not speaking interferes with educational, occupational or social communication functions.
- These difficulties occur for a minimum of one month (not including the first month of school).
- Failure to speak is not related to a lack of knowledge or comfort with the spoken language being used in the social situation.
- SM is not due to a communication disorder, autism spectrum disorder, schizophrenia or another psychotic disorder
Essentially, SM is a specific anxiety disorder in which children are unable to speak in select social situations due to a fear of social embarrassment and excessive shyness. It is relatively rare as it affects approximately 1% of elementary school students.
As SLPs, it’s important to remember that this disorder is not the result of an inability to speak or understand language. Although, according to Dr. Aimee Kotrba, clinical psychologist and well-known expert in this area, 35-75% of children with this diagnosis also present with a language impairment and 30% are bilingual, neither are the cause SM as it is an anxiety disorder. Rather, SM may develop in these children because some recognize they are having difficulty being clear and become mute to protect themselves. Dr. Kotrba also emphasizes the importance of recognizing that SM is a form of deliberate self-protection and not oppositionality.
So, what is our role as SLPs?
According to ASHA, SLPs should play a role in the diagnosis and treatment of SM as part of a team including the child’s pediatrician and psychologist or psychiatrist.
Diagnosis
Again, when it comes to diagnosis, a comprehensive team approach is critical. It is recommended that the SLP’s evaluation consist of an educational history, hearing screening, oral-motor examination, parent/caregiver interview, and evaluation of speech and language skills.
How do we assess speech and language skills in a child that does not speak? ASHA suggests recruiting parents. Ask them to engage in structured storytelling or general verbal discourse on video. You also may be able to obtain useful information by engaging in pretend play. Receptive language may be easier to gauge as responses can often be obtained through pointing and multiple choice questioning.
Treatment
The approach to treatment tends to be largely behavioral in nature, which is why collaboration with a psychologist is extremely important. The three primary behavioral interventions found to be effective in assisting children with SM are:
Stimulus Fading: This technique can be used to gradually ease students into new settings or to introduce more communication partners. Using the latter as an example, if a student is comfortable speaking with the SLP in an office setting, they begin speaking with the door open. Once the student becomes comfortable speaking with the door open, a teacher casually pretends to take care of something by the doorway. Small steps are taken over time to increase the student’s comfort level with the teacher entering the room, remaining in the room, engaging in conversation and, ultimately, having a 1:1 conversation with the child.
Shaping: This strategy is typically employed when a child does not speak in any school setting or with any communication partner. This entails reinforcing all communication attempts from the child and gradually taking small steps (i.e. blowing, whispering, sound production) geared towards verbal communication, utilizing a significant amount of positive reinforcement.
Self-Modeling: This involves video taping the child speaking effectively (e.g. with family members at home) to increase self-confidence and generalize this desired behavior into other settings.
If there are speech and language difficulties present, Dr. Kotrba recommends first focusing on positively reinforcing any speech production and gradually working on these skills. She also suggests coordinating a home program to more effectively address these skills. I gained a great deal of valuable information from her on-line CEU course on this topic.
If you are working with a child who has SM, I highly recommend utilizing this free online library compiled by the Selective Mutism Group. This library includes printable articles, materials and handouts organized into a variety of pertinent topics.
For further information, I also recommend visiting ASHA (naturally!) and the Selective Mutism Foundation.
I hope this has helped shed some light on our role in this challenging and complex anxiety disorder. Have you ever played a role in helping a child with SM? If so, I’d be so interested to hear about it.
28 Comments
Great post Claudia. I am so glad you pointed out ASHA’s position on the SLP’s role with children with selective mutism. I so agree that we have to look at these children through the lens of their communication and social skills, not just their speech output!
Thanks for your feedback, Donna! Yes, I think children with this diagnosis help remind us of how broad our scope of practice is since communication is so incredibly multifaceted. I appreciate you sharing your thoughts!
Great and very informative blog post. Thank you! I have an 8 y/o girl on my caseload with SM. In addition to using any form of communication to participate in an exchange (nonverbally or verbally), I have also emphasized self-help and self-advocacy with her in a goal, e.g., requesting needed items. I find it is important to ask classroom teachers if these students ask for needed materials on their own as well as if they ask to use the bathroom- going back to those basic wants and needs. I also had the student do a writing assignment a few weeks ago where I had her complete a graphic organizer about different feelings and times she feels those feelings. Discussing topics of interest is great, too. Gotta love those Shopkins! I asked my student last week if the Shopkins talked like this…? (raising my pitch as high as I could). While I know the temporary voice was not the best for my vocal folds, it actually made her laugh!! I’ve worked with her for two years and it was the second time I got her to laugh. I think being comfortable with your therapist and making therapy a positive experience is of utmost importance. Loved hearing her laugh!
Thank you so much for sharing your experience! I think the self-help and self-advocacy goals you set for her sound wonderful. I am sure that the trust and rapport you’ve developed have had a real impact on her growth. I’ll bet you will always remember the moment you made her laugh…how special.
Great insight on a topic that I unfortunately don’t know enough about! I’m wondering though, is there a preferred age of diagnosis! I work with the birth- three population, is they too young to start touching on this as a possible area of concern?
That’s an excellent question, Lauren. SM often emerges between the ages of 3-5 years when children first enter school. Commonly, school triggers the anxiety. I’ve read that it’s important not to jump to any conclusions during the first month of school because of course it’s natural that children will feel shy initially. Fortunately, the diagnostic criteria outlined in the DSM-5 helps give a point of reference. A thorough and comprehensive team-based assessment is definitely essential in cases like this. As you know from working in Birth-to-Three, early intervention is key to preventing a pattern of behavior from occurring. Thanks for your great question!
I am working with a three year old child with SM. I started with him at 18 months when he wasn’t speaking at all to anyone. He remained very quiet in sessions with his dad and myself. About the time he was 2-4 the gap had widened drastically. He was using all the things that I was teaching in session, but NEVER made sounds, words or laughing out loud. I brought up the the issue of SM and said that they would need a psychologist to co-ordinate with me. Right before he turned 3, they did and got an official diagnosis. The psychologist added specific goals and hierarchies of speaking situations and a tangible reinforcer. The progress was dramatic! He started whispering with me, then talking in a high pitched voice, then shouting. I still don’t hear his typical voice, but it is such great progress. He is beginning to speak to family outside his immediate one and to the neighbors. A fascinating journey to be sure.
Wow. This is certainly impressive progress! Thank you so much for taking the time to share your experience, Cindy.
you mention the importance of a psychologist as part of your team approach with SM, however, I also want to mention that a Board Certified Behavior Analyst (BCBA) may actually be as or more helpful to the team especially in the applied setting and application of techniques. Another tool that would be helpful would be for a BCBA to conduct a FBA (functional behavior assessment) to help determine the function of the SM. This would better help the team in coming up with a treatment plan.
These are all excellent points! I thank you for mentioning the value of having a BCBA on the team. This profession has so many skills to offer. You are absolutely right about the importance of conducting a FBA. In my research I learned that many adults throughout the child’s day “rescue” him or her from the stress of speaking (by speaking on his/her behalf). This is well-intentioned, of course, but inadvertently reinforces the pattern of behavior. A FBA helps shed light on so many critical variables like this. Thank you for your comment!
Thank you so much for this post! I have a student with SM whom I have served since first grade. He is now about to leave me for 4th grade at the Intermediate Center. I was honored and humbled at his recent IEP meeting when his mom said they were talking about going to the new school, with new teachers, and a new speech teacher. He said, “But Mom! Mrs. Andrews is the ONLY one I can REALLY talk to!!!” Granted, this means we still have plenty of work to do! But considering he wouldn’t even speak to me as a first grader, at least there’s some progress!
Thanks for the additional resources! I’m always looking for more ideas and materials to use with this student to serve him the best I can!
Thank you so much for sharing your experience! It sounds like you have made such a big difference in this child’s life. I appreciate hearing your thoughts!
Interesting article. I’m struggling with a 4.5yrold who I believe is SM rather than language disorder (probably has some language and phon diffs but not major). Definitely given me lots to think about. Thanks!
I completely agree that it is complex. I definitely recommend checking out the resources in the free online library link in this post and wish you all the best! Thank you for your comment!
I am person who suffered from Selective mutism. I did not speak ever at school . Therefore i did not attend college. I did however start to speak after i graduated from high school wich allowed me to start working at 17. I now speak plenty and dominate conversations. However nothing has changed for me i still cannot develop friendships. So is this a complex or aspergers ?
Hello Pete, Thank you so much for sharing you personal experience with selective mutism. It sounds like you have overcome many challenges and have come such a long way. While I’m unable to provide a specific answer to your question, it is always valuable to meet a specialist to provide more detail. Dr. Amy Kotrba of https://www.selectivemutismtreatment.com seems quite knowledgeable in many areas and perhaps she might be a helpful resource as you continue to push for further progress. I hope this helps and wish you the very best.
Thank you for discussing this important topic. In my 23 years as a school SLP, I have had 6 students with SM. I have found the key to opening the door to speaking at school, is to find something that motivates the student.
For example, I has a four year old student who would only speak to the mother, and only while in their home. After three months of speech therapy and attendance in a preschool with disabilities classroom, he had not spoken or even made a sound. One day, I had a balloon in my classroom that had lost the helium. As I picked it up to move it, he hit the balloon and giggled. Three minutes later, he was saying “more” to hit the balloon. After 20 minutes of laughing and playing with the balloon, we took it to the classroom. He said “more balloon” to the teacher so that he could hit the balloon. From then on, he spoke at school. He still showed extreme anxiety outside of the classroom, but he spoke in the classroom. I have since lost touch with the family, but I like to think that he continued to speak, and is now a happy teenager.
I now have a 13 year old student with SM, and it is interesting that she cannot explain why she can’t talk in class. I even made a “forced choice” survey to narrow down the possible causes, but she could not answer those either. We will continue to work together, and we have asked for a counseling evaluation. Has anyone else had experience with trying to define the cause or put words to it?
Thank you for sharing your experiences. It is so interesting that you worked with six students with this diagnosis! As you said, many things I read encourage providers to find what motivates or excites students and clearly you did with that child-how wonderful! To answer your question about the cause, it appears it is all anxiety-based. I enrolled in an online course about this topic and the presenter, Dr. Aimee Kotrba provided a lot of insight (I have a link in the post). I wish you the best of luck and thank you again for sharing!
Interesting and I’ll look at those other sites for more information. I have a 2.25 year old who was NOT vocalizing or talking at 18 months. He is now talking with his family in 1-2 word phrases and is becoming more comfortable talking with them. I have only heard him laugh and he communicates with me using a few signs. I have taken to coaching the parents with speech and language expansion and production techniques and he continues to improve. His preschool and I have yet to hear him speak. I’m not sure if this would be selective mutism. Any thoughts?
Thanks for sharing your thoughts and questions! Of course my knowledge of this case is too limited to comment specifically but it is important to remember that children with SM can usually speak normally in at least one environment (typically at home with a parent) and the onset is often when school begins as anxiety is the root cause. If this is not the case and the child isn’t speaking across all settings then it sounds like an assessment for a speech and language delay is most likely warranted. Best of luck!
I feel that incorporating OT into the picture can also help. Sometimes a little sensory input, especially the vestibular & proprioceptive can rouse a child’s system and make them more likely to verbalize! Though, some children may be too ‘paralyzed’ to participate, as well.
Thanks of this insight! I also believe each pediatric specialist has insight to offer and have certainly learned a great deal from occupational therapists over the years!
I enjoyed your article and learned a lot more about SM. I am an SLP working with middle schoolers and have a student (6th grade, bilingual ) who I think is displaying all the signs of SM except for her age. She was only made eligible for Speech Services last April, partly due to lack of communication. Do you have any suggestions for working with a student of this age.
Thank you for your kind words, Jana. Unfortunately, I do not know enough about the case to provide specific guidance. It does seem like a more complex case given the bilingual piece. I hope that some of the tips I shared in this post are helpful as you work with her. Best wishes to you!
Do you have any advice on how to approach articulation issues with adolescents who have SM and Autism. I currently have a client on my caseload, and I attempted to work on articulation in the past; however, his self regulating behaviors began to increase when I worked in artic via PROMPT. Following, I saw Dr Kotrba’s presentation, and she stated that you want to work on getting communication and then work on speech in a “naturalistic” manner. I think we are ready to work on articulation; however, I’m perplexed on how to go about it with all of the other things he has going on. Your insight would be greatly appreciated!
Hi Lauren! That is an excellent question. It’s wonderful that you’re at a point where working on articulation is an option. Of course, it isn’t possible for me to comment with specific therapy advice in this context but, generally speaking, I think treading slowly and carefully by breaking things down into very small steps with gentle cues at first would help to ensure that your student is comfortable as she is already self-conscious about speaking. I hope this helps and I wish you all the best!
I am an SLP and have an 8 year old daughter with SM. We recently completed a 4-day intensive with Dr. Kotrba at my daughter’s school, and I highly recommend this approach. Dr. Kotrba provided us with things to do prior to her visit so our daughter was well-prepared and she added almost 20 “talking buddies”, read aloud in class, led her class in games, and her confidence soared. Progress can be sooo slow and her progress that week is not typical, but having such an intensive week of practicing and many successes in a short period of time was just what she needed. Now, the school SLP and I are working together to continue helping her move forward. The SLP can be such a vital resource for the child at school.
Thank you so much for sharing your experience, Kelly. It sounds like you have done exactly what your daughter needs. It is certainly not an easy journey and your daughter’s progress is a testament to your dedication. It’s so wonderful that you were able to work with Dr. Kotrba- I was so impressed by her insights and expertise after enrolling in some of her courses. I wish you all the best moving forward. It really sounds like you’re doing such smart things!