Introduction
Welcome and Introduction to the Presenter
Hi everybody and welcome! My name is Mika IOC, and I'm a member of the public education committee for the Anxiety and Depression Association of America (ADAA). Today, we're hosting a webinar on selective mutism, from diagnosis to treatment. Our presenter is Dr. Rachel Botsman.
About the Anxiety and Depression Association of America
The ADAA is the leading nonprofit organization in the field of anxiety and depression. Our mission is to improve diagnosis and promote the prevention, treatment, and care of anxiety, depression, and stress-related disorders through education (like this webinar), practice, and research. We work to end stigma and spread the word that these conditions are real, serious, and treatable.
I encourage you to visit the ADAA website at adaa.org. It's a great resource with a list of treatment providers (just click on "Find a Therapist" from the homepage). We also have a free peer-to-peer online support group, and you can support the ADAA by making a charitable donation on the website.
About Dr. Rachel Botsman
Dr. Rachel Botsman is the senior director of the Anxiety Disorder Center and director of the Selective Mutism Service at the Child Mind Institute. She leads a team of clinicians providing evaluation and innovative treatment to children with selective mutism. Dr. Botsman is president of the Selective Mutism Association, the nation's largest network of professionals, families, and individuals with selective mutism.
She has extensive experience providing cognitive behavioral therapy to children, teenagers, and young adults struggling with anxiety disorders and school difficulties. She also has specific interests and expertise in the evaluation and treatment of obsessive-compulsive disorder, separation anxiety disorder, social anxiety disorder, and specific phobias.
Dr. Botsman has worked with children in both inpatient and outpatient settings at a major academic medical center, where she directed a multidisciplinary team. She has taught and supervised psychiatry residents and child psychiatry fellows and lectured extensively on a variety of topics, including the evidence-based assessment and treatment of anxiety disorders in children and teens.
Fear and the Fear Response
Normal Fear Response
Fear is something we all experience, and it manifests in different ways in different people. When facing a threat or fear, our bodies and brains react quickly. This is normal and adaptive. We go into fight or flight mode, where we either flee a situation or fight it. Sometimes, people freeze.
For example, when a deer jumps in front of your car while driving, your heart races, you feel queasy, and you think a lot of things at once. You react quickly by slamming on the brakes to avoid hitting the deer. After the threat passes, your body resets, and your breathing returns to normal.
Anxiety in Children
When we talk about kids with anxiety, we often refer to those with an overactive "smoke detector" or "fire alarm." They may perceive threat or danger where there isn't any, or their response is an extreme version of what's typically expected.
To determine if anxiety is a problem, we consider three things: frequency (how many symptoms a child has), duration (how long the child has been having these symptoms), and impairment (how much the anxiety interferes with the child's ability to function as a student, friend, or family member). For selective mutism, the duration is at least a month of symptoms.
What is Selective Mutism?
Definition
Selective mutism (SM) is an anxiety disorder. It occurs when a child is unable to verbalize in specific social situations where speaking is expected, despite being able to speak just fine at home.
For example, a child may be a chatterbox at home but completely silent at school, on a playdate, or in an activity. There's a discrepancy between how the child speaks in different situations. This often happens in places like school, music class, ballet, playdates, or with family members the child doesn't see often.
Diagnostic Criteria and Variations
The impairment caused by SM is not just occasional; it's a significant part of the child's state of being. It's not exclusive to the first month of school. Some kids may take a little time to warm up in a new environment, but those with SM often haven't been speaking for many months or longer at school.
There are also unique variations from child to child. Some kids may speak to their parents in all places, while others stop talking to them before entering the school. Some kids have more rigid boundaries, and some have less rigid boundaries.
Myths about Selective Mutism
Myth 1: It's the Same as Shyness
Selective mutism is not the same as shyness. Shyness is more of a temperament or trait where a child may observe a situation before slowly warming up. In contrast, SM is an anxiety disorder specifically related to speaking in certain social situations.
Myth 2: It's Willful
SM was previously called elective mutism, which gave the impression that the child was being willful or choosing not to speak. However, this is not the case. The child's anxiety is getting in the way of speaking, not a conscious decision.
Myth 3: It's Caused by Trauma
While kids can experience traumatic events and develop post-traumatic stress disorder (PTSD), SM is not directly caused by trauma. Children with SM are not speaking across situations, not just about things related to a trauma.
Myth 4: It Will Be Outgrown
Unfortunately, many pediatricians and primary care doctors may tell parents that their child will outgrow SM. However, anxiety disorders are not outgrown. In fact, the longer a child doesn't speak at school, the worse the situation can become. While some people may seem to outgrow it, the risks of not evaluating and treating SM far outweigh the benefits of waiting.
Myth 5: It's the Same as Social Phobia
There is a high rate of overlap between SM and social anxiety disorder, but they are not the same. SM is specifically related to speaking, while social anxiety disorder is the fear of embarrassment, judgment, or negative evaluation in various social situations, which may or may not involve speaking.
Myth 6: It's Related to Autism or Learning Disorders
While children with SM may not talk to their peers, make eye contact, or seem disengaged, which can be similar to autism, they are very different disorders. Children with SM are often quite engaged and interested in others when they are comfortable.
Similarly, it's hard to evaluate a child for learning or language disorders when they're not speaking. However, the vast majority of kids with SM do not have learning disorders.
What Causes Selective Mutism?
Nature and Nurture
Selective mutism is a product of both nature and nurture. Genetics and family history play a role in predisposing a child to anxiety disorders. However, the environment and interactions with the child also have a significant impact.
Negative Reinforcement
The environment can inadvertently reinforce a child's non-speaking behavior. For example, when a child is prompted to speak and doesn't respond, the person asking the question or a parent may jump in and answer for them or make light of the situation. This makes it more likely that the child will not speak in the future.
Similarly, if a child nods or shakes their head in response to a question, and the person accepts that as an answer, it reinforces the non-verbal behavior instead of the verbal one.
Prevalence and Outcomes
Prevalence
Selective mutism is not unique to the United States. It affects about 0.3 to 2% of children, with a higher rate diagnosed in females. The age of onset is around 3 or when a child enters school or daycare, but the average age of diagnosis is 6, indicating a gap in when it's noticed and when treatment is sought.
Outcomes
SM does not tend to remit on its own and is associated with negative short and long-term outcomes. These can include school problems, difficulty making friends, and problems with substance use later in life.
Treatment for Selective Mutism
Cognitive Behavioral Therapy (CBT)
The literature shows that CBT is an effective treatment for kids with anxiety disorders, including SM. CBT focuses on the relationship between thoughts, feelings, and behaviors. It's a directive and specific treatment for the disorder.
For SM, there have been fewer studies, but those that exist support a behavioral intervention. Some studies have looked at parent-child interaction therapy (PCIT) adapted for SM, which shows positive results.
Comprehensive Diagnostic Evaluation
Before starting treatment, it's important to have a comprehensive diagnostic evaluation. This involves the mental health professional spending a significant amount of time with the parents and child to assess the problem. It's difficult to evaluate a child who isn't speaking, so an observation of the child and parent is often part of the evaluation process.
Goals of Treatment
The goals of treatment for SM are to increase the number of people, places, and activities where the child speaks, both responsively (answering questions) and spontaneously (talking on their own). Treatment also focuses on building distress tolerance, which means helping the child and parent cope with situations that cause anxiety.
Parent-Child Interaction Therapy (PCIT)
Our treatment for SM involves an adapted version of PCIT. PCIT is a treatment that heavily involves the parent. We coach parents in the use of specific skills to help their child speak more.
PCIT consists of two sets of skills: child-directed interaction (CDI) and verbalization-directed interaction (VDI). CDI skills are used when the child is not yet ready to be prompted to talk, while VDI skills are used to purposefully ask questions and prompt the child to speak.
Child-Directed Interaction (CDI) Skills
PRIDE Skills
CDI skills are based on the PRIDE acronym:
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Praise: Use labeled praise to specifically tell the child what they did well. For example, "Great job getting your coat and shoes on."
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Reflection: Repeat what the child has said as a statement in a regular tone of voice. For example, if the child says, "I like pink," you say, "You like pink."
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Imitation: Show your enjoyment and investment in the child's activity by imitating what they do. For example, "That looks like a lot of fun. I think I'm gonna do that too."
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Description: Narrate what the child is doing. For example, "I see you're unpacking the bag of stuff that we brought."
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Enthusiasm: Use a positive and enthusiastic tone of voice to show your interest in the child.
Don't Skills
During CDI, avoid asking questions, criticizing, being sarcastic, mind-reading, and submitting to non-verbal responses. For example, instead of saying, "Oh, you're drawing a turkey," when the child is tracing their hand, say, "I see you putting your hand down on the paper and now it looks like you're drawing the outline of your hand."
Verbalization-Directed Interaction (VDI) Skills
Types of Prompts
VDI involves the planned and intentional use of prompts. There are four types of prompts: yes/no questions, forced choice questions, open-ended questions, and direct commands.
Yes/no questions should be avoided as much as possible, as they often result in non-verbal responses. Forced choice questions, such as "Do you like chocolate, vanilla, or something else?" are more effective in getting a verbal response. Open-ended questions, like "What's your favorite flavor?" can also be used, but they may be more difficult for some children.
Direct commands can be used to request a non-verbal behavior, such as "Go ahead and point to the one you want." However, they should not be used as a substitute for asking questions.
What to Do with Different Responses
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Verbal Response: Praise or reflect the child's response. For example, if the child says, "Stuffing," in response to the question, "Is your favorite food for Thanksgiving turkey, stuffing, or something else?" you say, "Stuffing. Thanks for telling me."
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Non-Verbal Response: Describe the non-verbal behavior and then rephrase the question. For example, if the child shrugs their shoulders in response to the question, "Do you like turkey, stuffing, or something else?" you say, "I see you shrugging. Maybe it's hard to choose. Do you like turkey, stuffing, or you're not sure?"
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No Response: Wait five seconds and then either rephrase the question or go back to CDI. For example, if the child doesn't respond to the question, "Do you like turkey, stuffing, or something else?" you say, "Well, we'll come back to that later. Let's keep drawing our turkeys."
Fade-In Process
The fade-in process is used to transfer speech from one person to another. For example, if the child talks to the parent at home, the parent can gradually introduce a new person, such as a neighbor, into the conversation. The parent continues to use CDI and VDI skills while the new person gradually gets closer and more involved in the conversation.
The fade-in process can be done in different ways, such as having the new person make comments, ask questions, or use CDI skills. The key is to make the new person more interesting and engaging to the child.
Targeted Practice and Exposures
Targeted practice and exposures are an important part of treatment for SM. This involves creating planned and intentional situations to practice talking or bravery. Exposures can be done just about anywhere, such as school, family gatherings, stores, coffee shops, and birthday parties.
The key is to approach the situation with a goal and to know where the child is at. For example, if the child rarely talks outside the home, start by going to places that are not super crowded and prompt them to engage with you. As the child becomes more comfortable, gradually increase the difficulty of the exposures.
Working with Schools and Other People
Consultation with schools and other people is often necessary to help the child with SM. This can involve doing a training like this for teachers and staff, coaching them on how to use the skills, and providing support and resources.
It's also important to tell other people what they can do to help, such as praising the child for any positive behavior, describing what the child is doing, and being engaged and interested in the child.
Conclusion
Selective mutism is a complex anxiety disorder that requires a comprehensive approach to treatment. By understanding the diagnosis, myths, and treatment options, parents, teachers, and other caregivers can help children with SM overcome their anxiety and start speaking in social situations.
If you have any questions or need more information, please visit the ADAA website at adaa.org, the Selective Mutism Association website at selectivemutism.org, the Child Mind Institute website, or the Parent-Child Interaction Therapy International website.
Thank you for watching our webinar!