Selective Mutism: SLP Guide to Evaluation & Treatment

Introduction

• Presenter's Background: Brenda Ray, a speech-language pathologist and co-director of the Selective Mutism Program at Seattle Children's Hospital, is set to discuss selective mutism for SLPs.

• Purpose of the Talk: This presentation aims to provide information about selective mutism, basic techniques, and tips for dealing with children who may have this condition during evaluations.

What is Selective Mutism?

Definition and Characteristics

• Selective mutism is an anxiety disorder.

• The main characteristic is that children are unable to speak in at least one situation but can speak in others. For example, they may talk at home but not at school or in public.

• It affects about 1% of elementary school kids and 0.7% of the population, though it may be underdiagnosed or misdiagnosed.

• It often first appears when kids start school, around 3 or 4 years old.

Associated Factors

• 30 - 40% of kids with selective mutism have comorbid speech or language delays.

• It's more common in bilingual or multilingual children, premature children, and girls.

• One or both parents and extended family often have a history of anxiety.

• Kids with selective mutism may have increased sensory sensitivities, be picky eaters, and anecdotally, many are academically gifted.

DSM-5 Criteria for Selective Mutism

• Consistent failure to speak in social situations where speaking is expected, often school, while speaking in other situations.

• Interference with social, occupational, or academic achievement.

• The condition must last for at least a month.

• The failure to speak is not due to a lack of language understanding or knowledge.

• It cannot be better explained by another disorder, such as autism or stuttering.

Common Characteristics of Kids with Selective Mutism

• Extreme shyness.

• Lack of eye contact and social engagement.

• High risk of temper tantrums and acting out when uncomfortable.

• Long response latency when asked questions.

• Younger kids may hide behind parents or stare blankly.

• Some kids may get silly or goofy as an avoidance technique.

• Rubbing eyes is also a common behavior related to anxiety.

• Non-verbal communication can be strong, and social interactions may improve as they get comfortable.

Causes of Selective Mutism

• There is no single known cause.

• It involves a genetic component, an environmental component, and a developmental component.

• Family history of anxiety is common.

• Kids often have an inhibited temperament.

• Environmental factors like being an immigrant, bilingual, or in a stressful environment can contribute.

• Overly enabling families can also play a role.

• Developmental delays, motor delays, and elimination disorders can co-occur.

Debunking Myths about Selective Mutism

• It is not just shyness. Shy kids usually warm up quickly, while kids with selective mutism have a more persistent issue.

• Kids with selective mutism are not being stubborn. They are terrified of speaking in new situations.

• It is not due to poor parenting.

• Kids are not likely to outgrow it on their own without intervention.

• It is not caused by trauma.

General Tips for Dealing with Selective Mutism

• The goal is to make the child comfortable, not force them to speak.

• Avoid direct eye contact initially to reduce pressure.

• Allow enough time for a response (at least 5 seconds).

• Acknowledge when the child speaks without overreacting.

Techniques: Cognitive Behavioral Therapy Approach

The PRIDE Acronym

• Praise: Be specific in praising behaviors.

• Reflection: Repeat what the child says.

• Imitation: Follow the child's lead in activities.

• Description: Label and describe the child's and your own behaviors.

• Excitement: Make the activity fun.

Child-Directed Interaction (CDI)

• Use PRIDE skills.

• Engage in the child's activity without expecting them to speak.

• This is the warm-up period.

Verbal-Directed Interaction (VDI)

• Start pulling for a verbal response.

• Use forced-choice questions initially.

• Move between CDI and VDI as needed.

Shaping Communication

• Start wherever the child is at and gradually increase the level of communication.

• Use techniques like imitation, oral motor exercises, and sound blending.

Fade-In and Fade-Out Technique

• Have the child and parent play in a room while you observe or step out.

• Gradually fade in and engage in the activity.

• Transfer control from the parent to the therapist.

Rewards and Reinforcement

• Reward the child for speaking.

• Use a combination of verbal, social, and tangible reinforcement.

• Rewards should be consistent, immediate, and reduced over time.

Evaluation Considerations

• Ask about the child's typical behavior, speaking at home, and any video evidence.

• Inquire about eating, bathroom use, and other areas of anxiety.

• Consider family history of anxiety.

• Receptive language is often intact.

• Articulation and expressive language may be affected by anxiety.

• Add a selective mutism questionnaire to the evaluation.

Selective Mutism Questionnaire

• A tool for parents to rate their child's speaking in different environments.

• It has sections for school, home, and public situations.

• The questionnaire helps inform the clinical diagnosis but does not diagnose selective mutism alone.

Scoring and Interpretation

• Calculate the average score for each section and the total score.

• Compare the scores to norms for kids with and without selective mutism.

• Use the scores to inform the clinical judgment.

What to Do After the Evaluation

• If the evaluation is incomplete, schedule a return to clinic.

• If the diagnosis is clear, recommend therapy through community or school-based interventions.

• Include accommodations, strategies, and resources in the report.

• Consider referring the family to psychiatry or psychology for additional recommendations.

Additional Information

• Handouts and training websites are available for families.

• The new epic report template has more information on selective mutism.