Selective Mutism: what does this mean how does this happen?

Selective mutism affects less than 1% of the preschool/early grade children (Selective Mutism foundation website). Most of the children impacted are female.  Although it is hard to diagnose, antidotal reports suggest that the actual numbers are somewhat higher.

This is a psychiatric disorder characterized by a persistent failure to speak in select settings.  These children are usually within normal limits academically, and make their needs known by gestures, nodding their head, pointing, or remaining motionless and expressionless while waiting until someone guesses what they want. The condition is usually not obvious until the child begins school, because at home they are talking to parents, grandparents, etc.   Importantly, time not speaking is paramount in predicting the success of interventions.  By the time school starts, if life without speech has become a “way of life” many of these children find it harder and harder to speak at all outside of specific and distinct situations.

Immediate intervention is crucial. The longer the child is allowed to remain in the non-verbal mode the harder it will be to remediate.  The younger the child, the better prognosis for recovery since the time in specific settings without speech is shorter.  The impact on school and other social situations is also lessened with early interventions. Some primary research suggests that without treatment the disorder can become irreversible.

In that regard, Dr. E. Steven Summit III an advisory board member of the Selective Mutism Foundation states that he has, “…yet to hear of a case …(preschool onset and persistence past the first few months of school) where the disorder remitted spontaneously, i.e. the child “outgrew it” without treatment.”

Description of the Disorder

Selective Mutism is thought to be an anxiety disorder and published research reports much success has been achieved with the use of medications such as Prozac in combination with other behavioral therapies.  The effectiveness of the medication/therapy protocol usually takes 3-6 months to begin to take effect.  The success rate in young children (preschool/kindergarten through first grade) is reported to be as high as 80-90%.  This rate of remission steadily and considerably decreases, as remediation is delayed.

It is important to note that this is not a language disorder, as children can speak fluently and coherently when they are comfortable and in what they perceive to be anxiety-free situations.  Speech disorders are not limited to specific situations (as Selective Mutism is) and are observed globally as the child communicates.

According to the DSM-IV (Diagnostic and Statistical Manual of
 Mental Disorders— DSM) the definition of Selective Mutism is: "the persistent failure to speak in specific social situations, (e.g. school, with playmates) where speaking is expected, despite speaking in other situations."

Secondary characteristics may include: excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, excessive crying, compulsive traits, temper tantrums or other controlling or oppositional behaviors (these may be more prevalent at home or in school/social situations).

Occupational Therapy Treatment Protocol

It is also highly recommended that the treatment protocol be inclusive of families, psychologists, teachers, and related social and behavioral interventions. Progress is usually slow and incremental; patience and understanding are needed for children to overcome this disorder.

Occupational Therapy is valuable here to provide the child with multiple sensory-motor experiences that will increase their self-esteem as well as increase their ability to create expanding realms of confidence and competence.  Such therapy should incorporate play-based situations where the child can lead and increase achievement levels within task demand situations.  Specifically, having the child make and then “speak through” a hand puppet and/or other projective experiences can help with verbalizations.

It is essential to address this condition early as it can interfere with academic, social and/or occupational successes.  Therapy should utilize puzzles, board games, sign language, rhymes, music/songs, within both fine and gross motor activities that can facilitate spontaneous responses. Slowly introducing eye contact and alternating between whispers and “funny voices” can allow the child to interact in and at the same time feel emotionally safe.

Other techniques that can be incorporated into an occupational therapy treatment session are:

1. Teach the child to sub-vocalize and talk themselves through a sequential task
2. Acknowledge the anxiety (sadness and/or anger) and help the child deal with it*—do not deny it  (*you cannot kid a kid!)
3. Increase physical activities
4. Increase creative experiences (arts and crafts, music etc.)
5. Increase positive self-talk (one idea is to make a “Positive Tree” and put leaves on the tree each time a skill is achieved)
6. Help the child anticipate situations that may be stressful and to role play them in advance
7. Promote the decrease of “startle” (Moro) reflexive responses and other neuro-sensory-motor responses that persist beyond their developmental age criteria.

Research by Sally Goddard, Director of the Institute of Neuro-Physiological Psychology (author “Reflexes, Learning and Behavior”, Fern Ridge Press, 2005) relates Selective Mutism to primitive neuro-reflexes that should have developmentally self-extinguished but have not.  She provides what she calls a “roadmap” of the brain and relates “the inability to speak” to a retained fear paralysis reflex. This is an early reflex that exists in utero. It is eventually transformed into the Moro reflex, but never fully disappears. When we are faced with a sudden shocking situation we may freeze… totally unable to move. (I refer to it as the "frightened deer" reaction. When you come across deer they won’t just run away, they stand there, completely still. It’s not that they are brave … they can’t move. It’s a protective mechanism, because an immobile target is harder to see for a predator.) Also included here in addition to the Moro Reflex, is a sustained symmetrical tonic neck reflex that can posturally place a child so close to the desk (or other writing surface) that no other stimuli can be acknowledged and thus all stimuli becomes “unexpected” eliciting a startle response.

This research has primary implications for treatment within occupational therapy.  By facilitating the child to move and react we are increasing her ability to “defrost” from what Goddard refers to as frozen neuro-developmentally delayed responses.  She goes on to explain that these children cannot speak because they are in constant overload from ferreting out stimuli that other children readily ignore  (i.e., unexpected sounds, movements or situations).

Conclusions

The OTR, by careful application of activity can help these children whose physiological and psychological systems are impeding them from fully participating in the process of growing up. Occupational Therapy teaches the “art” of living, and verbal expression is an essential element of that art.