Running head: Treatment Interventions for Selective Mutsim 1

Treatment Interventions for Selective Mutism

Evioghene I. Aki
Georgia State University












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Abstract
Selective mutism (SM) is a psychological disorder where children are talkative and
converse normally at home with their family, but when placed in social situations like
school or with their peers they become mute. SM has a low prevalence rate, but the
current literature has been effective in researching and providing intervention treatments
for those with SM. The current paper aims to address those interventions; specifically
behavioral based interventions and medical interventions (the use of SSRIs). How
effective these treatments are, including the strength and weaknesses of the interventions
will be addressed. The limitations and future research of interventions are also assessed in
the paper. It is important to discuss the research and findings so that future implications
for treatments can be more readily available to the subset diagnosed with SM.
Determining how effective these treatments are can help with the diagnosis of SM, and
catch it at an earlier onset.










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Introduction
Selective mutism (SM) is a childhood disorder where children speak in some
situations, but do not speak in others. Specifically, this disorder takes place in a child who
may speak normally at home; but when they get into situations outside of the home
(school/social environments) they become mute and do not speak at all (Giddan, Ross,
Sechler, & Becker, 1996; Bergman , Gonzalez, Piacentini, & Keller 2013). This disorder
is often comorbid with social phobia, but can be more severe because the child cannot
communicate at all in social situations.
Lang, Regester, Mulloy, Rispoli, & Botout, (2011) reported that the prevalence
rate for SM in children is typically less than 1% of the population. The disorder is
typically diagnosed around the ages from 4 to 6 years old. This is the time were children
begin school (preschool and kindergarten) coincidentally making it easy to observe if the
child suffers from SM or not. Often times it is difficult for parents to assess whether or
not their children suffer from SM because at home the child may be talkative, but in other
environments where the parents are not around the child; there is little to no
communication being held. SM is also often confused with shyness or a developmental
delay (Schwartz & Shipon-Blum, 2005); contributing to another reason why SM may not
be as readily diagnosed. The diagnosis typically becomes evident when the child enters
school and communication is forced and necessary.
SM historically has been a diagnosis that has not been as researched as other
psychological disorders; typically because of its lack of prevalence in the population.
Because of the lack of research in comparison to other disorders; there are not as many of
a wide range of interventions researched to treat selective mutism in children. Typically,
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the researched interventions have been consistent with behavior therapy. Specifically for
selective mutism, school based interventions have been researched and found to be the
most effective. It has also been determined that treatment of SM with SSRIs have found
to be effective in children who have been undergoing treatment consistent with behavior
therapy and also those who were not under any behavior interventions.

Interventions
A study by Manassis & Tannock, (2008) compared different interventions for
selective mutism in a pilot study. They utilized 17 children with a mean age of 7.83 who
had been previously diagnosed with selective mutism in a previous study along with their
mothers. The original study consisted of 20 children, but only 17 agreed to enter into the
current study. The17 that agreed were originally part of a cognitive and linguistic
abilities in SM study in a childrens hospital. All the children initially assessed had not
spoken while at school for at least one full year. In addition to meeting the criteria for
SM, all of the children expect one were also diagnosed with social phobia through the
Anxiety Disorders Interview Schedule (parental interview).
At follow up the treatment received by the children were determined. To measure
the outcomes of the treatment parent-report questionnaires; the Selective Mutism
Questionnaire (SMQ) and the Clinical Global Improvement Rating (CGI), were
administered by a clinical psychiatrist who was blind to the treatment status. The
Childrens Global Assessment Scale was also completed by the psychiatrist and was
based on the interview and clinical notes of the child. Treatment of SM was left up to the
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parent to decide, and members of the research team assigned no children any specific
treatment.
The results of the study determined that improvement was evident in children
with SM after 6 to 8 months of treatment, but the majority of the children still met the
criteria for the diagnosis of SM. One of the intervention treatments that some of the
parents decided to give their children after being offered it at the time of the assessment
were the SSRIs fluoxentine and sertraline; (8 received fluoxentine and 2 received
sertraline). It was determined by the clinicians that children who were medically treated
with the SSRIs had higher functional gains than the children who were not treated with
medication (Manassis et al., 2008). The mothers of the children also reported that the
level of mutism outside of the home significantly decreased. The study also showed a
significant improvement in the children with SM who did not partake in medication
treatment, but just behavior intervention.
This study was especially important because instead of just showing that SM
responds well to behavior based intervention; it showed that SM responded to SSRIs. Not
much research in the current literature is supportive of treating SM with medication, as
there is a large amount of research to support behavior therapy. This study successfully
compared the treatment of SM with SSRIs and behavior therapy, and showed that not
only are the two effective individually, but they both can be effective when used together.
Carlson, Mitchell, & Segool, (2008) state that some treatments that are effective in
reducing social anxiety also work with those diagnosed with SM, specifically
pharmacological agents. Since social phobia is often comorbid with selective mutism; it
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is hypothesized that this is the reason why SSRIs have been effective on the treatment of
selective mutism.
As previously stated most of the current research in the literature is in support of
behavior therapy for the treatment of SM. Treatment of SM has proven to be challenging
at times for several reasons. First, children often do not speak to their therapist in the first
initial sessions because of course they are suffering from the inability of speaking to
someone other than their parents or people they are comfortable with in their homes.
Secondly, with such an early diagnosis of mutism, typically around the age of 4, many
children are not at the cognitive age to understand cognitive behavioral treatment (CBT)
therefore rendering it useless. CBT has generally had to be modified to adapt to children
at that age so the treatment can be effective. Bergman et al., 2013 developed a study
where they determined the efficacy of an Integrated Behavior Therapy for selective
mutism. In their behavioral treatment there were 20 1-hour sessions that were held over a
24-week period. The intervention consisted of graduated exposure to a feared situation
(in the case of SM: verbal communication in a social situation). The behavior therapy
also assigned behavioral practices to be done outside of treatment; especially at the
schools were talking for the children was a necessity. To ensure that this was done, the
study recruited the childrens parents and teachers to be actively involved in the
treatment. Similarly, Lang et al., (2011) also used behavioral treatment, specifically
exposure in their study on Leslie, a 9 year old girl with the diagnosis of selective mutism.
Like the previous study, the participants were gradually exposed to fear of verbal
communication in places outside of their home i.e. the classroom, restaurants, and parks.
However, unlike the previous study this study used video self-modeling (VSM) and role-
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play in addition to the behavior therapy. Role-play occurs when the participant practices
the desired behavior and receives feedback and reinforcement on that behavior (Lang et
al, 2011). Each time the participant was exposed to a social situation each encounter was
videotaped so that the participant could later go back and watch it.
The idea behind the Lang, et al., (2011) study was to individually target each type
of social setting that a child may go through, and expose them to it. Ideally with this type
of exposure, the research revealed that the participants speaking frequency markedly
increased in very few interventions. However, the reality of being able to expose a child
with a diagnosis of SM to every social situation they may encounter in life; is highly
unlikely and not realistic. At some point the child would have to become comfortable
with speaking in any social situation rather than waiting to be exposed to it in treatment
first. Despite this shortcoming, this study proved to be effective in enabling a child to
speak; where unlike before the child was not speaking at all. Before where the child
would not respond to speech at a baseline of 0; it increased to 5 for ordering restaurants, 6
for meeting adults, and 16 for socializing with fellow classmates. In this study, the child
was simply treated with the behavioral intervention and no medication at all.
Behavioral therapy across the literature shows to have the most successful impact
of treatment with children with a diagnosis of SM. Specifically; it is most successful
when the intervention is composed of a team rather than on an individual basis with just
the therapist. A team typically will consist of the therapist, the child, the parent/parents,
and the teachers of the child. It has been found especially crucial to have the teacher
and/or someone else in the school setting; i.e. a school nurse, also assisting with the
intervention treatment. Ponzurick, (2012) assessed a team-based approach to the
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treatment of selective mutism emphasizing on the role the school nursed played. In his
study, Ponzurick noted that the school nurse was critical in the treatment of selective
mutism because they act as an advocate for the child, providing communication between
parents, the school staff, and the therapist; almost like the role of a liaison. Borger,
Bartley, Armstrong, Kaatz, & Benson, (2007) noted that to deal with students with a
diagnosis of SM that the team approach in the school environment has proven to be
effective. Giddan et al., (1997) also emphasizes the role of school-based treatment in SM
calling it a multidisciplinary intervention. Like Ponzurick (2012) they noted that different
school personnel should be involved in the successful treatment of SM, even enlisting the
aid of speech language pathologist for evaluation and treatment of SM.
In the study before the child was referred to psychologist/ therapist the school
staff intervened on the childs behalf first; only recommending that a child need to be
further evaluated by a therapist if they did not respond to treatment typically after 30
days. The process first starts with the teacher of course noticing a mute child in their
class. The teacher then relays this information to the parents and school principal.
Subsequently, the school nurse, guidance counselor, and speech/language teacher are
notified. The team all meets and discusses the baseline data, any inputs from the parents,
and the goals of treatment for the child to be done in the classroom. Interventions in the
classroom would typically consist of having the teacher build rapport with the child with
mutism, creating a nurturing environment, and special seating (seating the child in the
front of the classroom so they can be more readily heard) with the main goal tor reduce
the childs anxiety in the classroom setting. Often times in the classroom based
intervention the child is assigned a buddy to increase the likelihood for the child to speak.
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The teacher can allow nonverbal communication from the child, but have to keep in mind
that they must be consistent with the child to ensure that vocalization is the end goal
(Crundwell & Marc, 2006; Johnson & Wintgens, 2001). The school nurse then serves as
a role of support to the child and the parent, educating the parent that the child is
suffering from an actual diagnosis and explaining the diagnosis to them. With the main
goal of education and support by the school nurse; this can make treatment go along more
smoothly and make things less frustrating, as there is often a stigma with a diagnosis of a
mental illness. This type of team-based intervention has found to be successful in the
treatment of SM often eliminating and significantly reducing mutism in a child before
they even get to the stage of seeing a therapist or clinical psychologist.

Study Limitations
Research for treatment interventions of selective mutism have consistently
consisted of small sample sizes. While this may be considered a design flaw in the
construction of research, it is important to note that the diagnosis of selective mutism in
children has a very low prevalence rate. This in itself can make it difficult for studies to
have relatively large sample sizes in comparison to other disorders that are more readily
prevalent in the community. In addition to small sample sizes, some of the studies
mentioned in this paper for example Bergman et al., (2013) used self report as a measure
of determining the effectiveness of treatment. This can be viewed as a confound because
of the age of the participants being so young (4-8), questioning the reliability of what
they report. Specifically, there was found to be lack of age appropriate self -reports for
the age group.
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Another limitation consistent with the research for intervention based treatments
for SM is the time frame of treatment intervention studied. Often studies follow
participants for 3 to 6 months and then present the results as a significant decrease of
mutism and even remission. Some studies follow up to see if the remission of SM is still
retained, but others do not. Often times it is not known what the rate of the child
regressing back to becoming mute after the interventions. Studies that followed a longer
evaluation and treatment plan of SM would be more effective in retained knowledge of
how effective certain interventions are.

Future Research
In the Manassis et al., (2008) study the participants were not randomized
introducing different biases into the results. Educational and economical biases could
have an affect on the results presented in the study. In contrast to the Bergman et al.,
(2013) study that was randomized making it a more representative sample; even though
the sample size was small. Further future research should attempt to include larger
sample sizes in their research; so that the results can be applied to the general population.
Also ensuring that this sample size is randomized can also control for the population to
be more representative.
Further research should also be attained in using medical treatment to treat SM.
Not many studies have been done on the effectiveness of SSRIs on SM. More of these
studies could be done on a larger sample to further ensure the effectiveness of SSRIs on
SM. Also, since social phobia has such a high comorbidity rate with SM; it should also be
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further researched if some of the medications used to treat social phobia would also be
effective in treating SM.
Presenting the research to the general population is something that should be done
in preschools, kindergarten, and elementary schools. While it is common for children to
undergo shyness; making parents aware of selective mutism can help catch it an early
onset. If SM is caught early on, it can be treated before it becomes somewhat of a norm to
the child making it harder to treat as they get older. The dissemination of this research
into schools makes the school staff, parents, and teachers aware that there is such a
disorder and if they ever encounter a child that is reluctant and unwillingly to speak; that
they watch that child carefully and not just attribute it to shyness. Although the
prevalence of SM is low; it is still attainable to get the information out there to the public
because there are children who suffer from this disorder and there is research to support
that.
With their being such a stigma around mental disorders in the United States,
making the disorder of SM to the population would help them to more readily except the
disorder. Not only that, but showing that there are effective treatments for the disorder
can help a family who may be going through these things seek help and find support.
These interventions if explained carefully and properly to the consumers will be more
readily accepted. Any type of intervention that is carefully planned out and presented to a
consumer with a high effective rate is likely to be accepted by that consumer and make
them less hesitant to try it. Chances are if a consumer is shopping around to find a
therapist/psychologist they have done some research of their own. Ensuring that these
studies are made available to the public will help aid in this process.
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It should also be taken into consideration that children of any race, ethnicity, and
background can suffer from SM. As with any other disorder in clinical psychology; it is
crucial to be mindful and knowledgeable of the different cultures and how they may
respond to different treatment plans. Giving the clients full access and knowledge to the
type of treatments that a therapist may try to recommend to them is critical in ensuring
that you have met that clients needs and requests. Cultural, but also individual expected
outcomes may be different in each family. Ensuring that what they expect out of
treatment and aligning it with the reality of what the general outcomes of the intervention
will allow the clients to be realistic about the interventions given. It will also give them
the opportunity to choose between what type of interventions they want to utilize as there
are different ways in treating SM not just in medication, but even within the behavioral
model.

Conclusion
Although the prevalence rate of SM is not as high as other psychological
disorders diagnoses in children; it is important to note that SM is a real disorder that can
be effectively treated with the interventions mentioned in this paper. Current literature is
in support of treating SM with behavioral based interventions in a clinical setting and also
in a school setting. SSRIs have also found to be effective in the treatment of SM as well.
Having multiple lines of interventions that have proven to be effective aids in the
progression of SM as a diagnosis. With multiple treatment interventions being explored;
it gives clinicians a wide plethora of options to help treat their clients suffering with
selective mutism.
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