Early intervention for selective mutism is key to remediation. Continued difficulty speaking in certain situations and contexts strengthens this pattern. Consistency in the intervention and expectations, at home and at school, of everyone on the team involved is important when working with children with selective mutism. When providing predictability and control for the child with selective mutism, he/she will feel a decrease in anxiety and an improvement in self image based on mastery of skills in a variety of settings (Kotrba, 2015). The use of social stories and scripting can be helpful ways to reduce the child's anxiety and uncertainty in a variety of social situations (Dow et al., 1995; Kotrba, 2015).
The behavioral perspective views selective mutism as a learned behavior that the individual has developed as a coping mechanism for anxiety. The purpose of treatment is to decrease anxiety and increase verbal communication in a variety of settings, incorporating practice and reinforcement for speaking in subtle, nonthreatening ways (Cohan, Chavira, & Stein, 2006; Camposano, 2011; Kotrba, 2015). Reinforcements may be
- verbal (e.g., praise);
- tangible (e.g., toys, special outings, belongings); and/or
- privileges (e.g., staying up later, having additional time to play a video game, choosing a movie or board game to enjoy with a parent/caregiver).
Behavioral strategies may be incorporated into interventions for children with selective mutism across disciplines. These strategies include:
Exposure-based practice. This involves the child saying words in gradually but increasingly difficult or anxiety-provoking situations. Exposure-based practice aims to (a) replace anxious feelings/behaviors with more relaxed feelings and (b) increase the child's feelings of independence by gradually improving his/her ability to speak in different situations (Kearney, 2010; Middendorf & Buringrud, 2009).
Systematic desensitization. This involves the use of relaxation techniques along with gradual exposure to successively more anxiety-provoking situations (Cohan, Chavira, & Stein, 2006; Kearney, 2010).
Stimulus fading. This involves gradually increasing exposure to a fear-evoking stimulus (e.g., the number of people present or the presence of an unfamiliar person in the room while the child is speaking). This process usually includes rewarding the child when he/she is speaking in the presence of someone to whom he/she does not typically speak (Middendorf & Buringrud, 2009; Viana et al., 2009).
Contingency management, positive reinforcement, and shaping. This includes (a) providing positive reinforcement contingent upon verbalization and (b) reinforcing attempts and approximations to communicate (i.e., shaping) until such attempts are shaped into verbalizations, with the goal of making verbalizing more rewarding than not responding. Shaping is commonly used in combination with contingency management and positive reinforcement.
Augmentative and Alternative Communication (AAC)
Augmentative and alternative communication (AAC) involves supplementing or replacing natural speech with aided symbols (e.g., pictures, line drawings, tangible objects, and writing) and/or unaided symbols (e.g., gestures). Some children who have been diagnosed with selective mutism may temporarily adapt an AAC system to facilitate classroom communication during initial stages of intervention. Use of AAC is not a long-term solution. AAC should be carefully monitored to ensure that it facilitates interaction rather than replaces verbal communication.
Please see ASHA's Practice Portal page on
Augmentative and Alternative Communication for further information.
In augmented self-modeling, the individual watches a video segment or listens to an audio segment—one in which he/she is engaging in a positive verbal interaction in a comfortable setting (typically, at home)—while in a setting that is uncomfortable or challenging for the child with selective mutism (Kehle, Bray, Byer-Alcorace, Theodore, & Kovac, 2011). This allows the child to obtain a "virtual glimpse into communicating successfully in a setting that causes heightened anxiety" (Klein & Armstrong, 2013). This could also involve making a video recording of the child and editing it so that the video shows the child speaking in settings where the child does not speak, such as the classroom. With others present, the child then watches and listens to him/herself speaking and learns to think positively about speaking in front of others (Viana et al., 2009).
DIR (Developmental, Individual Differences, Relationship-Based) Floortime ® is a developmental and interdisciplinary framework based on functional emotional developmental capacities (FEDCs). It utilizes the concepts of self-regulation, attention, engagement, intentional communication, and purposeful problem-solving communication. Goals are based on evaluating the child's FEDC (i.e., moving from nonresponsive, to using gestures, to making sounds, and then to being verbal) and supporting individual differences (sensory processing, praxis, speech and language challenges, visual spatial processing, postural stability) to move the child up the FEDC ladder. It incorporates sensorimotor and play-based activities (often having co-treatments with an occupational therapist) and instruction regarding anti-anxiety strategies from a social worker or other behavioral health professional (Fernald, 2014).
Ritual Sound Approach
Ritual Sound Approach (RSA), a cognitive and behaviorally based treatment, is a part of Social Communication Anxiety Treatment (S-CAT). RSA first teaches sound production from the mechanical perspective; then, shaping occurs to reinforce oral movements with sounds that gradually progress to phonemes, syllables, and words (Shipon-Blum, 2010). The SLP talks with the child about nonspeech sounds (e.g., breathing, blowing, and coughing). He/she describes how voiceless phonemes are similar to these actions and how these phonemes are produced physically. The child then progresses to approximating voiceless phonemes (e.g., /h/, /k/, /t/, and /p/). Then, using an alphabet board, the child crosses off the sounds that he/she can produce. Looking at the alphabet board also serves as a distraction from needing to make eye contact, which can help reduce anxiety about speaking. The SLP talks about how sounds are blended to form words in RSA's chaining so that voiceless consonants are paired with vowels and other voiceless consonants to form words (Klein, Armstrong, Skira, & Gordon, 2016).
This integrated approach emphasizes participation in social engagement (nonverbal and verbal) at increasingly difficult levels. Shaping and reinforcement, in the context of interactive routines, are used to move the child with selective mutism from acceptance of being a part of joint activities (such as games, art, social play), then using nonverbal communication (reaching, pointing, gesturing yes/no, facial expression) during joint activities, and through a hierarchy of production of sounds (i.e., non-speech sounds to speech sounds, and finally to using words). At the word level and beyond, consideration is given to the hierarchy of using language functions. For example, the child may begin with answering noninvasive questions (e.g., "What color is your shirt?"), and progress to answering increasingly more personal questions (likes/dislikes, family and friends) before eventually being able to ask noninvasive personal questions, and participate in conversation over multiple turns.
When the child changes communicative partners or contexts, tasks may need to be simplified. The approach considers different variables of the communicative context
- who the child is communicating with (familiar vs. unfamiliar);
- where the child is communicating (therapy room, school library, classroom before school starts, in small group inside the classroom, etc.);
- the purpose of communication (regulating another's behavior, social interaction, joint attention); and
- the ability to manage conversation (multiple turns, repair conversation, select/maintain/terminate conversation, take another's perspective; Hungerford, et al., 2003)
Vocal Control Approach
The Vocal Control Approach (Ruiz, 2013, as discussed in Klein & Armstrong, 2013) uses nonspeech tasks to help the child with selective mutism gain control over voicing and then systematically works to maintain vocal control. The child hums and varies pitch while noting vibration in his nose and throat and then works to extend the length of time humming. The child could also use voice-altering apps while humming to reinforce humming for longer periods of time. Then, the child makes environmental sounds (e.g., animal or engine sounds), with the goal of demonstrating improved voice initiation. Next, the child works to shape the hum into /m/ and add vowels, extending to initial /m/ words and introducing non–/m/-initiated syllables, words, phrases, and sentences.
Generalizing spontaneous speech to different people in a variety of settings may involve (Johnson & Wintgens, 2001; Middendorf & Buringrud, 2009):
- Having the individual rate situations and people from most difficult to least difficult in a hierarchy
- Preparing and reassuring the individual with selective mutism of his/her abilities by thoroughly explaining the plan to generalize skills
- Changing only one variable at a time (either the location or the people present), alternatively
- Moving from structured and carefully planned occurrences to spontaneous and unplanned situations
Monitoring the individual's success at each level of the treatment plan through ongoing assessment will determine the successful completion of consistent communication with a variety of people in a variety of settings. Anxiety and avoidance behaviors will indicate the need to break down communication steps, locations, or audience size into smaller increments (Kotrba, 2015).
Continued collaboration between the SLP and behavioral health professionals, classroom teachers, and the family is necessary for treatment continuity, clear delineation of roles and responsibilities, and appropriate hierarchical goal setting. Having the SLP on the team, even in a consultative role, helps the child with selective mutism gain confidence in what he/she may perceive as decreased communication skills (Dow et al., 1995).
The SLP can work with the child's teacher and school staff to:
- Form small, cooperative learning groups that include the child's preferred peers
- Help the child communicate with peers in a group by first using nonverbal methods (e.g., signals, gestures, pictures, writing) and gradually working toward verbal participation
- Watch for opportunities to reinforce small improvements
- Reassure others that the child is still comprehending even if he/she is not talking
- Try to minimize symptoms—the child may not want to talk, but he/she can point, show, gesture, or draw
- Avoid speaking for the child, justifying child's silences, or pressuring the child to speak, all of which may reinforce mutism and anxious behaviors
- Support peer acceptance of nonverbal participation in classroom and recreational activities
- Find nonverbal jobs that the child with selective mutism can perform to build confidence
- Maintain the classroom routine, and try making the same request of the child at the same point in the schedule to decrease anxiety
- Try to arrange one-on-one time with the teacher and student so that he/she can seek assistance quietly rather than in front of peers (Richard, 2011; Schum, 2002, 2006)
Initially, children may require individual treatment sessions—particularly to establish rapport and to practice relaxation techniques and pragmatic skills—in a safe, comfortable setting. Typically, therapy progresses from child-directed interaction to verbal-directed interaction. During child-directed interaction, the adult observes the child performing an activity that the child chooses, and then the adult joins in, when appropriate, by imitating, describing, and demonstrating enjoyment without asking questions, giving commands, or using negative talk. Verbal-directed interaction allows adults and peers to ask questions, direct some play, and give instructions (Kurtz, 2015; Mac, 2015).
English Language Learners
When treating an English Language Learner with selective mutism, it will be important for the SLP to be aware of possible stressors within the child's school setting that will need to be addressed through staff development, interventions, and accommodations (Toppelburg et al., 2005):
- Lack of class support for learning a second language
- Potential for negative views of the child's culture or language of the home
- Limited communication between parent/caregiver and school
Bilingual Service Delivery and
Cultural Competence for more information related to providing culturally and linguistically appropriate services.
Treating Concomitant Speech and Language Problems
Children with selective mutism can also have a concomitant communication delay, disorder, or weakness (Richard, 2011). Children with selective mutism may avoid speaking out of fear of being teased regarding speech sound production or vocal quality (Anstendig, 1999). Evidence of a concomitant communication disorder is not restricted to specific settings or social situations, even when co-occuring with selective mutism.
It may be beneficial to address only selective mutism goals initially, in order for the child to gain some confidence in communicating and to establish a relationship with the SLP, before addressing specific speech and language deficits.
Adolescents and Adults
Treatment of adolescents and adults with selective mutism can prove difficult if they report not wanting to talk because they do not see the benefits of speaking. An older individual has also developed strategies to avoid talking and has defined themselves as being primarily nonverbal in a school setting. Increasing internal motivation to elicit behavioral change by helping the adolescent or adult explore and resolve ambivalence through discussion is a client-centered counseling technique called motivational interviewing. A motivational interview for someone with selective mutism could include asking about the positive (i.e., maintaining selective mutism) and negative aspects of selective mutism, exploring life goals and values, and then asking for a decision which hopefully results in a willingness to change and set goals (Kotrba, 2015; Rollnick & Miller, 1995).
Pharmaceutical intervention may be considered with this population to address the social anxiety or phobia (Manassis, Oerbeck, & Overgaard, 2015). It is important for the clinician to consider the behavioral influences and side effects of medications on treatment.
Format refers to the structure of the treatment session (e.g., group vs. individual) provided.
Children may require individual treatment sessions initially, depending on the strategies and techniques being applied, to establish rapport and to practice relaxation techniques and pragmatic skills in a safe, comfortable setting.
Small-group therapy can facilitate communication with peers, beginning with nonverbal play using scripted interactions involving single words and phrases and moving toward the ultimate goal of speaking spontaneously (Klein & Armstrong, 2013).
Forming groups of individuals with selective mutism who are of similar age, cognitive functioning, and speech-language skill is another service delivery model. Groups may need to be adjusted based on progress as individuals advance at their own pace (Kearney, 2010).
Provider refers to the person offering the treatment (e.g., SLP, SLPA, caregiver).
Dosage refers to the frequency, intensity, and duration of service.
For some, intensive treatment sessions for selective mutism may be helpful and can take place in a variety of settings. In the school setting, using stimulus fading and/or shaping, the child's schedule is disrupted for the duration of a week. School staff need to receive training in behavioral intervention so as to continue with appropriate treatment and provide accommodations after the week is over. Intensive group treatment in a summer camp simulates a school setting, and the child with selective mutism can receive intensive practice in a safe setting without interruption to his/her school schedule. Families also receive the benefit of meeting other families who are dealing with selective mutism (Kotrba, 2015).
Setting refers to the location of treatment (e.g., home, school, community based).