1.) What causes SM?+-
SM likely results from complex interactions among various risk factors, which may differ by individual child (e.g., Cohan et al., 2005; Viana et al., 2009). Early theories emphasizing the role of childhood trauma in SM are currently less accepted. Although most research on SM has been cross-sectional, it appears that genetics, temperament (e.g., behavioral inhibition), environmental influences, neurodevelopmental variables (e.g., speech and language problems; general developmental delay; neurological anomalies), and avoidance are all implicated in the etiology of SM (see Muris & Ollendick, 2015 for a comprehensive review). Many of these vulnerability factors play a role in other anxiety disorders as well (e.g., Muris, 2007). Longitudinal research is needed to better understand developmental pathways to SM specifically.
2.) I am interesting in becoming more experienced in how to best treat children with SM. How can I get more experience/training?+-
The SMA has a lot of helpful resources for treating professionals, including handouts and information that you can find in our online library (http://www.selectivemutism.org/online-library/), reading lists for SM and child anxiety in our bookstore (http://www.selectivemutism.org/learn/shop/), as well other opportunities to learn from professionals who treat SM. Additionally, by becoming a treating professional member of SMA, you can also have access to peer support from colleagues who treat SM through our active Treating Professionals Listserv.
SMA also offers other opportunities to increase awareness and information about SM through our annual conference, which typically takes place in the Fall and varies in location throughout the country, as well as through the Selective Mutism Proficiency Program, which is an intensive, interactive, and skills-based two-day training program for professionals who work with kids diagnosed with SM.
The following links include some helpful resources that can provide further information about treating SM:
3.) Is medication helpful for children with SM?+-
A medical doctor (psychiatrist, pediatrician) can prescribe medications that address the anxiety that may underlie the child’s inability to speak in certain situations. Medications are most effective when combined with cognitive, behavioral, and/or other psychological strategies, especially to help the child maintain gains in communication over time. In particular, the SSRI (selective serotonin reuptake inhibitors; e.g., Prozac, Zoloft) have the most evidence for being useful in youth with anxiety conditions. Fluoxetine (or Prozac) has been the most frequently used SSRI for treating children with SM (see Carlson et al. 2008). The Child Anxiety Multimodal Study (CAMS) found that both cognitive behavioral therapy and sertraline (Zoloft) reduced the severity of anxiety in children with anxiety disorders (60% and 55%, respectively), but that the combination of the two therapies had a superior response rate (81%) among children ages 7-17 with anxiety disorders.
Medication may be an option when you are simultaneously working on tactics/techniques to help and no matter what you are doing, anxiety is too high to allow the child to feel successful or a sense of mastery of the situation. When a course of cognitive and behavioral or other psychological strategies have been tried without much success, then it may be time to recommend a medication consult to determine if augmenting the psychotherapy with a medication would be useful. It may be that the medication may bring down the anxiety just enough to allow the child to engage in active cognitive and behavioral exposures that they have been unable to engage in before or are unsuccessful in staying in the exposure task. The goal is that the child will make gains from the learning that occurs in the exposure tasks and that eventually the child can be tapered back down or off completely over time. A medical doctor (MD or psychiatrist) are the ones that should assist in the tapering up and down of the medication and should provide families with support on what the best options are for their specific child as all children have different responses. Most of the medications that are used with children to date, only cause minimal side effects (e.g., stomach distress, headaches) that decrease after a few weeks of being on the medication (e.g., Black and Uhde 1994; Dummit et al. 1996). Click here for Dr. Steven Kurtz ‘s presentation on medication use in children with SM.
4.) I have been asked to speak about SM in my community. Where can I find resources for this?+-
As for information on selective mutism, reading materials etc. here are a few links to help you get started:
This is a direct link to our recommended reading list, and there you will find a link for parents: http://www.selectivemutism.org/learn/recommended-reading-list/recommended-reading-for-parents/
Here is a link under the reading list, specifically for school: http://www.selectivemutism.org/learn/recommended-reading-list/recommended-reading-for-teachers-and-schools/
In this link you will find more specific information explaining more on what selective mutism is:
Lastly, here a link to our useful websites: http://www.selectivemutism.org/learn/useful-links/
5.) Where can I look at the existing literature about SM and evidence-based treatment of SM?+-
Large-scale studies of SM treatment are needed. However, available research (e.g., waitlist-controlled pilot studies) suggests that behavioral/cognitive-behavioral interventions and pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) are effective for treating SM. The efficacy of these treatments for other anxiety disorders in children and adolescents has been supported by multiple randomized controlled trials (e.g., Walkup et al., 2008). The following peer-reviewed journal article addresses research specific to SM and its treatment:
Muris, P., & Ollendick, T.H. (2015). Children who are anxious in silence: A review on selective mutism, the new anxiety disorder in DSM-5. Clinical Child and Family Psychology Review ,18(2), 151-169.
Several prior reviews of psychosocial intervention (e.g., Cohan, Chavira, & Stein, 2006) are also informative. Additionally, the therapist guide for an integrative behavioral approach studied with funding from the National Institute of Mental Health is available for purchase:
Bergman, R. L. (2012). Treatment for children with selective mutism: An integrative behavioral approach. Oxford University Press.
Also, the following web-based learning resource provides an overview of the evidence base as well as video demonstrations of behavioral treatment strategies: http://selectivemutismlearning.org/selective-mutism-101/. Please visit the SMA bookstore for other resources.
6.) Where can I find books for parents of children with SM? What about books for children with SM? Educators? Treating Professionals?+-
The following is an excellent book is written for parents of children of SM:
Helping Your Child with Selective Mutism: Practical Steps to Overcome a Fear or Speaking by Angela McHolm, Charles Cunningham, and Melanie Vanier
The following book is a well-written for educators working with children with SM:
Helping Children with Selective Mutism and their Parents: A Guide for School-Based Professionals by Christopher Kearney.
The following books are designed for treating professions and describe effective therapy techniques:
Treatments for Children with Selective Mutism: An Integrative Behavioral Approach by Lindsey Bergman.
The Selective Mutism Resource Manual by Maggie Johnson and Alison Wintgens
Selective Mutism: Implications for Research and Treatment by Thomas Kratochwill
The following books are designed for multiple audiences and can be useful for parents, educators, and/or treating professionals:
The Selective Mutism Treatment Guide: Manuals for Parents, Teachers and Therapists: Still Waters Run Deep by Ruth Perednik
Selective Mutism: An Assessment and Intervention Guide for Therapists, Educators and Parents by Aimee Kotrba
The Silence Within: A Teacher/Parent Guide to Helping Shy and Selectively Mute Children by Gail Kervatt
Can I Tell You About Selective Mutism? A Guide for Friends, Family and Professionals by Maggie Johnson and Alison Wintgens
7.)What evidence based resources/practices are available for treating adolescents or young adults with SM?+-
It is really important to know that many people with psychiatric disorders, including SM cannot always seek treatment early on for a variety of reasons. As such, when treating the older teen or young adult, it is really important to do a full diagnostic evaluation, and possibly have the individual bring someone with them to the evaluation (if needed) who could help them communicate. There are often co-morbid conditions (e.g. Depression, axial anxiety disorder) and all of the disorders need to be addressed. Especially when depression may be involved, a combination of therapy, including CBT and medication may be needed. For older teens and young adults, there can and often is a more cognitive aspect of the treatment, which is something that is often less present in the treatment of much younger children. The psycho-education itself, which is a very important part of treatment, is definitely integrated into the work with an older teen. It is really important that treatment start with a shared understanding of SM and other disorders that may be present. Treatment goals and the method of treatment need to be discussed and the older teen or young adult needs to understand that treatment will be both challenging and systematic. Older children and teens often can be a more active participant in the treatment and designing of behavioral exposures, as they are more able to think about their own experiences, rate how hard or easy things are (e.g. Ordering at a restaurant vs speaking in a small group).
8.) My patient's parents want me to provide a training to school staff on selective mutism/or the school has asked that I do this. How do I go about getting paid for my time?+-
If the school has asked a professional to provide a training on selective mutism, it is acceptable to simply inquire about whether this is a paid or unpaid presentation. Some schools have a portion of their budget set aside for staff training and may have a rate that they offer to professionals coming in to give talks. At other times, schools ask the professional for their rate and pay them accordingly. If the school is asking you to come in and present on a voluntary, unpaid basis, it is up to the professional to determine whether they want to do so.
When parents are requesting a presentation to school staff, the professional can talk with the parents about payment. If parents are requesting the training, the school may assume that the parents are paying the bill. If you are wanting or expecting to be paid for your time, have a direct conversation with the parents about this so that the plan is established before the training occurs.
9.) What are some of the most common co-morbid problems? And what do I treat first?+-
Children with selective mutism often have co-occurring disorders and problems, which can complicate treatment. Selective mutism often occurs with internalizing disorders (e.g. generalized anxiety, separation anxiety and social anxiety) (Vecchio & Kearney, 2005). However, children with selective mutism most often meet criteria for social anxiety. Symptoms of both disorders often include avoiding social situations, expecting humiliation, experiencing high distress in social situations, and a fear of speaking to strangers and being judged. Other comorbid disorders may include obsessive-compulsive disorder (OCD) and depression.
Children with selective mutism may demonstrate oppositional behaviors, such as refusing to speak or participate in activities, but they do not necessarily meet criteria for oppositional defiant disorder. Children with selective mutism typically demonstrate avoidance behaviors. Parents and others may misinterpret these behaviors as controlling or oppositional instead of an expression of severe anxiety (Kristensen, 2000; Yeganeh et al., 2003).
Language disorders/delays in children with selective mutism may be comorbid in 20-68% of cases (Carmondy, 2000; Kristensen, 2000). Kristensen (2000) reported that 50% of youth with selective mutism and 12% of a control group had a communication disorder, including phonological disorder (43%), mixed receptive-expressive language disorder (17%), and expressive language disorder (12%). Children with selective mutism may avoid speaking because they fear they will be teased for mispronouncing words.
Children with selective mutism also may have self-regulation difficulties, and are unable to adjust their level of arousal or regulate their emotions effectively. Elimination disorders, such as enuresis (involuntary urination) and encopresis (involuntary defecation) may co-occur in 7-42% of children with selective mutism (Arie et al., 2007; Kristensen, 2000). Furthermore, comorbid developmental disorder/delays have been reported in 68.5% of cases (Kristensen, 2002).
Children with selective mutism should be assessed by a child psychologist to determine if co-occurring disorders or problems further complicate treatment. Youth who present with co-occurring language disorders may need treatment by a speech and language pathologist to help the child develop and understand language. Furthermore, youth with selective mutism with severe anxiety or oppositional/controlling behaviors may benefit from a referral to a psychiatrist to discuss medication for reducing anxiety and behavior problems. Children undergoing therapy for selective mutism may also learn relaxation skills and reduce their anxiety through exposure therapy. The type of treatment and treatment focus should be discussed with a mental health provider, with consideration of the parent and child needs, and co-occurring problems or disorders.
10.) What resources are available for conducting group treatment of selective mutism?+-
Group therapy may be an effective mode of treatment for children with SM. Some children with SM feel alone in their struggle to speak in settings such as school and may find support from others who are dealing with the same challenges. Group therapy offers in vivo practice opportunities to speak in a safe setting with understanding communicative partners as everyone is practicing brave talking. Group therapy programs may include fun outings such as going on a scavenger hunt at a mall, ordering and eating at an ice cream parlor, or going trick-or-treating at a senior citizen living center. Some group therapy programs for children with SM offer a simultaneously run parent group that offers education and advice on managing SM. To date, there has been few published research studies on group therapy for children with SM. One exception is the work of Sharkey, McNicholas, Barry, Begley and Ahern at the Lucerna Clinic in Ireland. These authors published a study titled Group Therapy for Selective Mutism: A Parents’ and Children’s Treatment Group which was published in the Journal of Behavioral therapy and Experimental Psychiatry in 2008. Finally, some summer group treatment programs offer intensive, therapy sessions conducted every day for a week in a school-like setting. Many treating professionals are beginning to offer intensive therapy sessions. Current intensive programs can be found in the calendar section of www.selectivemutism.org.
11.) How can I connect with other treating professionals and share ideas?+-
Consider becoming a member of the SMA. Membership benefits include an online professional profile as well as participation in our active email list serv. Through the SMA listserv, professionals share referral information, ask and give guidance to treatment concerns, and share ideas and information. In addition, consider attending the SMA annual conference—it’s a great way to network and connect with other professionals who share the same interests.