Interventions/Treatment
Multimodal treatment works best
Individual, behavioral, and family therapy
Psychoanalytic Therapy- using this approach has proven to be long and difficult, with a poor outcome. This therapy focuses on hostility and unconscious conflicts (Giddan et al., 1997).
● The child learns the importance of tolerating and understanding his or her feelings before taking actions.
● The very act of taking the time to study the silence of a child provides the child with a less anxiety provoking therapeutic environment.
● The child is not pushed, questioned or pressured to speak; they are understood.
Joining and Mirroring Techniques
● Joining is an understanding and an agreement with the conscious and unconscious emotional states of the patient.
● Mirroring is when the therapist matches the feeling states of the patient as his own feeling state.
● These two techniques are described as a communication from the therapist that gives the patient the feeling that the therapist agrees with him.
● The joining technique, when working with a child with Selective Mutism, may take the form of telling the child that being silent is good if it helps the child not feel scared.
● “Joining” along with the child’s attitude has optimal effectiveness in demonstrating an understanding.
Example:
The child states, “I am afraid if I talk and make a mistake that my friends will make fun of me.”
Joining
“You are right to be quiet if you think your friends will make fun of your mistakes.”
Mirroring
“Oh yeah, I’m afraid if I talk and make a mistake that my friends will make fun of me too.”
(Moldan, 2005)
Contact Functioning
● Is defined as direct attempts by the client to obtain information about the therapist or to include the therapist in some emotional problem that the client cannot verbalize with words.
● Spotnitz (1985) explains that the therapist responds to the contact functioning initiated by the client with intermittent verbalizations to gratify the client’s immediate need for words.
● Joining, mirroring and contact functioning are done for the child to feel understood, but not overwhelmed. This dynamic is essential in helping the child to develop the ability to self-regulate appropriately.
Psychodynamic Therapy (adaptation of psychoanalytic therapy) uses art and play therapy to determine underlying fears and anxieties (reactions to trauma, abuse, divorce, death of a loved one, a life-threatening experience, or frequent moves, etc.).
● For young children a play therapy approach is recommended. The play therapy should consist of games, pretend situations, and coloring material in order to make the child feel comfortable without any initial communication.
● Allow the child to take the lead. Do not force interaction or participation, and do not focus exclusively on verbal responses until the child feels comfortable.
● Music and art promote interaction and communication.
● As the treatment progresses, work towards a sign system, verbal cues, and one word responses leading to full sentences.
● Indulge the child in favorite pastimes and activities and try to provide them in the office setting.
● Keep the focus on the child and the present moment.
● Use telephones, microphones, screens, and puppets to allow the child a means of communication through projective approaches. Be creative!
● Remember that anxiety is the underlying factor…promote safety, empowerment, and security.
● Incorporate enhancing self-esteem activities in the therapy setting.
(Coiffman-Yohros, 2004)
Family Systems Therapy is used to discuss a treatment plan and to identify and discuss any stressors. The involvement of the family is a critical part of the overall treatment. The home is a wonderful place to learn about social interactions and rules of behavior.
● It is always important for the family to be informed about Selective Mutism and to be included in the child’s treatment plan in order to provide a supportive environment for recovery.
Home Interventions
● Provide a safe and loving environment.
● Accept the child for who they are.
● Do not use threats or punishments to get the child to talk.
● Instill hope in the child, reassuring them that there is help and they can overcome their situation.
● Foster self-esteem.
● Provide the child with plenty of opportunities to explore extra-curricular activities, such as swimming, gymnastics, art, theater or dance.
● Provide opportunities for after-school play dates. Invite a peer that the child likes to the home, allow the free time to play and interact. Once the child talks to this peer freely, take them to the park or outdoors to promote communication outside the home.
● Continue bringing peers into the home (one or two at a time). Once a peer group has been established, consider having play-time at the other child’s home.
● When taking the child to social activities arrive early and allow the child to check out the environment. Do not force them to interact or play.
● Parents want to provide opportunities for socialization and not reward isolation and withdrawal. This is done in a caring manner.
● Seek advice and help from professionals.
● Establish a support network for you as a parent. Children perceive their parents anxiety and frustration.
(Coiffman-Yohros, 2004).
● Provide several opportunities for your child to observe you talking in a relaxed manner in a number of different situations such as in the neighborhood with friends, at school gatherings, and while ordering at restaurants.
● Always reinforce any attempt your child makes to speak in a public place by gently patting them on the shoulder and providing verbal praise.
● Do not talk about your child’s “problem” with relatives or friends when the child is present.
Pharmaceutical
● The use of medication is based on the understanding that Selective Mutism is related to social anxiety.
● Medication in the form of serotonin reuptake inhibitors (SSRIs) such as Prozac, Paxil, Celexa, Luvox, and Zoloft are often prescribed in the treatment of anxiety disorders.
● There are several small scale studies that have shown these types of medications to be effective in the treatment of Selective Mutism.
● Response to medication is inversely proportional to age. When therapy is begun at an early age, response is much quicker and greater.
● When medication is used with other treatments, the goal is to usually have the child take the medication for 9-12 months.
● Medication is not always necessary for the treatment of Selective Mutism, but in many cases it appears to very useful in helping a child take the first steps.
Behavior Therapy uses positive reinforcement for initially all forms of communication, including facial expressions and gestures. It is then gradually applied only to whispers and normal verbalizations. The child is never punished for not speaking, but reinforcement will be withheld. A behavior plan is developed with significant adults in the child’s life (parents and teachers). Behavior therapy has proven to be the most promising approach!
Behavior Therapies
Shaping
Positive Reinforcements/Token procedures
Shaping
Shaping can be understood as “taking baby steps”. There is an end goal in mind (e.g., verbally answering a question during reading class with a complete sentence), and this goal is divided into smaller steps; each time the person completes one of the smaller steps, he/she is positively reinforced for completing that step. The next larger step is then introduced.
Example:
● A teacher discovered that her student, Stephanie, talked at home with her neighbor Natalie (who was also in her class) about books they read.
● The teacher decided that because reading was interesting to Stephanie and she had a peer in the class that she already talked to (at home), she would work on increasing Stephanie’s speech in reading class.
● First, she wanted Stephanie to speak to Natalie in the classroom (which she had never done). During recess, she allowed the two girls to be in the classroom by themselves (with the teacher outside the door), so they could talk about the books they were reading.
● Once Stephanie spoke to Natalie in the classroom when they were alone, the teacher gradually entered the classroom: first the teacher was visible in the doorway as the girls talked; second the teacher sat at her desk; third the teacher moved to a desk that was closer to where the girls were sitting; lastly, she sat next to the girls and talked with them about the books.
● The teacher used similar procedures to slowly introduce Stephanie’s classmates to the book discussion, until Stephanie was able to verbally answer questions during reading class.
● Whenever Stephanie spoke at each step, she was given a cat sticker (her favorite); for each set of 5 cat stickers she earned, her mother agreed to buy her a book.
● Shaping can be used in various ways. In the example, the setting (in terms of the people to whom Stephanie was speaking) was gradually changed.
● Shaping can also be used with speech. For example, the student may first be required to whisper a one word answer in class. The teacher can gradually increase the expectation from whispering to a volume that can be heard across the room, as well as from one word to several sentences (
Positive Reinforcements/Token Procedures
● Positive reinforcement should only be introduced after anxiety is lowered and the child is ready to begin working on goals.
● Positive reinforcement of speech is essential to helping students with selective mutism.
● Positive reinforcement is a way for the teacher to effectively communicate to the student that speech is expected and required.
● In order for a teacher to clearly communicate this message to a student with selective mutism, the teacher needs to eliminate any other reinforcement of the selective mutism. This means stopping other students or adults from answering for the student.
● Asking questions in a way that requires a verbal response rather than a nonverbal response is also important.
● Only requiring the student to talk when you are sure that they will talk will give you the best opportunity for positive reinforcement. Shaping and gradually increasing the expectation of speech will help with this goal.
● Selection of the reinforcement is also important. The reinforcement needs to be meaningful and important to the student; therefore the student’s preferences need to be considered (
● Use a mystery motivator. A mystery motivator is defined as a hidden reward designed to increase the anticipation and value of the reinforcer. The technique consists of a manila envelope, displayed in the classroom openly, with a question mark and the child’s name printed on it. Inside is a desired reward for the child. The class is told that the mystery motivator will be given to the child when it is asked for in a tone that is audible and clear to the class (Kehle et al., 1998).
● For some children a behavioral program with rewards (trinkets, food, social praise, and activities) can be very effective. Make sure there are a lot of small steps and frequent praise. Charts with goals that show progress can also be helpful. Involve parents and siblings.
(Coiffman-Yohros, 2004) and WashburnChildGuidanceCenter
General Techniques to Help Reduce Anxiety
Teach deep breathing, muscle relaxation, stretching, mental imagery, problem solving skills, coping with peer pressure, positive self-talk
Provide reassurance and encouragement
Seek creative outlets (music, art, athletics, etc.)
Increase student's level of physical activity
Be an active and understanding listener
Don’t dwell on mistakes
Avoid derogatory labels
Encourage social interaction
Acknowledge the anxiety and deal with it, rather than denying it
Avoid negative self-talk ("l don't know this stuff", "I know my mind will go blank", "I'm going to fail", etc.)
Anticipate the problem of feeling anxious in advance so student is not overwhelmed or frightened by it when it happens. Provide practice opportunities
Practice interrupting negative thoughts and replacing them with positive statements
Teach student how to self-instruct (talk themselves through a task)
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