Tackling Selective Mutism

A Guide for Professionals and Parents

Benita Rae Smith, Alice Sluckin

• Publisher: Jessica Kingsley Publishers
• Year: 2014
• Print ISBN: 9781849053938
• eBook ISBN: 9780857007612
• Topic: Education
• Subtopic: Inclusive Education

Bringing together the latest research and understanding on selective mutism, this edited book gives essential information on the various treatment and therapy options. Experts in the fields of speech and language therapy, psychology, music therapy education and communication offer a wide range of professional perspectives on the condition, while case studies from people with selective mutism, past sufferers and parents reveal the personal impact. The book also clarifies what support a person with selective mutism is likely to need at home, school and in social situations.

This definitive volume on selective mutism will be key reading for professionals such as speech and language therapists, educational psychologists, child psychiatrists, child and adolescent mental health workers and anyone working with selective mutism in therapeutic and educational settings, as well as family members wanting a closer understanding of what selective mutism is and how they can help.

CHAPTER 1

Introducing Selective Mutism and an Overview of Approaches

Alice Sluckin and Rae Smith

This book was conceived as a companion volume to a fictional book published by Jessica Kingsley Publishers: Can I tell you about Selective Mutism? (Johnson and Wintgens 2012). This was written by two specialist speech and language therapists from the point of view of a fictional selectively mute child, and it reveals much of what children have told their helpers over the years.

The chapters of the present book have been collected in response to some of the needs of such children and their families.

Selective Mutism (SM) is a relatively rare and, until recently, little understood emotional disorder of childhood. These children converse fluently with intimates, usually in the privacy of their home, but do not speak in unfamiliar environments to people they are not familiar with, even sometimes those related to them. Much more rarely a child may speak outside the home but not within it. There is evidence in the literature (Cline and Baldwin 2004, pp.44–5) that a small minority of SM children have experienced some form of abuse or rejection in the home. Most SM children don’t speak at school to their teacher or peers, but may collaborate in classroom activities non-verbally and communicate by gestures, although some of them even have difficulty making eye contact and can appear withdrawn and defensive.

In the past these children were thought to be stubborn and contrary, but more recent research indicates that the majority of them are anxious (Johnson and Wintgens 2001; Cline and Baldwin 2004), a view that official classifications now recognize.

There is speculation that, for some individuals, overwhelming anxiety may even result in temporary paralysis of the larynx, and it is beyond doubt that many who appear superficially calm are avoiding anxiety by avoiding speech.

Alice Sluckin now describes SM on the basis of her lengthy experience

As one of the editors of this book, I would like to share with you what I learned about SM while helping such children and their parents and working over many years in a clinical setting. I hope this introduction will also contribute to a better understanding of the chapters written by parents about their SM children and of those recovered sufferers in the text. Next I want to tell you more about the SM child’s problem within his/her family.

Parents coping with an SM child

Parents often first notice SM when the child enters a nursery at the age of three. Since it is a relatively rare condition, thought to occur in approximately one per cent of the population (Bergman, Piacentini and McCracken 2002), misdiagnosis of separation anxiety may be made. Parents may describe some of these children as being shy and timid, but also at other times as noisy and non-compliant and also oversensitive to noise and touch, as well as unable to tolerate a change of routine. There may also be problems at bedtime.

Parents may find the child difficult to manage, particularly as they may not have come across another family with an SM child before. The family’s health visitor may refer the child to the local general practitioner (GP) who hopefully might recommend referral to a speech and language therapist (SLT) and psychologist. The earlier the better, so that medical, neurological and cognitive problems can be excluded and possible co-morbidity (co-existing conditions) explored.

Unless SM is recognized early it can become entrenched, and in time will seriously interfere with the child’s social, emotional and cognitive development.

What causes SM?

No single cause has been established. Research points to the presence of genetic factors (Cline and Baldwin 2004), as SM is more likely to occur if there are other members of the family showing similar behavioural traits.

A child’s inborn temperament may also play a role in causation. Kagan and Snidman (2004), two internationally known researchers into biological and neurological aspects of innate childhood temperament, observed that 10–15 per cent of all newborns may be having problems with regard to adapting to unfamiliar people as well as being unable to face change. They called such children ‘behaviourally inhibited to the unfamiliar’. When tested at four weeks and retested at 11 years they were more likely to be found shy and timid. It is possible that some SM children belong to this group.

There is international agreement that girls are more likely to be affected (Wright 1968; Cline and Baldwin 2004). Very bright children as well as children with learning disabilities can become selectively mute. Speech delay has been found to play a significant part in causation (Kolvin and Fundudis 1981). The condition is more frequent in ethnic minority families (Brown and Lloyd 1975; Cline and Baldwin 2004). Also, twins are more prone to SM (Wallace 1986). Frequent moves and isolated living may be factors, as well as an unsettled home background.

The SM child in the classroom

Often the SM child does not answer the register, does not read to the teacher and does not talk to peers. At mealtimes s/he does not say ‘Please’ or ‘Thank-you’ as requested by the dinner lady, and there may be problems over going to the school toilet.

Margaret Buck (1988) was one of the first teachers to draw attention to SM, and made very useful suggestions as to how such children could be helped. She pointed out that a classroom is a language environment, and she regarded talking as the pre-eminent instrument of learning. Hence the teacher who fails to establish communication with a pupil can feel inadequate and become frustrated and angry.

An example of how even a very experienced teacher might react with frustration or even despair to a non-responding child is described in the Times obituary (08.06.2012) of Elizabeth Manners, late Head Mistress of Felixstowe College, Suffolk. The obituary quotes Dame Elizabeth’s comments on interviewing Lady Diana Spencer, later Princess of Wales, who had applied for admission to her college. The interview went as follows:

She (Diana) just sat there with her head drooping. I said to her that, if she were to attend Felixstowe College, she would have to speak to me and I would have to see her face, but her head drooped further. There was nothing I could do.

Fortunately, many more teachers are by now able to deal confidently with SM children. Alison Hall, an experienced teacher, describes how she taught a 10-year-old boy to speak to her and read to her, though he had never spoken in school before (Hall 2008).

Diagnosing a selectively mute child

The criteria to be used for diagnosing SM children vary in different documents. However, it is widely agreed that the simple fact that a child is known to speak confidently in some situations while remaining consistently silent in others where speech is expected is sufficient for a child to be regarded/diagnosed as SM, provided that the child is not in their first term at school or in a new country in the first six months of learning a new language. More complicated diagnostic approaches are seen as potentially misleading, since the affected children differ from one another and may well have overlapping conditions, which need to be recognized and treated alongside the mutism.

More formal diagnostic recommendations include the following:

•The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5) (APA 2013) has once again updated its view of SM. Previously APA (1994) classified SM in the section ‘Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence’. It is now classified as an Anxiety Disorder, given that the large majority of children with SM are anxious. The diagnostic criteria are largely unchanged from DSM-IV.

•The ICD 10 (International Classification of Disabilities) (WHO 1994, update due 2014). This manual is widely used in the UK. It now adopts the term ‘Selective’ rather than ‘Elective’ Mutism as previously, and categorizes it under ‘Fear and Anxiety Related Disorders’ in its ‘Mental and Behavioural Disorders’ section. The question of comorbidity and possible exclusions from the diagnosis of SM is still under discussion.

•The UK NICE (National Institute for Health and Care Excellence) Guidelines, constantly in the process of being updated, now include SM as an additional or associated diagnosis rather than, as previously, a variant of social anxiety disorder (2014, p.76 and p.253). A variety of alternative forms of communication are recommended for reluctant speakers (p.79 and p.242).

It is sometimes stated that children with other disorders of communication might be excluded from a diagnosis of SM. Our view is that this can be an unhelpful exclusion, as the conditions overlap. Both difficulties need to be tackled together using a team approach.

Helping children to overcome their fears and helping parents

As was said before, the problem of SM is not a new one. Joan Tough (1976), a highly respected English educationalist, when referring to children not speaking at school thought that mutism was usually due to a number of causes, but leaving the child on their own for long periods hoping that he or she would in time begin to approach and talk to others was likely to make it more difficult. In her view, the child would then adopt a role or position from which it would be increasingly difficult to escape.

It is now realized that the prognosis with regard to recovery from SM is much more promising if treatment commences at an early age, before the child acquires a non-speaking identity and is being treated as a non-speaker by peers and teachers (Johnson and Wintgens 2001; Roe 1993, 2004).

Although most children outgrow SM, sadly it can follow some into adulthood, as can be seen in the Appendix.

Until the 1950s, the treatment of SM was largely influenced by misleading psychodynamic interpretations of the condition, which blamed difficulties in the mother–child relationship, but ignored the children’s inability to speak with strangers. At that time it was not understood that the child, by not speaking, was probably avoiding being devastated by feelings of anxiety.

From the 1960s onwards there was a radical shift to a new orientation in psychology toward Behaviour Modification, an approach based on the principles of learning and developed after experiments with animals. These had shown that fears and phobias were, in many cases, learned by an individual in vulnerable situations and could be unlearned (Herbert 1959; Marks 1969).

An English educational psychologist was the first to propose that SM was learned; he also noted that such children were very anxious (Reed 1963). To understand the condition better, parents were encouraged to keep records of the child’s frequency of talking to specific people in specific situations. Nor was the condition any longer perceived as primarily controlled by the affected child, but was one that was strongly influenced by the response of others. Thus Cunningham et al. (1983) observed that, in response to children’s silence, teachers often adopt a pattern of verbal interaction (for instance, questioning) which reinforces their silence, while peers in contrast ignore them. Hence it was realized that parents and teachers were key people in the management and treatment of SM. The use of behaviour modification strategies in the treatment of SM became even more accepted after the seminal paper by Black and Uhde (1995). Thirty SM children ranging in age from 5 to 16 were studied, and it was found that their characteristics resembled children suffering from a social phobia and avoidance disorders.

When devising a behavioural programme, achievable intermediate targets must be set to enable the child by very small steps to move through non-verbal communication to speech, as the child’s level of anxiety gradually decreases. If necessary, a behavioural approach can be combined with the use of puppets, play and music therapy, or ‘cognitive-behavioural’ guidance in the case of olde...

Table of contents

• Cover
• Of Related Interest
• Title Page
• Copyright
• Dedication
• Contents
• Foreword
• Acknowledgements
• 1. Introducing Selective Mutism and an Overview of Approaches
• Part I Current Understanding Of Selective Mutism
• Part II Related And Co-Morbid Conditions
• Part III Interventions, Strategies And Supports
• Part IV Conclusion
• Appendix: Selective Mutism In Adults
• References
• Resources
• Contributors
• Subject Index
• Author Index
• Also available