Even if they are very talkative at home, children with Selective Mutism (SM) show a consistent lack of speech in specific social situations in which they are expected to speak. Age of onset in this relatively rare and severe anxiety disorder is typically before children turn five. SM runs in families and is considered to be hard to treat. If left untreated, SM can impair social and academic functioning well into adulthood.
Previous experiments have demonstrated increased speech in children with SM using an integrated Cognitive Behavior Therapy (CBT). Note that this treatment requires guidance from a practitioner. This clinic based does not seem suitable in all geographical areas of the world, such as those with less dense populations and underdeveloped healthcare.
We saw the need for an intervention tool to be used by local non-expert therapists, or under telephone guidance, at school where symptoms of Selective Mutism are most severe. As severe social anxiety most often is an integral part of SM, we therefore developed “defocused communication” as a general treatment principle in our treatment approach.
What is Defocused Communication?
The aim is to reduce social anxiety and make the child feel more comfortable in the situation. First find the level of communication the child has mastered at this point in time and communicate at the same level. Some children with SM are fluent non-verbal “speakers” and stay close to you, while others need more space and can seem very withdrawn. The general idea is to give the child the opportunity to speak, but without the expectation of them doing so. Here are some tips on how to create an inviting environment for your child:
- Sit beside, rather than opposite the child and create joint attention using an activity the child enjoys. Try not to focus on the child.
- Try to “think aloud”, and give alternatives instead of asking the child direct questions. Above all, don’t ask questions about the child’s emotions (even though you really want to know how they feel).
- Give the child enough time to respond rather than talking for the child. Know that it is generally very hard for grown-ups to refrain from talking in these situations.
- Continue the dialogue even though the child does not respond verbally, thereby showing the child that you are not completely dependent upon their verbal response.
- Try to receive a verbal answer in a neutral way rather than praising the child excessively. Keep on doing what you did before the child spoke out for the first time.
We try to tell teachers to have a lot of fun and try to do all the mistakes you can in front of the child. It’s important to show the child that mistakes are okay.
Psychoeducation and Selective Mutism in Children
Telling a child that their act of silence is a choice could be detrimental─sometimes they are truly unable to speak in certain situations. This is why we think psychoeducation is an important part of treatment.
Every child with SM should be told that they are not alone with this problem, other kids struggle too. Furthermore, we know they want to speak, and it’s a matter of us helping them learn how. Training them in how to speak more needs to start in safe environments, for instance at home with parents.
For parents and teachers, we believe that an initial psychoeducational session (which includes basic information about SM the practical arrangement of the training situations, as well as a guide on how to use defocused communication) should be held with the parents and teacher together. If necessary, phone in all necessary individuals. The joint information between parents and teachers is important because children with SM behave so differently in each setting. Misunderstandings and assumptions are common between parents and teachers. It’s best that both parties are on the same page when it comes to treatment.
Behavioral Exercises
Practice is everything. Use a “sliding-in technique” based on the UK Selective Mutism Resource Manual and children practiced behavioral exercises half an hour, twice a week to increase their speaking behavior.
The child starts at home with a parent in a play situation that elicits speech. Gradually a therapist is introduced into this “safe” environment through the course of several small steps. Take it look at this example list of goals and exercises:
| Speaking Level | Description of the goal to be obtained in each speaking level |
| I | Speaks to the therapist (T) in a separate room with parent (P) present |
| II | Speaks to T in a separate room without P present |
| III | Speaks to one teacher in a separate room with T present |
| IV | Speaks to other teachers/caretakers and children in a separate room with T present |
| V | Speaks to teachers/caretakers and children in some settings without T present (speaks to some adults but not to all or most adults; speaks in some groups but not in most or all groups) |
| VI | Speaks to teachers/caretakers and children in all settings without T present (normal speech, indistinguishable from other children) |
The same procedures must then be used at school, including, first, one teacher, then other teachers, and then other children—again, in small steps. We think predefined steps are important, and small rewards for each victory seem very useful for most children.
Sources
Oslo University Hospital
Oerbeck B, Stein MB, Wentzel-Larsen T, Langsrud O, Kristensen H (2014). A randomized controlled trial of a home and school-based intervention for selective mutism – defocused communication and behavioural techniques. Child and Adolescent Mental Health, 25 October 2013; DOI: 10.1111/camh.12045
Oerbeck B, Stein MB, Pripp AH, Kristensen H (in press). Selective mutism: follow-up study 1 year after end of treatment. European Child and Adolescent Psychiatry,30 September 2014;DOI: 10.1007/s00787-014-0620-1
Beate Oerbeck has worked as a clinical psychologist within child psychiatry since her graduation in 1992. She specializes in both child psychology and clinical neuropsychology. In 2005 she defended her doctoral thesis, which was a follow-up-study of children with congenital hypothyroidism. Her postdoctoral position on treatment of children with selective mutism ended in 2012. She currently holds a senior research position with a main focus on referral and treatment of children with ADHD, using different health registries at Oslo University Hospital, Norway.
Her clinical approach is eclectic, but as the evidence base for cognitive-behavioral therapy (CBT) for anxiety disorders is so strong, postgraduate CBT-training has been emphasized.
