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Selective mutism is a condition in which children and adolescents consistently do not speak in certain contexts, even though language comprehension and the ability to speak are normal. Here you read more about selective mutism and what can be helpful.

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This article is mainly based on a review article on selective mutism written by Beate Ørbeck at the Regional Center for Child and Adolescent Mental Health, Health Region East and South, and published on the Psychologists' Association's website.

"Imagine what your life would be like without your voice. For me it is a reality"





- Person with selective mutism 

 

What is selective mutism?

The child with selective mutism has the ability to speak and has an almost normal understanding of language, but consistently refrains from speaking in certain contexts. Beate Ørbeck writes:

Selective mutism is a relatively rare condition in which children and adolescents consistently do not speak in certain contexts. The children are most often silent in kindergarten / school, while talking to their immediate family at home.





In addition to the silence itself, a large proportion of these children have also reduced non-verbal communication, in the form of little gestures and weak eye contact.

Selective mutism is understood as an anxiety disorder, and is in the new diagnostic system DSM-V listed under the anxiety disorders. This is elaborated in an article on mutisme.no. They write: 

A child with selective mutism becomes silent due to physical symptoms of the strong anxiety they feel. They are not defiant, stubborn or 
disobedient. They are also not silent as a result learning difficulties, autism, general developmental disability, oppositional disturbances, etc. This does not mean that other lateral disorders can not occur, but these are not the very cause of selective mutism. 

"Kindergarten and school are a nightmare. You feel like an alien, a stranger."

- Person with selective mutism

 

  1. She´s given up talking. Paul McCartney

    In this song, Paul McCartney aptly describes a girl with selective mutism.

  2. My story of selective mutism

    In this video we get another depiction of life with selective mutism.

 

Possible causes of selective mutism

Beate Ørbeck writes: 

Unambiguous causal factors are not described, but today the condition is perceived as closely linked to biologically mediated temperament traits, with shyness and inhibition as key vulnerability factors, along with varying degrees of developmental disorders.

There is also relatively broad agreement that selective mutism is best understood as a state of anxiety, and that it is particularly frequently associated with social anxiety disorder, although this is still being debated.

 

Investigation of selective mutism

Beate Ørbeck writes:

Investigation of selective mutism involves a careful mapping of symptoms with regard to the historical course of silence and how it behaves in relation to different situations / different people, as well as the degree of non-verbal communication in the child.

Here, questionnaires on Selective Mutism Questionnaire (SMQ, and School Speech Questionnaire; SSQ) provide valuable information for parents and teachers, respectively.

There is a lot of information that may be of interest when investigating the difficulties. Ørbeck mentions important points:

 

  1. If the silence has occurred acutely, as a result of a psychological trauma or an acquired brain injury.
  2. Whether there is selective mutism in the family and the occurrence of other concomitant conditions in the child
  3. Whether there is evidence of motor and linguistic development and professional functioning in kindergarten / school
  4. Whether the child hears normally
  5. The child's pragmatic use of the language, for example by using the questionnaire's Children's Communication Checklist; CCC-II, for parents and / or teachers.
  6. The child's vocabulary and grammatical understanding
  7. The child's ability to concentration in different contexts

 

The author of the article adds:

Investigation, and not least testing of children who are silent, can seem difficult. Investigators must use their creative sides and must probably be more than usual for the child's reactions, but from experience most of the children work well in a structured test situation.

The children must be told that they do not need to talk to the test leader during examinations, but that they can use pointing or write down answers. Otherwise, the child should be allowed to sit next to the examiner, not directly opposite.

This avoids direct eye contact, which these children are often very uncomfortable with, and both the child and the examiner gather around a focus in front of them, ie the test material.

"When you want to say something, it feels like you're suffocating."

 - Person with selective mutism

 

Treatment of selective mutism

The difficulties can lead to both academic and social problems for the child, and to great frustration for the environment, and it may be necessary to receive treatment for the selective mutism. Beate Ørbeck writes:

Selective mutism can trigger strong emotions, and sometimes even inappropriate behavior from the surrounding environment, which can help maintain, or even aggravate, the child's symptoms.

Therefore, providing good information about the condition, openness and conversation about common reactions in the environment, as well as achieving a good collaboration between home and kindergarten / school will be absolutely central in the work with selective mutism, Ørbeck believes.

One must constantly emphasize the importance of not trying to force the child to talk, something the environment often does completely unconsciously. For the individual child, it has been shown that understandable information about the condition, and that there are other children who have the same problem, arouses considerable interest and provides contact with the child.

 

  1. How to help children with selective mutism. Lecture

    In this lecture we get a thorough description of the children with selective mutism and what can be helpful.

 

Defocused information

Beate Ørbeck gives several tips related to the treatment of selective mutism, where "defocused communication" is included as a basic principle. Ørbeck explains about this:

One must take as a starting point the child's communicative level (gestures, language, distance, theme) and try to achieve a common focus "outside" the child. Good aids here are to sit next to the child, as well as to ask open and wondering rather than direct questions. Neutral themes, without a direct focus on the child's experiences and feelings, are central.

Experiencing directly to the child that he / she does not have to talk to you when you meet him / her has, from experience, been very liberating. If there should be a verbal answer, then try to take this for granted. Maintain a moderate level of affect and avoid looking directly and long at the child in excitement that it is talking to you.

The importance of avoiding giving too much focus to the child is well expressed in the paradoxical statement of a boy with selective mutism, who according to Ørbeck has put it this way:

I can not start talking, because then they will be so happy.

 

Gradual exposure to speaking

Beate Ørbeck says that there is currently no "gold standard" for the treatment of selective mutism, but that it is recommended to use elements from behavioral therapy and cognitive therapy. She explains:

"Stimulus fading" is central, and means that the child is first allowed to be in a room with a person they feel safe with, and talk about something that does not require a high degree of interpersonal contact, such as reading rules, saying names of colors or count loudly.

The therapist should first be far away, usually far away from the room, which has also closed its door. In collaboration with the child, the therapist gradually gets closer ("slide-in technique") until the child can talk normally with the therapist next to him.

It is emphasized that although this may sound easy, it can be a long way to go to achieve this. Good enough time must be used to build a therapeutic alliance with the child, and where coping experiences are built up gradually and with increasing difficulty over time. Among other things, Ørbeck refers to a Norwegian pilot treatment study that shows how the treatment is built up slowly and gradually around exercises as mentioned above.

She tells:

The results from the pilot study, which includes seven children aged 3-5 years, are very promising as everyone has started talking in kindergarten.

 

Documentary on selective mutism

 

  1. Part 1: Selective mutism: Help me to speak

  2. Part 2: Selective mutism: Help me to speak

  3. Part 3: Selective mutism: Help me to speak

  4. Part 4: Selective mutism: Help me to speak

 

Faciliation in the school

An article on mutisme.no elaborates that an important treatment arena for selective mutism will eventually also be in the classroom itself. They write:

For a selective mutism child, school is the hardest place to be. Teachers and fellow students expect all children to be active and participative within the classroom. When a child does not respond, all attention is turned towards him / her. This is quite ironic given that attention is the last thing a selective mutism child wants!

Anxiety must be learned slowly by taking small steps in the right direction. This process begins with the child himself and a key person at the child's school, whom the child gradually gains more trust in. If one proceeds in this way, the child can manage to overcome selective mutism. A child with selective mutism can, for example, go from "stiff with anxiety" to nodding / shaking his head, which is a big step forward for the child.

Accept non-verbal communication in the school environment, especially during the first months of school. Together with the student, you will find the right time to encourage more verbal communication. This can take some time, and in some cases, verbal communication may be absent. It is therefore important not to let non-verbal communication become a crutch. There is a delicate balance between pressure and encouragement. 

More advice on how to take "step by step" in the right direction in the classroom and gradually enable the student to use the spoken language also in class, you can read here (Norwegian) and here (English). 

 

Sources

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