Functional analysis and treatment of selective mutism in children.

Abstract

Abstract Selective mutism refers to a persistent failure to speak in public situations, especially school, where speaking is expected. Researchers have linked selective mutism to social anxiety in many cases. Functional analysis of selective mutism generally involves interviews, questionnaires, behavioral observations, and daily logs. Assessors should look closely for conditions under which selective mutism commonly occurs, especially directives from others, lack of attention from others, high child anxiety, and lack of interpersonal skills. Treatments for selective mutism often involve exposure-based practices and parent- and teacher-based contingency management. Keywords: Mutism; social anxiety; functional assessment; interviews; scales; questionnaires; behavioral observations; treatment; contingency management. Introduction Selective mutism refers to a persistent failure to speak in public situations where speaking is expected, despite speaking in other situations (American Psychiatric Association, 2000). Children with selective mutism commonly fail to speak in situations outside their home and especially in places such as school, restaurants, stores, and recreational settings. From a diagnostic perspective, selective mutism must last at least one month. This excludes children who are naturally reticent about speaking during the first month of school. Selective mutism is not diagnosed in cases where a child simply lacks knowledge or comfort with the language that is spoken in the public situation. A child whose parents speak only Spanish, for example, would likely not be diagnosed with selective mutism during his or her first year of school unless the child was already quite familiar with English. Furthermore, selective mutism is not due specifically to difficulties in communication such as stuttering or specifically to a developmental disorder, though these problems may co-occur. Many children with selective mutism do try to communicate in public situations via nonverbal means such as nodding, pointing, mouthing, or writing letters in the air (APA, 2000). Failure to speak in public situations, especially school, can hinder a child's academic progress because teachers are less likely to call upon these children for answers and because many of these children cannot undergo intelligence and other testing (Bergman, Piacentini, & McCracken, 2002). In addition, some of these children are teased or disliked by their peers, which further affects their social-communication development. Speech and language development may be delayed as well (Krysanski, 2003; Kumpulainen, Rasanen, Raaska, & Somppi, 1998). The prevalence of selective mutism is not well known because of the furtive nature of the disorder and lack of literature regarding this population. Prevalence estimates range from 0.2-2.0%, but the actual rate may be higher because many parents attribute the problem to simple shyness that the child will eventually outgrow (Bergman et al., 2002; Kopp & Gillberg, 1997; Kumpulainen et al., 1998). In addition, because many of these children speak freely at home, parents often delay seeking treatment. An overt speech or language problem does not seem evident to them. Initial studies on selective mutism indicated the prevalence of selective mutism to be higher for girls than boys, but recent evidence suggests a more equal gender distribution (Andersson & Thomsen, 1998; Hayden, 1980; Remschmidt, Poller, Herpertz-Dahlmann, Hennighausen, & Gutenbrunner, 2001; Wilkens, 1985). Age of onset for the disorder is typically 3-6 years but the problem is usually not recognized until school entry or later (i.e., age 6-8 years) (Black & Uhde, 1992; Ford et al., 1998). Selective mutism appears to have a variable but sometimes chronic course that can persist for years (Krysanski, 2003). In one study of second-graders with selective mutism, most (53%) had been mute since kindergarten and a substantial portion (18%) had been mute since preschool (Kumpulainen et al. …