Selective mutism can be defined as the difficulty some children present in communicating verbally in unfamiliar social environments and situations and/or with unfamiliar people.
This definition indicates, on the one hand, that children with selective mutism have adequate linguistic and communicative competence for their age and, on the other hand, that this good competence is usually manifested in the immediate family environment, but not in other environments and with less familiar people.
Many children with selective mutism also tend to present some characteristic personality traits such as shyness, social withdrawal, dependence, perfectionism, etc., which, if present in the child, can aggravate the problem or contribute to its consolidation.
This speech inhibition rarely resolves spontaneously and can last for a long time if no intervention is made. The role of the speech-language pathologist with training in educational speech therapy is of vital importance in these cases.
Selective mutism entails high levels of personal suffering and results in significant adaptation problems to the environment. It can mediate affective-emotional development and negatively impact the child’s social, personal, and academic development.
Selective mutism is a disorder straddling psychiatry, psychology, and speech therapy. Although the diagnosis usually belongs to the field of mental health (an anxiety disorder), the speech-language pathologist can detect and discern the differential characteristics of this problem and, above all, having experience in the recovery of language and communication disorders, can help that inhibited language flow and be re-established through its use.
Clinical Case of Selective Mutism
For a better understanding of the clinical case, we provide a real case of selective mutism below:
Patient Data
- 5-year-old boy, enrolled in the first year of early childhood education.
- With a sister a few months old.
- Context analysis: The child was an only child in the family, and his peer relationships were very limited.
Origin and Evolution of the Problem
Among the most important aspects of this clinical case of selective mutism, it is worth noting:
- Around two and a half years old, parents and teachers realize that the child does not interact the same way as other children his age (despite interacting, communicating, and engaging appropriately for his age within the family environment).
- There are characteristic family backgrounds and models,
- The father was like his son when he was little (he describes himself as very shy, even stopping talking in front of his uncles and aunts).
- The father states feeling uncomfortable in certain social situations.
- The mother is characterized as extroverted, but despite that, very protective, and her catchphrase when they left home was “be very careful with strangers”.
Problem Maintenance and Characteristics
- Parents, other adults, or children speak for the child.
- They interpret his gestures or guess what he needs.
- Non-participation in activities with other children.
- Relief from aversion in all previous occasions.
- Does not speak (verbal communication) in front of people who are not from his family environment.
- Speaks after a few minutes in front of familiar people with whom he interacts little.
- Always speaks with his immediate family (parents) in most places or situations.
Functional Analysis
For this clinical case of selective mutism, the situation was analyzed to understand the child’s behavior and better focus the treatment and work on the disorder more effectively:
- Someone not from his family environment greets him.
- He is playing in the park, and children come to where he is.
- Plays in the park while having a snack without speaking (verbal communication) to anyone.
- Physiological response: body and facial muscle tension.
- Cognitive response: not exactly known as we did not ask the child.
- Motor response: Escape/Avoidance (does not respond to requests, no eye contact, lowers head, hides, stays close to parents, moves away from other children…).
- Internal consequences: obtains negative reinforcement, as the child performs behaviors through which he eliminates the discomfort he is experiencing (especially tension).
- External consequences: obtains negative reinforcement, as, through the child’s behaviors, adults usually do things (facilitate the situation) that help him eliminate his discomfort.
- Contingencies: the reinforcement pattern is intermittent, as when he is with strangers, they offer negative reinforcement, but with his parents, this reinforcement does not exist.
Parents are explained, using the term “the trap,” that in the short term there is immediate relief and/or social reinforcement, but in the long term, it leads to the maintenance of the problem.
Intervention for Childhood Selective Mutism
Based on the data from the evaluation, the formulated objectives, and human and material resources, the intervention is established through the following techniques:
- Successive approximations.
- Stimulus fading.
- Shaping.
- In vivo desensitization.
- Contingency management and positive reinforcement.
Firstly, psychoeducation was provided to parents and the school environment, along with shaping and positive reinforcement. Guidelines were established for both the school and family environments: school guidelines primarily include activities for speech stimulation that can be carried out in the classroom, as well as guidelines for all teachers in contact with the child to avoid reinforcing the problem and improve verbal behavior, while, at the family level, the initial guideline was to modify the family’s “social life,” promoting more social and peer-interaction activities during free time and leisure.
Likewise, the intervention was specified through stimulus fading along with positive reinforcement in the classroom, setting the following objectives:
- Initiate and maintain verbal communication in any social situation,
- Improve social relationships and reduce tension when establishing social contact.
In speech therapy sessions, easy and small objectives were started to progress to subsequent and more complex objectives. For example, body language and written language were used as means to increase the expression of what was happening to the child. If he wanted to solve his problem, he had to write much more, move, and/or express himself. This was achieved through games.
Then, imitation of movies with non-verbal language and mime was applied. The patient engaged in dialogues where he interacted with the speech-language pathologist, representing comic strips, movies, games, music and dance, physical exercises like jumps and push-ups to give tone and expressiveness to everything he was asked to do. In this way, communication gradually shifted from written and gestural to sounds (though sometimes strange) that fulfilled the same communicative function.
Gradually, writing was phased out, and a more natural approach to speech was adopted, although initially it was voiceless, requiring lip-reading and non-verbal language. Thus, the patient, who was unable to cough, blow kisses, yawn, click, or maintain eye contact, had to start practicing and verifying that he could do it.
Finally, the child began to emit vowel sounds, say repeated words, and some spontaneous ones with a low voice volume and poor articulation. It is worth noting that it was fundamental to make him a participant in his progress and to feel that he was in control of his language.