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Selective Mutism in Children: A Psychogenic Voice Disorder.

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Presentation on theme: "Selective Mutism in Children: A Psychogenic Voice Disorder."— Presentation transcript:

1 Selective Mutism in Children: A Psychogenic Voice Disorder

2 Definition in the Diagnostic and Statistical Manual of Mental Disorders The persistent refusal to talk in one or more social situations, including school Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., school), despite speaking in other situations The disturbance interferes with educational or occupational achievement or with social communications The duration of the disturbance is at least 1 month (not limited to the first month of school) Failure to speak is not limited to lack of knowledge or comfort with social language required (e.g., bilingual or immigrant children) (American Psychiatric Association, 1994) The persistent refusal to talk in one or more social situations, including school Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., school), despite speaking in other situations The disturbance interferes with educational or occupational achievement or with social communications The duration of the disturbance is at least 1 month (not limited to the first month of school) Failure to speak is not limited to lack of knowledge or comfort with social language required (e.g., bilingual or immigrant children) (American Psychiatric Association, 1994)

3 Symptoms: Excessive shyness Fear of social embarrassment Social isolation Withdrawal Impulsive traits Negativism Clinging behavior Temper tantrums Controlling or oppositional behaviors Excessive shyness Fear of social embarrassment Social isolation Withdrawal Impulsive traits Negativism Clinging behavior Temper tantrums Controlling or oppositional behaviors

4 Theories of causation Anxiety is most commonly an underlying feature Significant early childhood trauma Injury that affects the mouth Possible family secrets Anxiety is most commonly an underlying feature Significant early childhood trauma Injury that affects the mouth Possible family secrets

5 Problems of Selective Mutism Provides limited opportunity for social interaction and growth Delays the development of appropriate oral reading and work attack skills Hinders the involvement in normal school activities Provides limited opportunity for social interaction and growth Delays the development of appropriate oral reading and work attack skills Hinders the involvement in normal school activities

6 Prevalence Estimated to occur in less than.8 per 1,000 of the population Slightly more common in females than males Onset is usually before 5 years Many times disturbances may not come into attention until entry into school One or both parents of a selectively mute child have a history of anxiety symptoms, including shyness, social anxiety, or panic attacks Suggests familial tren. (Giddan et. Al, 1997) Estimated to occur in less than.8 per 1,000 of the population Slightly more common in females than males Onset is usually before 5 years Many times disturbances may not come into attention until entry into school One or both parents of a selectively mute child have a history of anxiety symptoms, including shyness, social anxiety, or panic attacks Suggests familial tren. (Giddan et. Al, 1997)

7 History Previously called “elective mutism”, renamed in 1987 to “selective mutism” psychoanalytic schools of Europe in 1800s to contemporary behavioral interventions Previously called “elective mutism”, renamed in 1987 to “selective mutism” psychoanalytic schools of Europe in 1800s to contemporary behavioral interventions

8 History con’t Little attention paid to children with selective mutism until Baltaxe (1994) who examined 12 years of records at the UCLA Neuropsychiatric Institute: Of the 24 patients identified: 75% had articulation problems 86% failed auditory processing measures 60% demonstrated receptive language problems 75% showed expressive deficits Little attention paid to children with selective mutism until Baltaxe (1994) who examined 12 years of records at the UCLA Neuropsychiatric Institute: Of the 24 patients identified: 75% had articulation problems 86% failed auditory processing measures 60% demonstrated receptive language problems 75% showed expressive deficits

9 Variety of Theoretical Explanations of SM Psychodynamic theorists believe SM is a manifestation of unresolved conflict (Dow et al., 1995).Psychodynamic theorists believe SM is a manifestation of unresolved conflict (Dow et al., 1995). The family dynamics/systems perspective believes children with SM are involved in faulty family relationships that lead the mutism symptoms (Anstendig, 1998).The family dynamics/systems perspective believes children with SM are involved in faulty family relationships that lead the mutism symptoms (Anstendig, 1998). Behavioral theorists see SM as the product of a long series of negatively reinforced learning patterns (Leonard & Topol, 1993).Behavioral theorists see SM as the product of a long series of negatively reinforced learning patterns (Leonard & Topol, 1993). Cognitive behavioral theorists see SM in relation to anxiety disorders (Cohen, et al., 2006).Cognitive behavioral theorists see SM in relation to anxiety disorders (Cohen, et al., 2006). Psychodynamic theorists believe SM is a manifestation of unresolved conflict (Dow et al., 1995).Psychodynamic theorists believe SM is a manifestation of unresolved conflict (Dow et al., 1995). The family dynamics/systems perspective believes children with SM are involved in faulty family relationships that lead the mutism symptoms (Anstendig, 1998).The family dynamics/systems perspective believes children with SM are involved in faulty family relationships that lead the mutism symptoms (Anstendig, 1998). Behavioral theorists see SM as the product of a long series of negatively reinforced learning patterns (Leonard & Topol, 1993).Behavioral theorists see SM as the product of a long series of negatively reinforced learning patterns (Leonard & Topol, 1993). Cognitive behavioral theorists see SM in relation to anxiety disorders (Cohen, et al., 2006).Cognitive behavioral theorists see SM in relation to anxiety disorders (Cohen, et al., 2006).

10 SLP roles in Selective Mutism Communication and Linguistic specialist (Often the first consulted when a child is not talking in school) Coordinate efforts of a multidisciplinary team (Psychologist, psychotherapist, social worker, classroom teacher, special education teacher, parents, peers) Communication and Linguistic specialist (Often the first consulted when a child is not talking in school) Coordinate efforts of a multidisciplinary team (Psychologist, psychotherapist, social worker, classroom teacher, special education teacher, parents, peers)

11 Diagnosing SLPs first must refer the parents and child to a mental health practioner. Assess the child’s receptive language (To make linguistic diagnoses, the SLP will have to rely on language samples recorded on audio- or videotape at home) Remediation of the linguistic aspect of the problem can only be addressed once speech has been initiated in the therapy setting SLPs first must refer the parents and child to a mental health practioner. Assess the child’s receptive language (To make linguistic diagnoses, the SLP will have to rely on language samples recorded on audio- or videotape at home) Remediation of the linguistic aspect of the problem can only be addressed once speech has been initiated in the therapy setting

12 Treatment Types Two pronged approach: Individual psychotherapy to reduce the general anxiety A behavioral program at school to slowly shape appropriate communication Treatment revolves around: contingency management: rewards speaking behavior and ignores non-speaking behavior stimulus fading: introduces a new person to a situation where the child normally speaks response initiation: encouraging child to initiate communication (Schum, 2002) Two pronged approach: Individual psychotherapy to reduce the general anxiety A behavioral program at school to slowly shape appropriate communication Treatment revolves around: contingency management: rewards speaking behavior and ignores non-speaking behavior stimulus fading: introduces a new person to a situation where the child normally speaks response initiation: encouraging child to initiate communication (Schum, 2002)

13 Treatment Types (Krohn, Weckstein, & Wright, 1992) developed a response initiation approach -Begins with a psychiatric evaluation, information presented to parents, and a brief period of therapy - Children given message that speaking is necessary Therapist schedules a complete day when child will spend the day with the therapist The child is required to speak one word to the therapist before leaving the therapist’s office then goals are set! (Krohn, et. Al, 1992) (Krohn, Weckstein, & Wright, 1992) developed a response initiation approach -Begins with a psychiatric evaluation, information presented to parents, and a brief period of therapy - Children given message that speaking is necessary Therapist schedules a complete day when child will spend the day with the therapist The child is required to speak one word to the therapist before leaving the therapist’s office then goals are set! (Krohn, et. Al, 1992)

14 Psychoeducational Approach Multidisciplinary approach, includes psychologist, SLP, classroom teacher, parents Psychotherapy and Speech and Language Therapy Encourage nonverbal gestures: ( I.e. Making eye contact, following directions, nonverbal participation in group activities, pantomime activities) Leads to Stimulus Fading Response Initiation, whispering Expand on verbalizations by having child choose what things to say Multidisciplinary approach, includes psychologist, SLP, classroom teacher, parents Psychotherapy and Speech and Language Therapy Encourage nonverbal gestures: ( I.e. Making eye contact, following directions, nonverbal participation in group activities, pantomime activities) Leads to Stimulus Fading Response Initiation, whispering Expand on verbalizations by having child choose what things to say

15 Psychoeducational Approach con’t Child must agree to whisper in SLP sessions Generalize to classroom teacher, an aide, others in the school environment, peers Shaping, encourage use of other vocalizations Cough, sounds with a kazoo, animal sounds Increase volume, child must be interested and animated about topics Generalize voice to specific words, class subjects, and finally different settings Must use reinforcement rewards (Giddan et. Al, 1997) Child must agree to whisper in SLP sessions Generalize to classroom teacher, an aide, others in the school environment, peers Shaping, encourage use of other vocalizations Cough, sounds with a kazoo, animal sounds Increase volume, child must be interested and animated about topics Generalize voice to specific words, class subjects, and finally different settings Must use reinforcement rewards (Giddan et. Al, 1997)

16 Peer Approach Involve the child with peers in various activities Most selectively mute children are well accepted and liked SLP identifies which peers show a mutual interest in the child Collaborates with teacher to set up instructional situations in which the child is paired with a preferred peer Peer can also attend speech and language therapy sessions Generalize from short activities to therapy sessions to home visits to activities outside home and school (Schum, 2002) Involve the child with peers in various activities Most selectively mute children are well accepted and liked SLP identifies which peers show a mutual interest in the child Collaborates with teacher to set up instructional situations in which the child is paired with a preferred peer Peer can also attend speech and language therapy sessions Generalize from short activities to therapy sessions to home visits to activities outside home and school (Schum, 2002)

17 Videotape/Audiotape Approach Self Modeling Child can see what it will be like when the child talks Tape at home, listened to at therapy Good for children who are resistant to behavioral therapy Video freeforward: Videotapes of the child talking obtained in situations in which the child talks fluently are edited with videotapes of the child in situations in which the child does not talk so that the edited intervention videotape depicts that child talking in situations in which he or she has been mute. (Blum, N.J. et. Al, 1998) Self Modeling Child can see what it will be like when the child talks Tape at home, listened to at therapy Good for children who are resistant to behavioral therapy Video freeforward: Videotapes of the child talking obtained in situations in which the child talks fluently are edited with videotapes of the child in situations in which the child does not talk so that the edited intervention videotape depicts that child talking in situations in which he or she has been mute. (Blum, N.J. et. Al, 1998)

18 Treatment Issues The longer the child is silent, the more entrenched the behavior gets Course of treatment is unpredictable (Based on length of time the behavior has existed, personality factors, willingness of the significant others to focus on the problem) Selectively mute children often found in immigrant populations (Due to cultural and linguistic differences between home and school) The longer the child is silent, the more entrenched the behavior gets Course of treatment is unpredictable (Based on length of time the behavior has existed, personality factors, willingness of the significant others to focus on the problem) Selectively mute children often found in immigrant populations (Due to cultural and linguistic differences between home and school)

19 Treatment Issues con’t Selectively mute children are often inadvertently rewarded for not talking Follow rules, quiet Fellow classmates often reinforce, support, and enable silence by speaking for the child Easy for people to become frustrated with the child Selectively mute children are often inadvertently rewarded for not talking Follow rules, quiet Fellow classmates often reinforce, support, and enable silence by speaking for the child Easy for people to become frustrated with the child

20 Treatment Issues con’t Recent medical literature reports use of antidepressants to treat selective mutism Found to be helpful in treating anxiety symptoms, does not treat mute behaviors Routine and structure important for an anxious child, know what is to come Often “slow to warm up”, let the child observe first (Schum, 2002) suggests using terms such as “shy” and “nervous” to describe feelings when they are reluctant to speak, and “brave” when they speak Recent medical literature reports use of antidepressants to treat selective mutism Found to be helpful in treating anxiety symptoms, does not treat mute behaviors Routine and structure important for an anxious child, know what is to come Often “slow to warm up”, let the child observe first (Schum, 2002) suggests using terms such as “shy” and “nervous” to describe feelings when they are reluctant to speak, and “brave” when they speak

21 Works Cited 1Up Health. Selective Mutism. Retrieved March, 30, 2003, from American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4 th ed.). Washington, DC: Author. Atoynatan, T.H. (1086). Elective Mutism: Involvement of the mother in the treatment of the child. Child Psychiatry and Human Development, 17, Baltaxe, C.A.M. (1994, November). Communication issues in selective mutism. Paper presented at the American Speech-Language-Hearing Association Convention, New Orleans, LA. Blum, N.J. (1998, February). Case study: audio freeforward treatment of selective mutism. Journal of the American Academy of Child and Adolescent Psychiatry, 37, Giddan, J.J., Ross, G.J., Sechler, L.L., Becker, B.R. (1997). Selective mutism in elementary school: multidisciplinary interventions. Language, Speech and Hearing Services in Schools, 28, Krohn, D.D., Weckstein, S.M., & Wright, H.L. (1992). A study of the effectiveness of a specific treatment for elective mutism. Journal of the American Academy of Child and Adolescent Psychiatry, 31, Schum, R. (2002). Selective mutism: an integrated treatment approach. ASHA Leader online. Wergeland, H. (1979). Elective mutism: Acta Psychiatrica Scandinavica, 59, Up Health. Selective Mutism. Retrieved March, 30, 2003, from American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4 th ed.). Washington, DC: Author. Atoynatan, T.H. (1086). Elective Mutism: Involvement of the mother in the treatment of the child. Child Psychiatry and Human Development, 17, Baltaxe, C.A.M. (1994, November). Communication issues in selective mutism. Paper presented at the American Speech-Language-Hearing Association Convention, New Orleans, LA. Blum, N.J. (1998, February). Case study: audio freeforward treatment of selective mutism. Journal of the American Academy of Child and Adolescent Psychiatry, 37, Giddan, J.J., Ross, G.J., Sechler, L.L., Becker, B.R. (1997). Selective mutism in elementary school: multidisciplinary interventions. Language, Speech and Hearing Services in Schools, 28, Krohn, D.D., Weckstein, S.M., & Wright, H.L. (1992). A study of the effectiveness of a specific treatment for elective mutism. Journal of the American Academy of Child and Adolescent Psychiatry, 31, Schum, R. (2002). Selective mutism: an integrated treatment approach. ASHA Leader online. Wergeland, H. (1979). Elective mutism: Acta Psychiatrica Scandinavica, 59,


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