Selective Mutism


Jared was a three-year-old who was extremely bright and talkative at home, but totally silent everywhere else. I saw Jared in collaboration with an occupational therapist and a play therapist that referred him to me. I used play therapy initially to create a non-verbal play environment to increase his social engagement. He used pictures, toys, and blowing tools to role play and use to gain attention and make requests. The occupational therapist diagnosed him with deficits in gravitational insecurity and bilateral coordination. Challenging his vestibular movement system and training his auditory system to have better sequencing and timing decreased his anxiety and gave him a basis to retrieve words in his social arena. Increasing his calm, organized thinking in more settings enabled him to begin speaking outside of his home. After 3 – 4 months he first began speaking inconsistently in therapy with the play therapist, then with his speech pathologist, and several months later with the occupational therapist. After about 6 – 9 months of therapy he branched out into speaking at school and other public forums. Because he had no experience talking with peers or adults, outside family members, he showed deficits in pragmatic communication even though his vocabulary and grammar language skills were well above age level. Prior to dismissal from therapy he was able to appropriately engage in a social skills group with increasing success. It is not been necessary for Jared to return to speech therapy in over a year. This is an unusually fast success rate of recovery not typical for this diagnosis. Traditional treatment for selective mutism usually does not include the sensory processing modalities used in this description which have facilitated the more rapid recovery.

Children with Selective Mutism are at the extreme end of the spectrum for timidity and shyness. The important distinction of SM from shyness is that SM interferes with the individual’s ability to function. If left untreated, it can have a severe impact on a child’s social relationships, emotional development, self esteem, and educational achievement.

A Sensory Processing Treatment approach is used at The Center for Therapeutic Strategies involves using team approach with a mental health practitioner, an occupational therapist, and a speech pathologist. We use multi-sensory methods which create calmness through modalities which:

  • Improve sequencing of timing of the individual within his or her environment
  • Train the auditory processing system to become more meaningfully aware of the auditory patterns of the environmental sound arena
  • Build a gradual platform for social engagement and eventually verbal communication with incremental steps

While shyness exhibits as a slow to warm-up time, the individual with Selective Mutism takes much longer to warm up, and they often are “frozen,” cannot respond at all. They seem to have a dual personality – restrained at school but talkative and even animated at home.

This failure to speak is not due to lack of knowledge or ability to generate spoken language, nor from a developmental delay. There is a growing trend of Selective Mutism with an estimated 1 in 143 children (compared to Autism: 1 in 150 – statistic changing) with more girls than boys affected (2:1). While the average age of diagnosis is between 3 – 8 years old; there may be signs of excessive shyness since infancy.

The stages of severity as listed on the Selective Mutism website range from 0 to 3 with:

  • Stage Zero indicating no initiating communication or social engagement at all either verbal or non-verbal
  • Stage One the individual is able to enter into non-verbal communication with some social engagement such as responding with gestures, pointing or head nodding and initiating with the same to get attention and needs met
  • Stage Two is using non-speech verbal sounds to communicate
  • Stage Three is responding and/or initiating with verbal sounds with increasing complexity and emotional comfort

Selective Mutism is a psychological diagnosis with the most successful interventions involving an interdisciplinary team. This team would include:

  • Parent
  • Classroom Teacher
  • School Psychologist/ Guidance Counselor
  • School Administrator
  • Pediatrician/Family Practitioner
  • Psychiatrist
  • Speech-Language Pathologist
  • Occupational Therapist
  • Mental Health Treating Professional (Clinical Psychologist, LICSW, Play Therapist)

Traditional treatment methodologies would include:

  • Visual Supports
  • Picture Schedules
  • Communication Board/Book
  • Picture Exchange Communication System (PECS) – Teaches initiation within the program
  • Social Stories – Carol Gray’s Social Stories
  • Literature – books can be very powerful motivators and change agents
  • Behavioral therapy
  • Cognitive Behavioral Therapy (CBT)
  • Play therapy
  • Psychoanalytic therapy
  • Medication
  • In some cases, family therapy
  • Related services such as occupational therapy and speech and language therapy

Selective Mutism is about a fear of the expectation to
therefore, the over riding goal of interventions is to alleviate anxiety by:

  • Improving organized engagement with their environment
  • Increasing the child’s self-esteem
  • Facilitate alternative ways to communicate in social settings
  • Create social engagement
  • Decrease social expectations for verbal communication
  • Focus on positive reinforcement
  • No negativity when mute – don’t force the child to speak

The type of treatment will vary depending on the age and cognitive development of the child. All benefit from using a multi-sensory movement approach which creates calm, focused attention/engagement. A young child may benefit from a more play-based approach, while older children or adolescents may benefit from a cognitive behavioral approach. It is important to provide a setting which has access to toys and equipment to allow the child to engage socially without the expectation to speak. Treatment should focus on first engaging non-verbally, then gradually bridging to verbal communication with movement and multi-sensory interactions with others.