Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C.E. Zupanick, Psy.D. and Mark Dombeck, Ph.D.
We previously described this disorder and reviewed its diagnostic criteria. In this section, we discuss treatment approaches.
First, the therapist rules out other possible communication disorders. In the case of selective mutism, children have the ability to speak but only in selectively chosen settings. Treating selective mutism is difficult because the mutism is an effective (but short-term) strategy for reducing children's anxious feelings. Unlike adults, children cannot easily escape situations that create a high degree of anxious distress. However, mutism serves as a child's version of escape. Since a child cannot escape, perhaps the next best thing is to become invisible via silence.
As we've discussed, escape is a common, but it is considered maladaptive because escape perpetuates the continuation of the disorder. In the short-term, escape reduces or eliminates anxiety. However, this strategy limits healing opportunities that lead to lasting recovery. The same is true for the child's version of escape: selective mutism.
Selective mutism reduces children's visibility in social settings they deem frightening. From a behavioral perspective, people around the child often reinforce this behavior unknowingly. As children continue to refrain from speaking in situations that make them highly anxious, the people they interact with start to accept the mutism. They stop expecting the children to speak. The child learns they can get people to stop bothering them simply by persisting in their muteness.
Treatment begins with a thorough evaluation of the home and school environments. Next, the therapist develops a behavioral modification plan using the principles of operant conditioning. A clinician creating a behavioral modification plan for Selective Mutism would first identify the situations and people that prompt the mutism. The clinician will coach teachers and family members to avoid rewarding mutism. Next, the clinician would develop a reinforcement system that rewards appropriate behavior. In this case, the child is rewarded for making an effort to speak in challenging situations. The behavior plan might use a token system, where the child receives tickets or stickers for desirable behaviors. Later on, the child can trade tickets or stickers for candy, toys, or privileges of his or her choosing.
Another behavioral therapy that is helpful is a modified version of exposure therapy. It is called systematic desensitization. Through systematic desensitization, children gradually learn that an object, person, or situation is not actually a threat. At this point, Mutism should decrease, as there is no longer a need to use this type of behavior to cope with anxiety. In other words, the child has more adaptive stress-coping skills. This approach helps children feel more relaxed and able to tolerate situations and settings that they find particularly threatening.
Antidepressant and anti-anxiety (anxiolytic) medications may be used to treat Selective Mutism. Tricyclic antidepressants such as Clomipramine and Imipramine (i.e., members of the older generation of antidepressants that existed before SSRIs like Prozac), and anxiolytics such as Clonazepam (a habit-forming benzodiazepine) and Buspirone (another kind of anxiolytic) are often tried. All of these medications have side effects associated with them. Therefore, they must be carefully taken as prescribed by a licensed physician. In addition, many antidepressants currently carry a "black box" warning for use in children. This class of drugs has been linked to a slightly elevated risk of suicidal behavior. Studies have shown that in a small number of children, these medications can increase suicidal thoughts and behaviors. A mental health professional should closely monitor children taking these drugs. This professional should closely monitor possible suicidal thoughts and behaviors. Everyone should check with their doctor about the risks and benefits associated with recommended medications. This is especially true for the caregivers of children.