for Selective Mutism
This chapter spans 70 pages in my book. I will keep it to just this one page for the purpose of this website!
Finding a Therapist
I do not treat private practice patients, since I conduct therapy in a therapeutic school. Parents seeking therapy for their child with SM will want the therapist:
to either be a specialist in the field of SM or else be very familiar with the specific therapeutic concepts and techniques that are used in a variety of intensive SM programs and treatment centers from specialists in the field of SM.
to be familiar with Parent-Child Interaction Therapy (PCIT), which is an antecedent management intervention that helps to create a safe environment for the child's anxiety to be reduced.
to be familiar with both gradual exposure techniques and operant conditioning, which helps to shape positive behaviors (in this case, speaking).
to be able to conduct proper exposures.
to be familiar with cognitive behavior therapy (CBT) to help reframe thought distortions to lessen ineffective anxiety symptoms.
to be familiar with mindfulness, an ancient Zen technique, which helps to regulate the amygdala and the fight/flight/freeze mechanism.
to know how to be an advocate for the child in his school setting, which means having a foundation of knowledge in special-education law and school accommodations.
Intensive Treatment Camps & Programs with Specialists in SM, Providing Therapeutic Intervention Possibly Including:
Psychoeducation, PCIT, Coping Strategies, Shaping Behaviors, Gradual Exposure Opportunities, and Operant Conditioning
Treatment for SM will usually be most effective with the foundation of intensive treatment and/or from specialists in the field of SM. There are many intensive treatment programs to choose from.
Some of these clinicians specializing in SM have similar philosophies on SM treatment, yet some have differing views as well. Regardless, these specialists are all using research informed techniques and have the same final goal of helping children to feel less anxious and more comfortable verbally communicating with others. None of these specialists, or the school, can guarantee success or an absence of symptoms. In my book, I cannot possibly cover every specialist or all of their methods, so keep researching!
Steven Kurtz, Ph.D., ABPP, founded an intensive SM treatment program, Brave Buddies, out of the NYU Child Study Center and later brought it to the Child Mind Institute®, which is now directed by Rachel Busman, Psy.D. This type of program was the first of its kind! Dr. Kurtz currently has another program in New York, SM Group Intensive out of his practice, Kurtz Psychology Consulting PC.
Brave Buddies is presented as a summer day camp, simulated in a school environment, and it uses PCIT (to be explained later), in addition to a gradual exposure model to shape behaviors with successive approximations and positive reinforcement. The children also participate in daily field trips as exposure opportunities to practice skills. According to Dr. Kurtz’s website, he has also trained teams of professionals in Chicago, Boston, Miami, and Vancouver to replicate Brave Buddies.
The very first sanctioned replication of Brave Buddies was founded in 2011 and is located in Oak Brook, IL (outside of Chicago) at Advanced Therapeutic Solutions, with the ATS Director of the Selective Mutism Program, Carmen Lynas, Ph.D., along with Andrea Brandon, Psy.D., a licensed clinical psychologist and specialist in SM, and Ashley O'Meara, Ed.D., ABSNP, a board certified school neuropsychologist, specializing in the psychoeducational testing of children. She also comes with a strong foundation in SM, due to her role at Advanced Therapeutic Solutions. Dr. Lynas' intensive SM program is called Adventure Camp, and this is where my twins have attended.
There are also other intensive SM camps with similar models (and some with different models), but they are not sanctioned replications of Brave Buddies.
In the therapeutic day school where I work, we have a student with SM who attended an intensive SM camp called Confident Kids Camp out of Thriving Minds Behavioral Health in Brighton, MI with SM specialist, Aimee Kotrba, Ph.D., LP.
The intensive camps are mostly one week long in duration and about 6 hours per day. That's 30 hours of therapy, which would usually take 30 weeks, if a child goes to therapy once a week for one hour at a time. Think about saving 29 weeks of your child's life! Once this foundation has been built with an intensive program, these therapists can help train the child's school staff members to use the same interventions to reduce anxiety and elicit speech. Therefore, the child can continue to progress in his natural environment, which is school. (Some of the week-long summer day camp programs also offer one-day "boosters" scheduled throughout the school year).
Brave Buddies, its sanctioned replication camps, and the other intensive SM camps cannot guarantee success or an absence of symptoms.
Elisa Shipon-Blum, D.O. needs to be commended for the advocacy for her own child with SM, in addition to the treatment she has been able to offer over 5,000 children with SM up to this point! Dr. Shipon-Blum has a research and treatment center in Jenkintown, PA. It’s called the SMart Center (Selective Mutism Anxiety Research and Treatment Center). She also developed the evidenced-based SM therapy: Social Communication Anxiety Treatment ® (S-CAT)®. She has been able to help the severely impaired children with SM through her Ritual Sounds Approach® (RSA)®, and she has been intergal in helping schools write IEP goals based on her Social Communication Bridge® and Selective Mutism-Stages of Social Communication Comfort Scale©. The SMart Center, in collaboration with SMRI (Selective Mutism Research Center) is offering a one-day Selective Mutism Boot Camp & Family Fun Day in July of 2015.
The techniques many of these SM specialists use are outlined in my book, but of course I possibly cannot cover every specialist or everything from every specialist, so keep researching to see what will work best for your child! The techniques I do discus are NOT all "do it yourself ideas." Rather, they need to be taught to parents by trained clinicians who also then can also train the school staff members to use these specific techniques. It seems as if when all of these techniques are used in an intensive program first, or with clinicians specializing in SM, the children with SM will be more receptive to parents and teachers using these techniques at school and in social settings.
Parent-Child Interaction Therapy (PCIT)
Parent-Child Interaction Therapy (PCIT) was developed by Sheila M. Eyberg, Ph.D., ABPP, in the 1970's out of the University of Florida. It was built from multiple theories of child development including attachment, parenting styles, and social learning. In the past, PCIT was intended mostly for 2-7 year-olds with disruptive emotional and behavior disorders, such as oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD), to work on enhancing relationships between the child and parent, for the child to develop more intrinsic motivation to comply and the parent to develop more positive feelings toward the child.
However, PCIT seems to help with anxiety and SM, too! In working with SM, the main PCIT concepts revolve around Dr. Eyberg's Child Directed Interaction (CDI) & PRIDE skills. It has been found that these PRIDE skills enhance any relationship, not just for those with disruptive disorders (and not just with "parents," but with school staff members and peers, too). PRIDE is shown to build confidence within the child. Therefore, if a child with an anxiety disorder, such as SM, feels comfortable with a certain relationship, she may feel more confident, less anxious, less behaviorally inhibited, and she will be more likely to speak! PRIDE can be used as an antecendent management intervention at school that helps to create a safe environment for the child's anxiety to be more effectively managed. These skills can be taught to school staff members by trained clinicians to help shape the child's environment at school. PCIT techniques cannot guarantee success or an absence of symptoms. Some therapists are Master Trainers in PCIT. Dr. Kurtz is a Master Trainer in PCIT, and Brave Buddies uses CDI and PRIDE, as do the sanctioned replications, as well as some of the other camps.
B.F. Skinner, Ph.D. was Professor of Psychology at Harvard University and was the father of behaviorism and operant conditioning. His theory is that people will continue behaviors that have desirable consequences and reduce behaviors that have undesirable consequences. He believes that environment plays a large role in controlling behavior. Obviously, with SM (and other mental health conditions), the child's brain chemicals and brain structure also contribute to behavior, so in my experience, it seems that children without mental illness respond a little quicker to these types of methods to modify behavior. However, with proper treatment, children with SM seem to be able to be very responsive to this type of behavioristic model. This is because in treatment, a foundation has already been set for them! What does operant conditioning involve?
Research from the behaviorists in psychology show that gradual exposure to the feared stimuli (in this case, speaking), while shaping behaviors with successive approximations has the most successful outcomes when habituating and desensitizing to anxiety. This means that children with SM are challenged with small challenges first, then positively reinforced for meeting those challenges, and then their challenges are gradually increased as they habituate and desensitize to their anxiety. Desensitization means that the more a person can sit with uncomfortable feelings, the more desensitized the person becomes to these feelings. This means these anxious feelings don’t feel “as bad,” even when they actually remain as strong the next time the person feels them, so they continue to progress with more gradual exposure and successive approximations. With the desensitization process, it's possible the person may still present just as anxious, but they can get through situations with more ease.
Skinner defines successive approximations as shaping successive trials towards a desired target behavior by rewarding the segments of behavior with positive reinforcement, and that people will continue to use behaviors (speaking) that have positive consequences. Professionals using Skinner's methods cannot guarantee success or an absence of symptoms.
Brave Buddies uses operant conditioning, as well as its sanctioned replications, and some of the other camps and programs.
Cognitive Behavior Therapy (CBT)
Any form of cognitive therapy work best for children ages 7 and older, due to the abstract nature of this type of psychotherapy. Children under this age will mostly be using play therapy as their means of interpersonal therapy, but still with the techniques that are research informed for SM, such as those found in PCIT and operant conditioning. It's should be noted there is no current research to back play therapy and SM treatment. However, if the play therapist is using the SM techniques that specialists in SM use, the child may still benefit, as my 5 year-old twins do in play therapy with their licensed clinical therapist, Jack Flight, LCSW, RDDP, CSOTS out of Tri-County Counseling. Once a child reaches age 7, if the child with SM is still nonverbal with the therapist, CBT may not be effective, and the other techniques will continued to be used. Even if CBT does become effective for a particular child after age 7, I still recommend using the other specific research informed SM techniques in combination with CBT.
Cognitive behavior therapy (CBT) was developed by leading psychiatrist and professor emeritus of the University of Pennsylvania School of Medicine, Aaron T. Beck, M.D., back in the 1960’s. Dr. Beck has authored or coauthored hundreds of articles and books on CBT. This particular form of psychotherapy has been scientifically tested and found to be effective in hundreds of clinical trials for many different disorders, including an array of anxiety disorders. (There is another form of cognitive therapy created prior to CBT, called Rational Emotive Behavior Therapy (REBT), developed by Albert Ellis, Ph.D., ABPP, which has very similar concepts as CBT. I frequently use Ellis’ approach in combination with Beck’s approach for with people with anxiety.)
CBT is based on a cognitive theory of psychopathology in which people’s thoughts or perceptions regarding the situations and events in their lives can positively or negatively influence their emotional, physiological, and behavioral reactions.
In terms of selective mutism and social anxiety disorder, people have some thought distortions, automatic negative thoughts (ANTS), and they live by invalid rules and assumptions that, unfortunately, help to maintain their ineffective anxiety.
If people constantly think these automatic negative thoughts and live by these invalid rules and assumptions, their emotions will be negatively influenced (will feel scared, stressed, embarrassed, worthless, lonely, sad, etc.), and their body systems will be negatively impacted (such as increased heart rate, sweaty palms, red face, headaches, etc.). Their behavior will be negatively influenced (mute behaviors, social withdrawal, behavioral inhibition, etc.).
People with anxiety exaggerate the threat of danger, and to complicate matters, they also do not notice information that can actually contradict inaccurate beliefs! They also overgeneralize situations. As an example of all of this, my daughter might say, “Chloe thinks I am stupid.” When my daughter thinks someone else thinks she’s stupid, it triggers feelings of sadness, loneliness, embarrassment, worthlessness, and anxiety. The consequences of these thoughts about the event evoke negative feelings. The future consequence is that this schema-driven behavior further confirms the schema. Without proper treatment, this can be a never-ending cycle.
The actual situation might be that my daughter with anxiety (SM) has her shoe untied, so Chloe tries to help her by letting her know it needs to be tied. Chloe offers help in a kind, genuine, helpful tone of voice, but my daughter with anxiety (SM) takes it as negative criticism and that she’s being made fun of, meaning that she ignores Chloe's actual positive tone of voice and also ignores Chloe's facial expression (which actually does not demonstrate disapproval). The child with anxiety and SM has schemas (the prisms through which she sees the world), and these schemas are shaped by her life experiences and then activated by matching events. Many people with anxiety misinterpret social situations because of their schemas. So, in the past, if someone was legitimately mean to the child with anxiety about mistake, this child now interprets most all interactions in this manner, leading to absolute thinking patterns (such as things are "all bad") and subsequently, perseverating thoughts about these negative perceptions.
The thought distortions, ANTS, absolute thinking, invalid rules/assumptions, schema-driven behavior, catastrophizing, overgeneralizing, perseverating thoughts, and "ignoring the positive" in anxious people are all concepts needed to be challenged in therapy.
As a disclaimer, CBT, REBT, any other cognitively-based therapy, and play therapy cannot guarantee success or an absence of symptoms.
Other Modalities of Therapy
There are other interpersonal modes of therapy that can be used, in addition to typical psychotherapy, such as music therapy, art therapy, dance/movement therapy, animal-assisted therapy, and recreation therapy. These are not research-based specifically for SM, but some are for anxiety disorders in general, so I do touch on these different treatment modalities in Suffering in Silence. In fact, I dedicate a full chapter to these other modes of interpersonal therapy because each child may gravitate toward something different that can help them with their self-management skills and interpersonal skills. These therapeutic modalities are NOT a substitute for typical psychotherapy and also cannot guarantee success or an absence of symptoms.
Mindfulness is an ancient Zen technique, popularized by the development of dialectical behavior therapy (DBT) by Marsha Linehan, Ph.D., APBB. She is a Professor of Psychology and adjunct Professor of Psychiatry and Behavioral Sciences at the University of Washington. DBT is used to help with emotional regulation, distress tolerance, and interpersonal effectiveness, originally intended for people with chronic suicidal ideation. Since suicidal patients are my personal specialty, I am very familiar with the mindfulness component of DBT.
However, it's found that mindfulness can be beneficial for people with other mental health concerns, such as anxiety, and SM is an anxiety disorder! Selective mutism is an overlearned physiological response. It has been researched that a person with anxiety experiences a hypertrophy (an increase) in the volume of neurons in the amygdala, heightening fear responses that are disproportionate to the event (anxiety) and causing an overactive amygdala to keep perpetuating the anxiety.
Luckily, mindfulness is a specific therapeutic technique that can physically alter the amygdala in a beneficial manner, leading to less severe stress responses: MRI research results show that mindfulness can actually decrease grey matter density in the amygdala in human beings. “This finding is particularly interesting as it suggests that an active re-learning of emotional responses to stress (such as taught in Mindfulness-Based Stress Reduction) can lead to beneficial changes in neural structure and well-being, even when there is presumably no change in the person’s external environment,” (Holzel, et al. 2009). This means that a person’s external stressors may remain the same, but the person does not feel as "stressed-out" by the stressors. “The present study investigates the potential relationship between changes in perceived stress and morphological changes in the amygdala… The more participants’ stress levels decreased, the greater the decrease of gray matter density in the right amygdala,” (Holzel, et al. 2009). When the brain physically changes, anxiety can be lessened!
Mindfulness combines deep breathing and sensory input to promote a sense of acceptance and serenity while in the present moment, otherwise known as the “here and now.” It’s defined as the non-judgmental awareness of present experiences.
Mindfulness should be used both proactively and reactively. As a proactive measure, I have my daughters practice mindfulness almost daily. Reactively, I prompt them to use mindfulness when they are emotionally dysregulated or in a tantrum/meltdown. Many children with SM will tantrum or meltdown, and mindfulness can be extremely helpful in these instances.
I treat children with anxiety disorders (and other mental health disorders) in a therapeutic special-education school setting, and I have worked with children in special-education buildings from ages 3-21, both as a teacher and as a therapist, so not all ideas in my book will work for each child, simply due to the nature of the child's age and the way his anxiety and SM presents. But, many of the ideas in my book can be adjusted slightly to fit your child's particular age or symptoms.
Unlike where I work, most children with SM will remain in their general education environment with typically developing peers, which is usually for the best. However, they can still obtain special-education services to help them succeed. My own twins remain in their regular general-education class, but they are considered special-education students because they have access to counseling services and speech therapy services, in addition to resource services and accommodations in the classroom to help reduce their anxiety and increase verbal output. In my book, I have listed about 40 accommodations that can help a child with SM succeed in the classroom, both academically and socially.
Therefore, it's recommended to solidify special-education services for a child with SM (or another anxiety disorder) under a 504 plan or with an IEP under the OHI (other health impairment) or ED (emotional disorder) category. Many parents have a stigma with the terminology of "special-education," but these services are provided under the IDEA law (Individuals with Disabilities Education Act), which is regulated by the federal government, to "level the playing field" for your child, so the child is able to be more successful at school both socially and academically, with legalized accommodations to help the child succeed.
In Suffering in Silence, all of this information is covered in chapter 9, and it is the second longest chapter of the book! In this chapter, I give a "sample letter" of how to get the special services process started for your child, the types of questions to ask, and I also discus what types of accommodations are appropriate for children with anxiety disorders and SM, in addition to what types of goals should be implemented and how those goals should be monitored. These special services cannot guarantee success or an absence of symptoms, and each child will have his own individual needs.
Currently, there is no FDA approved medication specifically for SM, but there are plenty of FDA medications approved for anxiety, and SM is an anxiety disorder, so it works! From the CAMS study that has been made public knowledge, it seems as if a combination of CBT psychotherapy and medication (SSRI) shows the best outcomes for a variety of anxiety disorders. There are several SSRI medications to choose from, and Prozac seems to be the most common prescribed for SM. My own daughters have had success with Zoloft, another SSRI. In Suffering in Silence, I go through the different SSRIs, in addition to some other medication prescribed more specifically for social anxiety disorder, and their potential benefits and side effects. In my opinion, it's best to see a psychiatrist rather than a pediatrician when dealing with psychotropic medication, as that is their specialty. You can sign a 2-party consent so the psychiatrist and pediatrician can communicate and coordinate treatment, as well as sign a 2-party consent for the treating therapists. As a disclaimer, I am not licensed to prescribe, and medication cannot guarantee success or an absence of symptoms.
As a disclaimer, there is no guarantee for success or an absence of symptoms, even with a combination of intensive treatment, specific SM techniques to reduce anxiety and elicit speech, such as those used in PCIT, operant conditioning, CBT/REBT psychotherapy, mindfulness, school services, the Social Communication Anxiety Treatment ® (S-CAT)® modality, the Ritual Sounds Approach® (RSA)®, medication, etc.
The definition of "success" also varies, and proper perspective needs to be kept: A frozen child going from complete nonverbal communication to then responding and initiating with one word at a time is clearly making progress, and progress is successful. The child will not need to be using complete age appropriate and socially appropriate reciprocal communication to be considered "successful." (Although, age appropriate reciprocal communication is the long-term goal.) In my experience, once gains with SM are made, these gains are held nicely. I have seen gains made with other mental health conditions that do not hold as well, specifically with (but not limited to) bipolar disorder, borderline personality disorder, trichotillomania, and obsessive compulsive disorder.