Early detection and treatment of selective mutism
Children who do speak at home but exercise complete silence at school and elsewhere: ‘selective mutism’ (SM) seems often hard to detect. Meanwhile, early intervention has proven to be important to live a happy (adult) life in our predominantly verbal society. A recent study by Dr Beate Ørbeck and Hanne Kristensen at the Oslo University Hospital and Centre for Child and Adolescent Mental Health (Eastern & Southern Norway) underlined the importance of an early intervention in selective mutism.
The recent follow-up study of home and school based cognitive-behavioural intervention for children with selective mutism follows up an earlier RCT study on selective mutism (2013). Ørbeck found a moderate and continuous increase of speaking behaviour among the children who took part. Diagnoses at older ages had a negative impact upon the outcome.
How early could selective mutism be detected?
Beate Ørbeck: “Children with selective mutism have always been like this. The earliest detection is mostly done by the caregivers at their kindergarten, around the age of two or three. The main thing is to notice the discrepancy between what happens at home and at the kindergarten, or school. Preschool teachers in Norway tend to be very active and observing. Without thinking of diagnosis, they do see it as a problem when a child refrains from speaking. For these cases, our study shows the importance of immediate upscaling to diagnosis and treatment. It could be damaging to the child if a teacher simply leaves the problem or starts acting on his own – I have seen examples where speech was demanded from a child or where children were even punished and locked up when they refused to speak.”
How familiar are caregivers, teachers and general practitioners with selective mutism?
“Perhaps not as familiar as they should be. Selective mutism deserves to get the same attention that is given to for example autism spectrum disorder. The prevalence is about one per cent, which is nearly the same as in autism. Increasing the awareness and knowledge level of caregivers and teachers is essential. As is the exchange of experiences with the parents, of course. Some teachers seem to blame themselves for not getting these children to speak and do not communicate about it – out of a kind of shame maybe. Sometimes they also presume that the parents know about it and think that something may be wrong with the parents or with the situation at home. They should drop their assumptions and talk to the parents.”
“Also, we are not supposed to diagnose selective mutism if a child has already been diagnosed with a disorder from the autism spectrum. Obviously there is a small overlap in the real world, but not in the diagnostic criteria. This makes selective mutism less visible. Therefore I could imagine that doctors and teachers still see it as one of those rare disorders that they don’t need to know about.”
Your study shows that treatment – preferably early treatment – can be effective.
“Yes, we found a steady increase of speaking behaviour in our Norwegian study. Children speak more freely after treatment and, years later, they mostly even describe their lives as ‘good’. It will be interesting to see broader figures that will be published shortly by Dr Boris Hartmann at the German SM self-help association. Those are very thoroughly collected data on available treatment from different European countries.”
“Our treatment method is based on three pillars: a behavioural intervention, psycho education and the use of defocused communication. An essential factor in this treatment is not focusing directly on the child, nor at the emotions of the child. We ease the anxiety of the child by concentrating on a certain pleasant joint activity and we communicate only on their level. We approach them with a genuine respect and we show that we are there for them with the best intentions. Pushing the boundaries of the children – like teachers sometimes tend to do – appears to be insensitive and easily makes them feel uncomfortable. In developing this treatment, we have learned a lot from the British approach and the American experts at UCLA – specifically the Lindsey Bergman questionnaires and treatment. I am sorry to say that SM research in the USA seems to be way ahead of us. The academic standards in treatment and research are much higher and the US culture demands speech even more than we do. American parents feel that their children must speak. Period. To get anywhere near to this level, European researchers and clinicians will really need to get together and cooperate. This is why Dr Hartmann’s work is so crucial.”
“In the very densely populated Los Angeles area they have an army of first rate CBT experts available. That makes their treatment more effective than we could ever reach. In Norway – as in many other European countries – many people live in remote places with no experts available. That is why we develop treatment programmes that can be performed at school by local non-expert therapists under telephone guidance from experts and in close cooperation with parents and teachers.”
Beate Ørbeck and her team will present a symposium at the ESCAP 2015 Madrid conference, titled: 'Selective Mutism: a challenge to assess and treat. Long-term follow-up results of a psychosocial intervention and a review of pharmacological treatment.' The symposium will take place on Sunday 21 June at 5:00 PM in the Londres room.
Background: Selective mutism (SM) describes children who consistently do not speak in certain social situations, while they talk freely in other situations. SM is now understood as an anxiety disorder (DSM-5), but knowledge is still sparse on effective interventions, and long-term outcome. How the affected children view quality of life and their own speaking behavior is rarely described. More understanding on quantitative symptom measures, when to apply a categorical diagnosis of SM, and the effect of pharmacological treatment, is also needed.
Aims: To increase knowledge about SM by presenting long term outcome in the form of categorical and continuous measures of SM, as reported by parents, teachers, and children 4-6 years after completion of a home- and school based treatment we developed in 2007. Finally, to present an overview of pharmacological treatment.
Materials and methods: Three presentations report follow-up results from 30 children, (aged 3-9 years at study inclusion). I. Diagnosis of SM: The Anxiety Disorders Interview Schedule and the Kiddie-SADS-PL, II. The SM questionnaires: rated by parents (SMQ) and teachers (SSQ), and III. The Children’s own voices: The Inventory of Life Quality (ILC). Included here is also an overview of the treatment, which includes defocused communication, psychoeducation, and behavioural techniques (sliding-in-technique with rewards). Finally; IV. Pharmacotherapy in SM: A review study, including treatment guidelines.
MUTISMUS.DE, special issue
Mutism International is the theme of the October 2014 special issue of the Cologne (Germany) based magazine 'Mutismus.de' (ISSN 1868-6575), published by Dr Boris Hartmann. This issue presents an overview of Selective Mutism in ten countries, and – remarkably – in their own languages, with the framework still in German and summaries in English. This colourful mix of German, Polish, French and English headlines right beside each other suggests a strong urge to communicate about the treatment, research and public perception of Selective Mutism. 'Mutismus.de' is the first and only special interest magazine that focuses on Selective Mutism only.
The contents of this special, international issue:
Boris Hartmann, Köln:
Michael Lange, Monheim, Petra Frießnegg, Cottbus:
Alice Sluckin, Lindsay Whittington, Leicester:
Barbara Oldakowska-Zylka, Warszawa:
Jan Hammer, Lier, Beate Oerbeck, Oslo:
Sandra Melliger, Beat Schweizer, Zürich:
Valérie Marschall, Colmar:
Steven Kurtz, New York:
Veysel Kizilboga, Mersin:
Loredana Pilati, Christian Callifano, Torino:
Anita Huang, Guelph:
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