Early diagnosis leads to more timely intervention and prevents long-term effects of SM. Diagnosis is typically made based on interview and observation, and standardized measures such as the Selective Mutism Questionnaire (Bergman, Keller, Piacentini, & Bergman, 2008). Behavioral treatment, as well as pharmacotherapy, should be considered once the diagnosis is made.
Treatment for SM is not often studied, with only two randomized controlled trials performed on SM (Bergman, Gonzalez, Piacentini, & Keller, 2013; Oerbeck, Stein, Wentzel-Larson, Langsrud, & Kristensen, 2014). However, cognitive-behavioral therapy has been proven effective as first-line treatment (Klein, Armstrong, Skira, & Gordon, 2016; Smith-Schrandt & Storch, 2017b). Two evidence-based approaches are integrated behavioral therapy (Bergman, 2013) and social communication anxiety treatment (S-CAT) (Klein et al., 2016).
Treatment should include: (a) gradual and systematic exposure to feared situations, and (b) significant involvement and coaching of family members and school personnel. Historically, treatment could take months to years (Jackson, Allen, Boothe, Nava, & Coates, 2005), but recent behavioral approaches attempt to shorten length of treatment. Intensive group-based delivery of behavioral treatment and “camp” type frameworks are becoming available, which include the benefit of peer interaction and are ideal in areas with a dearth of properly trained clinicians (Sharkey, McNicholas, Barry, Begley, & Ahern, 2008). Examples of this type of program are Brave Buddies (Child Mind Institute, 2016) (access https://childmind.org/center/brave-buddies), and Mighty Mouth Kids and WeSpeak (access https://www.selectivemutism.org/professional/kurtz-pyschology-consulting-pc).
Relaxation and coping strategies can be helpful early in treatment, but ultimately children should be encouraged to engage in activities that elicit anxiety. Exposure and experience of tolerating anxiety results in habituation and corrective learning (Farmer & Chapman, 2016). For example, each time children order at restaurants, ordering becomes easier and produces less anxiety (habituation). In addition, children learn that anxiety is uncomfortable but not dangerous, and their anxiety subsides over time. Children find that feared outcomes do not happen (e.g., they did not answer wrong) or are not as terrible as anticipated (e.g., no one laughs at their incorrect response).
Exposure must be gradual so children can experience success and do not shut down. Individualized hierarchies should be developed (Table). Communication exists on a spectrum from non-verbal responses to verbal initiation, and hierarchies can include steps such as communicating non-verbally, making eye contact, mouthing words, whispering, and using increasingly audible speech (Kearney, 2010). Individual functional factors that increase likelihood of speech are identified and integrated as steps in the hierarchy (Ale, Mann, Menzel, Storch, & Lewin, 2013). Typically, speech is easier in quiet settings with fewer people, a nonchalant approach, diverted eye contact, and focus on a shared activity. Multiple-choice questions, which require predictable and short responses (e.g., “What is your favorite subject?”), are effective early in treatment. Binary questions (with yes or no answers) will likely be met with only non-verbal responses, whereas open-ended questions (e.g., “Why do you think that is?”) may produce too much anxiety. Contingency management and rewards for exposure completion increase motivation and willingness. Technology and play (e.g., puppets, guessing games, televideo, talking animal “apps”) can be incorporated to facilitate communication and build rapport (Bunnell & Beidel, 2013).
Example Hierarchy for Systematic Gradual Exposure to Feared Speaking Situations
Other behavioral components that have proven helpful include shaping, “fading in,” and social skill building (Smith-Schrandt & Storch, 2017b). Shaping refers to gradually approximating speech. Initial exercises might include mouthing a response without audible vocalization, or starting with easy-to-pronounce phonemes (Klein et al., 2016). “Fading in” is a procedure in which speech is gradually transferred from a “safe” person to an unfamiliar person (Zakszeski & DuPaul, 2017). For example, a teacher may sit in the back of the classroom and gradually move closer to a parent–child conversation, ultimately joining in while the parent fades out of the classroom. Children with SM often lag in social skills, and may benefit from direct coaching such as role play, education about body language, or a list of conversation starters.
Any treatment of SM should include family coaching (e.g., Transfer of Control in S-CAT) to generalize treatment gains and reduce accommodation of avoidance (Khanna & Kendall, 2009; Klein et al., 2016). It is difficult for parents to see children in distress, and instinct is to rescue. It can be especially hard for anxious parents to tolerate their distress and their children's distress (Rudy, Storch, & Lewin, 2015). Parents benefit from psychoeducation on the exacerbating role of accommodation and coaching to reduce accommodation (e.g., counting to 10 before assuming non-response). Parents should also increase opportunities for children's exposure and allow for natural consequences. For example, parents may replace “Would you like a red lollipop?” with “If you want a lollipop, tell them which color you prefer,” and may refuse children the lollipop without speech. Parents are not the only ones who accommodate; siblings sometimes take on the “communicator” role, and children with SM will often befriend outgoing peers who are happy to do most of the talking. Siblings and friends can be coached to gradually reduce accommodation and “bridge the gap.” For example, a child with SM might be more likely to speak to new peers when a friend they already converse with is also at the playdate.
Importantly, school-based cooperation can speed improvement and facilitate generalization. Alternative methods of assessment (e.g., videotaped presentations, parents as test administrators) and other accommodations (e.g., bathroom pass, preferential seating by a friend or in the back of the classroom) may be initially necessary. Teachers can also benefit from learning factors that influence likelihood of speech (Child Mind Institute, 2016). For example, teachers can be warned against large reactions to vocalization because excessive attention, even if positive, can increase anxiety.
Behavioral intervention is considered first-line treatment, but some children may need medication as well. Currently, there are no published practice parameters for clinicians regarding medication management of SM. However, a recent systematic review of literature found fluoxetine to be the most studied medication, followed by sertraline, citalopram/escitalopram, other selective serotonin reuptake inhibitors and phenelzine, and a monoamine oxidase inhibitor. All studies showed symptomatic improvement (Manassis, Oerbeck, & Overgaard, 2016). Despite positive results, only three of the studies reviewed had unmedicated comparison groups, and only two were double-blinded. Limited evidence requires a careful risk–benefit analysis by a prescribing clinician, and medication should be reserved for children with persisting symptoms, severe impairment, or older age. In addition, clinical judgment is required when determining dosage, titration, and duration of medication treatment (Manassis et al., 2016).