When a Child Doesn’t Speak: Treating Selective Mutism
A program works to coax children who stay silent in public out of their shells.
By Andrea Petersen
Aug. 17, 2015 8:51 p.m. ET
It is circle time at summer camp and nearly a dozen 5- and 6-year-olds are sitting cross-legged on a blue rug.
“Is it Wednesday or Friday?” counselor Stephanie Schwartz asks.
Rachel, a little girl with a brunette ponytail and flowered dress, shyly raises her hand.
“Wednesday,” she whispers.
It seems like a typical scene. But the fact that Rachel is speaking is a big deal. She—and all the other children here—have selective mutism. Most of them have gone without talking at school, at play dates and the grocery store for months—some even years. The weeklong camp is actually an intensive behavioral treatment to get these children talking as much and to as many people as possible. The program, called Brave Buddies, is run by the Child Mind Institute, a New York group that offers psychological treatment and operates a nonprofit promoting children’s mental health.
Selective mutism is defined as a “consistent failure to speak in specific social situations in which there is an expectation for speaking (e. g., at school) despite speaking in other situations,” according to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the book used by psychologists and psychiatrists to diagnose mental illnesses. Symptoms must last at least one month (not including the first month of school) and interfere with school or activities. Children with the condition generally speak normally at home.
Less than 1% of children have selective mutism, studies estimate. The typical age of onset is between 3 and 5 years old.
Joon Varcoe, Rachel’s mother, says she always just thought her daughter was shy. Rachel would hang back at birthday parties and her younger brother would often answer for her when people asked Rachel questions. But last fall, when Rachel was four, the preschool teacher said the girl wasn’t speaking at all at school.
“That’s when we knew that it was more than just shyness,” says Ms. Varcoe, a stay-at-home mother of four in McLean, Va. There was a safety issue, too. Rachel has severe food allergies and she couldn’t ask for help when she had a reaction.
Many children with selective mutism also are highly anxious in social situations. Some scientists believe that selective mutism is an extreme version of social anxiety.
“You will get kids who are completely mute in any kind of public situation,” says Christopher A. Kearney, director of the Child School Refusal and Anxiety Disorders Clinic at the University of Nevada, Las Vegas. “You get kids that will whisper. Some kids who in school will talk to kids but not adults, and vice versa.”
The condition seems to be linked to temperament: Children who tend to avoid novel situations—what’s known as behaviorally inhibited—are more at risk, Dr. Kearney says. Parents can inadvertently fuel the condition, too, by speaking for children or allowing them to communicate by pointing.
Brave Buddies mimics the rhythm of the school day. The program mixes free play and story time with field trips to Central Park and visits from a police officer and dental assistant. There is even show and tell, something often impossible for children with selective mutism. Each child is paired with a grown-up volunteer. Many of these “Big Buddies” are undergraduate and graduate psychology students. They encourage children to speak, and treat them to small rewards when they do.
During free play, Big Buddy Erin Sadler holds a stack of yellow blocks while 5-year-old Josh taps it with a black and white plastic magic wand.
“Are you putting magic inside the tower or outside?” asks Ms. Sadler, a Ph.D. student in psychology at Yeshiva University.
“Inside,” whispers Josh, a little boy with a blue-and-white checked shirt and blue shorts who is participating in his second Brave Buddies program.
“Again? It is kind of loud in here,” Ms. Sadler says.
“Inside,” Josh says again, this time a little louder.
“Inside,” Ms. Sadler repeats. “Thank you for putting magic inside the tower.” She puts an American Girl doll sticker on a blue sheet of cardboard, Josh’s Brave Board. Each time the children answer a question or exhibit “brave talking,” they get another sticker. When they fill their boards with stickers, their Big Buddies give them a green Brave Buck. The children trade bucks in for prizes at the end of each day.
The Brave Buddies treatment consists of what is called Child-Directed Interaction and Verbalization-Directed Interaction. Before children are asked questions or prompted to speak at all, the Big Buddies and therapists simply narrate what the children are doing, express enthusiasm, repeat what they say when they do speak and praise them for talking.
This “helps build rapport, helps build a comfort level,” says Rachel Busman, director of the Selective Mutism Service at Child Mind Institute.
Once therapists and Buddies prompt children to speak, they avoid yes/no questions. (Children can easily just nod or shake their heads to answer those.) They also wait at least five seconds for the child to answer. If the child speaks, they repeat what the child says and give specific praise. While the children are at Brave Buddies, parents are in their own training sessions learning these skills. (The weeklong program costs $2,750 per child.) Child Mind therapists also often train the children’s teachers. Before attending Brave Buddies, children are assessed and many families complete several days of intensive sessions with Child Mind therapists to ensure that they are at least minimally verbal.
There is no published research on the efficacy of Brave Buddies. But a few studies have shown that behavioral interventions do help children speak more. In one study involving 21 children with selective mutism, those who received treatment improved dramatically over 24 weeks compared with those on a waitlist. The therapy—which consisted of 20 one-hour sessions—focused on gradually exposing the children to situations where they were expected to speak. At the end of the study, which was published in the journal Behaviour Research and Therapy in 2013, 67% of children who received the treatment no longer met criteria for selective mutism.
Children with the condition are sometimes treated with antidepressants like Prozac and Zoloft. But there are only a handful of very small studies that show SSRIs are effective in treating selective mutism. Larger-scale, randomized controlled trials have shown that antidepressants are effective in treating children with social anxiety disorder.
Josh’s mother, Dylana Dorelus, a high-school teacher in Brooklyn, N.Y., says during the months the little boy wouldn’t speak at school he told her “that the words were in his mouth, but he couldn’t get them out.” Things got so serious that he stopped speaking at home, too. But, after a Brave Buddies program and months of individual therapy and group practice sessions, Ms. Dorelus says Josh was then talking to all of the grown-ups at school. He was back at Brave Buddies to work on speaking to other children and boosting the volume of his voice.
After a long day of “brave talking,” Josh beamed as he counted his haul of 24 Brave Bucks. He traded them in at the program’s Prize Store for a small ball and a container of lime green playdough. Then a counselor placed a medal around his neck. “Extraordinary Bravery,” it read.
Write to Andrea Petersen at Andrea.Petersen@wsj.com
