Selective Mutism Lingo: Understanding Treatment for SM

Selective Mutism (SM) is an anxiety disorder characterized by consistent failure to speak in specific social situations. Kids with SM may struggle to speak at school, with adults, or with peers. They may have difficulty sharing personal information or making choices. Unfortunately, SM is not widely understood and neither are the important concepts that guide treatment for SM. This week we’re trying to increase awareness about SM treatment to better help families know what components they should be seeking from providers. Being a good consumer will help you to be the best advocate for your child.

PCIT-SM
Parent-Child Interaction Therapy for Selective Mutism (PCIT-SM) is an evidence-based treatment for SM developed by Dr. Steve Kurtz. It is based on the traditional PCIT model, which uses a two-step approach to manage disruptive behavior. In both models, the initial focus is on relationship-building techniques to facilitate trust. In the traditional PCIT model, this relationship building is followed by support in using effective discipline strategies. PCIT-SM shifts to verbally-directed interactions rather than those discipline techniques. The idea is: Once children feel supported and the focus on speaking is removed for a short while, they are more emotionally available to face their anxieties. At that point, we shift to helping them speak. The goal of PCIT-SM is to show children with SM that they can tolerate the uncomfortable feelings around speaking.

CDI
Child-Directed Interactions (CDI) are the first focus of treatment, which is the relationship-building phase. During CDI, we remove the pressure of speaking. Instead, we focus on positive behaviors and help kids to behaviorally engage. This helps build rapport before moving on to the harder steps.

VDI 
Verbal-Directed Interactions (VDI) are the second focus of treatment. During VDI, we help children with SM to answer verbally. We use specific techniques to remove the opportunity to respond nonverbally, while linking verbal responses with reinforcement. By thoughtfully identifying realistic goals, we meet children where they can be successful and slowly push further to help face the anxieties.

Anxious Avoidance
Anxious Avoidance is the escape from thoughts, feelings, or experiences that cause anxiety. Children with SM get really good at communicating in other ways and anxious avoidance has made them successful in this communication. Since facing anxiety feels “too hard,” kids with SM will often communicate nonverbally or remove themselves from verbal interactions altogether. In children with SM, anxious avoidance may look like: frozen face or body, hiding behind an adult, running away, nodding, or pointing. Adults also engage in anxious avoidance because we don’t want kids to go through negative experiences. Adults may support anxious avoidance by allowing a child to hide, answering for them, or telling others that the child does not speak. These behaviors get both kids and adults out of the situation that caused a surge in anxiety.

Contamination
Contamination is a long-learned history of not talking. Certain people, places, or even activities can become contaminated as children with SM begin to accept that they cannot speak in these repeated experiences. They also start to believe that others within those experiences do not think they can speak either. This furthers the anxiety, making it harder for a child with SM to speak and thereby, face that anxiety. This is why we always avoid questions when first meeting a child with SM. We do not want to have to undo contamination!

Reflections
Reflections are a repetition or paraphrasing of what a child says. In both CDI and VDI, we use reflections to let children know they were heard and also to echo their response to others nearby. It reinforces that you are listening while subtly changing the perception that the child does not speak.

Forced-Choice Questions
Forced-Choice Questions are questions that provide two or more verbal options. For example, “is your favorite color blue, purple, or something else?” By using forced-choice questions, we give opportunities for children with SM to respond verbally, rather than falling into patterns of nonverbal responses. This is also why we avoid yes/no questions, which often are met with a nonverbal nod or shake of the head.

Shaping
Shaping is the reinforcement of behaviors towards a more complex desired behavior. In PCIT-SM, we use shaping to help kids reach higher-level goals. With shaping, we first identify a larger goal, which then must be broken down to help a child with SM succeed. For example, if we want a child to answer a question in the classroom, we might first practice speaking outside the school, in the main entrance, in the hallway, and eventually in the classroom. If we started with speaking in the classroom, the degree of difficulty just might feel “too hard” and the child would not be successful. It is important to note that shaping is a nuanced and thoughtful process. Each child’s trajectory will look different.

Fade-Ins
Fade-ins are the process of incorporating new people into a verbal experience. These typically involve helping a child to verbalize with one person they are already comfortable with before introducing a new person slowly into the scenario. We use the idea of “passing the talking baton” to guide fade ins. Eventually, we work on helping the first person to fade-out of the verbal experience as well so that the child is speaking with the new person alone.

If you are looking for support in treating your child’s Selective Mutism, reach out to our team for a consultation call. We have clinicians licensed in New York, Illinois, & Vermont.