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Selective Mutism Care Pathway

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Selective Mutism Care Pathway 1 Selective Mutism Care Pathway Defining Selective Mutism (SM) and important clinical factors to consider: Selective Mutism Pathway Appendix A: What is Selective Mutism? Appendix B: Are there other associated behaviour or personality traits? Appendix C: Why does a child develop SM? Reference for SM article for parents Early Words Selective Mutism Care Pathway- July 2017 2 Selective Mutism Care Pathway When selective mutism is suspected, in conjunction with a speech-language concern, the following steps should be taken: • Emphasize the importance of a team approach (e.g. parent(s)/caregiver(s), speech language pathologist, childcare providers, psychologists, etc.) • Inform parent(s)/caregiver(s) that they are instrumental in creating positive changes in their child’s life • Give parent(s)/caregiver(s) an article entitled, “When the Words Just Won’t Come Out- Understanding Selective Mutism” by Dr. Elisa Shipon-Blum. • Share the website (www.selectivemutism.org) • Encourage parent(s)/caregiver(s) to attend the “I’m Shy” Workshop at Ron Joyce Children’s Health Centre; schedule is in the Growing Together guide. • Recommend that the child be seen for a psychological assessment. The family must contact Contact Hamilton http://contacthamilton.com/main/ (or 905-750-8888) and request a referral to the Child & Youth Mental Health Program at Ron Joyce Children’s Centre. • Children with suspected selective mutism should be identified as a priority for receiving intervention/consultation given that the research strongly supports early intervention in the prevention of establishing long-term dysfunctional social and family dynamics as well as significant anxiety disorders (e.g. social phobias, agoraphobia, panic disorders, anxiety disorders etc.). Research supports that significant positive gains can be made by implementing positive strategies to help families and children cope with the speaking anxieties at an early age (i.e. sooner rather than later). • The client with a speech and language concern, should be placed on the EW Child Services waitlist and seen asap • Therapy will depend on the nature and extent of the SM. Some clinic sessions may be held to promote speaking to the clinician however; services are best received when they are in the environment in which the client struggles to speak. Thus, 8-10 weeks of therapy consisting of in- clinic and community sessions may be held. Sessions may be scheduled (e.g. bi-weekly, monthly; depending on client need. Sessions should be offered in a location comfortable for the client). A subsequent block may be offered if appropriate. • The goal of the block is to increase the client’s comfort in challenging situations/locations. Parents/caregivers are responsible for carrying over the goals to those environments in successive steps developed with the SLP. CDAs who have attended a SM workshop and training may provide direct services. • A Selective Mutism kit with numerous resources, including a parent/caregiver guide, a teacher’s guide, books for SLPs, story books for children, treatment guides, workbooks (to copy) and computer app suggestions is available at RA for SLP reference. The kit was created with suggestions from Dr. Jeff St. Pierre, Psychologist, CPRI Selective Mutism Service, London. • For children entering JK, a referral to the school board SLP should be initiated, with parental consent • SLPs may consult with the SM lead- Aynsley Warden Early Words Selective Mutism Care Pathway- July 2017 3 Appendix A: What is Selective Mutism (SM)? Selective Mutism (SM), formerly called elective mutism, is defined as a disorder of childhood characterized by an inability to speak in certain settings (e.g. at school, in public places) despite speaking in other settings (e.g. at home with family). SM is associated with anxiety and may be an extreme form of social phobia according to researchers and clinicians who are familiar with the disorder (Black & Uhde, 1995; Dow et al., 1995, Dummit et al., 1997, Kristensen, 2001; Leonard & Dow, 1995). The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, referred to by clinicians as the DSM-IV, (APA, 1994) recognized that the social and avoidance characteristics of social phobia may be associated with SM, and thus, both diagnoses may be given. More than 90% of children with SM also meet the diagnostic criteria for social anxiety disorder, now termed social phobia (Black et al., 1996). Diagnosis of other comorbid anxiety disorders are also commonly diagnosed with SM and social phobia (Biedel & Turner, 1998). The name change from “elective” to ‘selective mutism” in DSM-IV deemphasized the oppositional behaviour connotation that a child elected not to speak and rather emphasize the characteristic of the disorder, that there are selected environments in which speaking does not occur (APA, 1994). The term selective mutism is consistent with new etiology theories that focus on anxiety issues (Dow et al., 1995). The DSM-IV-TR (APA, 2000) states that the following criteria must be met in order to qualify for a diagnosis of selective mutism: An inability to speak in at least one specific social situation where speaking is expected (e.g., at school) despite speaking in other situations (e.g., at home); The disturbance has interfered with educational or occupational achievement or with social communication; The duration of the selective mutism is at least one month and is not limited to the first month of school; The inability to speak is not due to a lack of knowledge of or discomfort with primary language required in the social situation; and , The disturbance cannot better be accounted for by a communication disorder (e.g. stuttering) and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder. Consistent with current research, Selective Mutism Association believes that Selective Mutism is best understood as a childhood social communication anxiety disorder. SM is much more than shyness and most likely on the spectrum of social phobia and related anxiety disorders. SM is NOT a child willfully refusing to speak. Early Words Selective Mutism Care Pathway- July 2017 4 Source: https://www.selectivemutism.org/learn/faq Appendix B: Are there other associated behaviours or personality traits? 1. Anxiety related issues, such as profound shyness, little eye contact, social isolation, fear of social embarrassment, withdrawal, clinging behaviour, compulsive traits, separation anxiety disorder, generalized anxiety disorder and specific phobias (Dummit et al., 1997) 2. Appearing negative or oppositional when attempting to avoid feared social situations, and display temper tantrums, particularly at home 3. Using non-linguistic cues such as gestures, nodding or shaking the head to get their messages across. A child may pull or push objects and obstacles, and in some cases, communicate in short or monotone voice or in an altered voice (APA, 2000). Some of these behaviours may not be present at the onset of SM. At the onset of SM, children may often stand motionless and expressionless due to anxiety. 4. Fundis et al. (1979) reported that 71% of the children in their studies displayed difficulty in performing motor activities and had bowel and bladder problems or, enuresis (wetting accidents) and encopresis (soiling accidents). Some individuals with social anxiety symptoms may also experience parureis, the fear of using public restrooms; perhaps it is the fear of making sounds while urinating that others may hear (Stein & Walker, 2002) Appendix C: Why does a child develop SM? The exact cause of SM is unknown, however, base don research and clinical observation, some factors appear to contribute to or co-occur with Selective Mutism. These can include: 1. A shy or anxious temperament. Many children who have SM are described as shy, inhibited, anxious or have social anxiety. These reports combined with Early Words Selective Mutism Care Pathway- July 2017 5 clinical experience suggest that SM may occur in an inhibited temperament, or inborn personality of mood (Dow et al., 1995). 2. A family history of shyness and/or anxiety. There is some evidence that there is a genetic link between children with SM and anxious parents or family members. Most commonly, social phobia, avoidant personality disorder, and parents with a history of SM themselves were more prevalent in families with a child with SM than those without (Black& Uhde, 1995; Chavira et al,. 2005; Kristensen, 2001). 3. Over reacting amygdala (brain area responsible for reacting to threats) which sets off a series of reactions that will help individuals protect themselves. The amygdala can set off a series of responses even when the individual is not really in danger. The anxiety responses are triggered where speaking is expected including school, the playground or social settings. Although there may be no logical reason for the fear, the feelings that the child with SM experiences are just as real as if an actual threat or danger were present. 4. Other factors may also contribute to the development of SM. A significant number of children with SM also have expressive language disorders and some come from bilingual family environments (Kristensen, 2000; Elizur & Perednik, 2003). While these factors do not cause SM, they can contribute to a child’s anxiety with speaking. The child may become more self-conscious about his or her speaking skills and may have increased fear of being judged negatively by others. 5. A stressful or unconnected environment may also be a risk factor in the development and maintenance of SM. If significant stressors are present, they may contribute to the SM by increasing the child’s already present anxiety. Kids with SM may be more likely to come from families who are not well connected with the school community (such as a child who lives in a different neighbourhood than his/her classmates). Adapted from: https//www.selectivemutism.org/learn/faq/ *An information article by Dr.
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