This talk by Katie Campbell, Eastern Kentucky University ‘Childhood Anxiety Disorders: A look into Selective Mutism’ is primarily aimed at students. Katie is mentored by Dr. Myra Beth Bundy, also of Eastern Kentucky University.
Communication and language are important factors for development, social skills and education and have longer term consequences for educational and socioemotional outcomes. The lecture covers the following areas:
- The theory behind selective mutism
- Assessment via clinical example
- Cursory reference to different kinds of treatment
- The service implications for training of personnel by comparing views and expertise of speech and language therapists and clinical psychologists.
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ACAMH would like to thank Dr. Nermin Khalil (SLaM) for leading on the creation of this series of videos.
My presentation is called ‘Childhood Anxiety Disorders – a look into selective mutism’. My name is Katie Campbell and for my research I had to have a mentor so her name was Dr Barbara Bundy and she is a psychology Professor at Eastern Kentucky University where I also go to school at. I’m currently a senior at Eastern Kentucky University and my major is communication disorders and sciences and so kind of why the reason that I’m here is because of EKU’s honors program and so the students enrolled in the honors program must complete an undergraduate thesis on a topic of their choice it can either be creative or a traditional thesis as I chose a traditional thesis.
The first semester you have to prepare for the thesis which involves researching and getting your rb approval. So the second semester is actually writing your thesis and working with the faculty mentor and presenting your research findings to an audience of and anyone can come so it’s actually a really interesting program and I’m glad I got the opportunity because now I’m here
So i like to start off with a quote that I think is really important when talking about communication and so ‘communication is not only the essence of being human but it’s also a vital property of life’ and I find that a lot of the times we take communication for granted. Even as babies you know we cry as a reflex to get food or you know we’re uncomfortable so I feel like it’s something that we need to be reminded to be grateful for.
So it might you might be wondering why I chose the topic selecting mutism so in the childhood development classes in the early intervention classes were taught that child development could be impacted in multiple areas as such as language and speech motor cognitive social emotional if these needs are not met then the child’s development can be impacted in a series of ways so without socialization.
So like someone with selective mutism if they’re not speaking in certain situations and they’re not socializing their language and speech may be impacted their motor skills may be impacted because they’re not getting experiences through play with peers and they’re not speaking cognitive can be impacted social and emotional can definitely be impacted because they’re too anxious to get out and speak. So they may become frustrated and a lot of the times parents can get frustrated too because they think that their child’s not meeting I guess their behavior standards when in reality a child is just really frustrated and doesn’t know how to process their emotions.
Also I had a personal interest in selective mutism because I remembered as a child I was very reserved and I remember a lot of the times that my parents would get frustrated because I wouldn’t speak in certain situations where I was expected to speak. So whether that was at a family get-together or at school sometimes like a parent-teacher conference I would try to hide away and not speak and they would get frustrated because you know they didn’t understand why I was doing this and so this led me to realizing that there’s little to no research completed regarding selected mutism so that’s why I chose to research this topic. So you may be asking what is selective mutism and I really like this definition I found in my research it’s this author puts it as someone who systematically refrains from speaking in some settings where speaking is expected and most of the times this is found in school settings a teacher will report that a child is not speaking when called on in class and they may think that it’s a behavior issue whenever in reality the child is just too anxious to speak up.
So the dsm-5 criteria for selected mutism starts out by saying that the child shows consistent failure to speak in specific social settings in which there is an expectation for speaking example at school despite speaking in other situations. So they may be chatty at home because they’re comfortable at home with the parents but whenever they get into a school setting they may be too anxious to anxious to speak. Another criteria is that the disturbance interferes with educational or occupational achievement or with social communication. So the educational aspect is that it can affect their academic performance and occupational achievement. You know they may not be getting that their life experiences going out and playing with peers and motor skills and then with social communication it can be slightly impacted if the child kind of freezes when they’re spoken to or kind of like a blank expression on their face that can kind of lead clinicians to believe that it’s a maybe a deficit a deficit in the social communication aspect of communication which could also be called a chromatic deficit.
So the third criteria is that the duration of the disturbance is at least one month and it’s not limited to the first month of school. I kind of found that interesting because I’m sure a lot of kids are really nervous the first month of school and it takes them a while to like warm up to the teachers. So that could be maybe the kids who never quite warm up after months of school maybe need to get some assessments and see if this is an anxiety disorder.
So the fourth criteria is that the phil the failure to speak is not, it’s not a lack of knowledge or comfort with the spoken language required in the social setting, it’s more that they’re just not using it and they know but they know how to use it.
And then the last criteria is that the disturbance is not better explained by communication disorder which could be a fluency disorder an articulation disorder and it does not occur exclusively during the course of autism spectrum disorder or schizophrenia or another disorder such as them so a lot of people. I find confuse selective mutism with autism spectrum disorder a lot and I’ll talk more about that because it is tricky I’m trying to figure out which is which but there’s definitely autism spectrum disorder is more about the pragmatic aspect of communication while selective mutism was more about the social interaction like initiating a conversation and some of the symptoms are that a child can have lack of eye contact they’ll cling to their parents if they’re spoken to hiding running away crying freezing some of them will have a tantrum and fast to speaking you know publicly so like if they’re asked in a class to answer a question and they didn’t want to speak and the teacher got frustrated with them they may you know result in a tantrum they also have an avoidance of eating in public sometimes they can also be anxious when having a picture or video taken and also anxious to use public restrooms as many disorders there are some common misconceptions some like four of these four.
I found that are pretty I guess evident when talking about selective mutism so the first one is my kid is just shy a lot of the times parents think that their kid is just has a shock and a personality and that there’s nothing to be worried about there’s another one that is she or he has been abused a lot of the times people think that selective mutism is only present if a child has been through something as traumatic while that is true that it’s not always the case.
It can also be that he had you know he has autism a lot of people say like I’ve already mentioned and I’ll talk about more later and then the last one which I find really sad and while they’re all disturbing to say you know whenever a child really needs treatment is just that she’ll just grow out of it. I find that sad because it’s just kind of brushing off the child’s symptoms and it’s kind of saying that the child will never receive the treatment that he or she needs and can affect them later in life.
So some differential diagnosis or sometimes like selective mutism will be diagnosed instead communication disorders autism spectrum disorders behavioral disorders can also be part of it. So a lot of the times again parents will think that the child is being unruly or not behaving the way that they think they should like if they’re not speaking whenever they ask them to speak somewhere. So they may think it’s a behavioral problem and some parents may have a thought that their child has like oppositional defiant disorder and then another one is social anxiety disorder and while a lot of the times that it can be co-morbid with selective mutism it’s not as extreme as selective mutism.
So we’ll look closer at how selective mutism is a little a bit different than autism spectrum disorders and so here’s the dsm-5 criteria for autism and the first one is that they have persistent deficits in social communication and social interaction across multiple complex contexts as manifested by the following and I highlighted social communication here because that’s one of the biggest differences between selected mutism and autism spectrum disorders.
Selective mutism the people who have selected mutism like struggle more with social interaction than they do social communication while they may you know freeze up there for a while they’ll eventually warm up and you’ll see that they use gestures and facial expressions and body language to communicate while some with autism kind of usually has some deficits in that area so these are the following that they have to have deficits in so the social emotional so like the abnormal social approach and failure of normal back and forth conversations a reduced sharing of interest emotions or effect and the failure to initiate or respond to social interactions.
And then next is that they have deficits and non-verbal communicative behaviors used for social interaction ranging for example from poorly integrated verbal and non-verbal communication and then it goes on to say to abnormal abnormalities in eye contact and body language which is something that I said that you know selective the kids with selective mutism may have issues with at first but they’ll usually warm up and start using that area of communication and they also may have deficits in developing maintaining and understanding relationships arranging for example from difficulties adjusting behavior to suit various social context so imaginative play or making friends or they may just not want to make friends and most the time a child with selected mutism may want to have friends they’re just too anxious to put themselves out there and start the conversation to make friends.
And then the second criteria for autism is that they have restricted repetitive behaviors and you can go on to see that they have stereotyped or repetitive motor movements insistence on sameness highly restricted and you kind of just don’t see that with selected mutism. It’s more with autism spectrum disorders but less it also says that they may be hyper or hypo reactive to sensory input and sometimes the sensory processing disorder may cause selective mutism because maybe the child doesn’t know how to respond to so much stimuli being thrown at them but it’s usually not as extreme as someone with autism may have because they may you know as it says here excessive smelling or touching of objects visual fascination with lots of movement with selective mutism it’s more of a overwhelming input and they don’t know how to respond to the stimuli or tell someone else what they’re feeling so it can cause them just to have you know that anxiety disorder that makes them not want to communicate.
And then the third one is that the symptoms must be present in the early developmental period which is true for selective mutism kind of selective mutism can be like a disorder that happens at any stage so it’s not really has to be present in the early developmental period and then symptoms can cause clinically significant impairment and social occupational or other importance areas of functioning. And while that that’s also true for selective mutism but lastly it says these disturbances are not better explained by an intellectual disability so selective mutism most of the time isn’t because of an intellectual disability either it’s more just the child it just has this anxiety disorder that makes them not want to speak and then again like there’s like kind of this up in the air type of thing that’s like is selective mutism a anxiety disorder is it a communication disorder or is it both.
So in my understanding that sometimes selective mutism can be co-morbid with a communication disorder so the child may have a fluency an articulation a phonological disorder or a language disorder so if you think about if the child has a language disorder they may not feel as if they can understand or express their thoughts as much as their peers can so that can cause them to be anxious and not want to speak up but I think that selective mutism was more of an anxiety disorder and not really a communication disorder so I gave an example to try to like make it clearer.
I said a child can have an articulation disorder due to a cleft palate but the anxiety disorder permits the child from speaking because he or she is aware that he or she has a facial anomaly and that makes them not able to really speak the same as their peers so they know that due to their cleft palate that they don’t sound the same and you know they may be getting bullied they may be getting made fun of and so that can kind of make them not want to speak anymore and anxious to speak so they may develop selective mutism.
And where there’s no like a lot of research for select and mutism there’s no like a definite cause of it so these authors that I found kind of split them up into four areas some possible causes and I kind of like the way that they did split it up so first they said you know that it could be genetic that the child could have a genetic predisposition to an anxiety disorder and that you know that may be the reason why they may be an anxious child and develop selective mutism.
Next was that they may be their temperament they may be a very reserved child and that can make them more prone to selective mutism if they develop this need that anxiety disorder and then the environment which I found is a big impact on probably a lot of mental health disorders and a lot more children who come from families who have left the country left their home country and are learning the English language or we call them English language learners sometimes will have a silent period whenever they’re learning the language and they won’t feel as if they are I guess fluent enough to speak to other peers in their new environment and they just may be nervous to you know they may mess up on the language and can just cause them to maybe develop selection mutism.
And then two a lot of children who come from immigrant families are much more likely to develop selective mutism because it’s can sometimes be scary to come into a new environment and not to expect like not to expect what’s going to happen next and then also too just an environment that is healthy and the family wants to you know push the children like help them can really help out kids with selective mutism.
And then on the other hand if there’s you know there’s a likelihood that a child with selective mute like may develop slag and mutism if the family is going through a divorce or a hard time I just think that environment has a lot to do with selecting mutism and then last was the neurodevelopmental issues.
So I mentioned cleft palate which may be something that happens in utero and the child you know has the cleft palate and knows that they’re different than their peers and can cause some problems in school and can cause them to not speak and also too like if a child has a language disorder like I said before that receptive and expressive language issues may cause them to be reluctant to speak and could just get frustrated and kind of just shut down and not speak at all.
So I was interested in my research who can really treat this disorder and so I split I thought the two clinicians that I thought would have a lot to do with this disorder was a speech language pathologist or a clinical psychologist. I was personally interested in speech language pathology because that’s the road that I’m going down for a future career and then my mentor being the psychology professor she was she was interested to see if clinical psychologists are the main like person to treat this disorder too.
So I kind of just laid out the roles of the slp in the clinical psychologist so the clinical psychologist is more about diagnosing or evaluating mental and emotional disorders of individuals and administering programs of treatment interviews patients in clinics hospitals and other settings and studies medical and social case histories while the communication disorder sciences person or speech language pathologist is going to be working more to prevent and diagnose and treat speech language social communication cognitive communication and swallowing disorders in children’s and adult children and adults so the social communication aspect is more of a speech-language pathologist job in that pragmatic field but a lot of the times like I said before children with selective mutism don’t really have issues with the pragmatic area of communication.
At first they may seem to but they definitely a lot of the times will just warm up and through therapy begin to show that they do have facial expressions gestures joint attention eye contact so potential therapy techniques while again there is not a lot of research on selective mutism and I found that these were the most like I saw these the most through my research coming up from journal articles and studies.
So the applied behavior analysis could be used for selected mutism and I thought that the a b model can be used to show that what happens before their behavior so the child can be it can be brought to their attention that they get asked a question in class and because of that their behavior is not speaking.
So that could be a start of therapy you know bringing it up to their attention that this is where they get nervous or this is where what causes them not to speak another one is stimulus fading so an example of that is a child is with a parent and slowly the parent lists the new conversation partner which would be the therapist join until the child does not rely on the parent to be present in new social settings which would most likely be in the therapy room another one would be shaping so providing praise or positive reinforcement whenever the child points to something then whispers until they speak comfortably comfortably in their new setting.
So the child may come into the therapy room and they’re only pointing and gesturing to things but hopefully we’ll get them to where they’re whispering and then slowly like talking to us and then again we can use cognitive behavioral therapy like with other anxiety disorders and also pharmaceutics can be used anxiety medications if that’s what’s best fit for the child.
So I added a clinical scenario to kind of describe what it may look like if a child came in with selective mutism and the parents not quite know what’s wrong. So a parent guardian comes into a pediatric speech-language therapy clinic worried because their child’s teacher called her stating that her child would not speak in class when asked a question the teacher also states that the child freezes then begins to cry when asked to answer a question in class the parent guardian reports to the speech language pathologist that her child is chatty at home and has hardly any behavioral issues the parents also state states that her child did not have any issues at birth or does not have any health issues present.
So the speech language pathologist and minister administers the goldman fristo to find that the child is in normal range for heirs at his age. So you can see that the teacher was the first person to realize or notice that their the child has had issues speaking up in class when asked a question and the parent kind of doesn’t understand because the kid seems chatty at home which sometimes happens with selective mutism and coming in the speech therapy clinic the speech therapist wants to make sure that it’s nothing to do with their speech or language abilities and after you know the child scores okay on the goldman frisco the speech language pathologist may recommend them to a clinical psychologist to see if this is more of an anxiety disorder.
So as I said before with Eastern Kentucky’s University’s honors program I had the opportunity to complete an undergraduate thesis and a topic of my choice and so I have some research findings after doing that and my mentor and I kind of sat down and we were trying to make this unique and so we were kind of doing this like slps versus clinical psychologists and we wanted to know if there is a difference in the confidence level between communication disorders graduate students at EKU and clinical psychology graduate students at EKU concerning their knowledge and treatment of selecting mutism and we picked graduate students specifically because we wanted to see if our programs were teaching.
We’re teaching selected mutism and if it’s something that needs to be taught more in pre-service programs so our thesis our hypothesis was that both future slps and clinical psychologists have little to no experience treating selective mutism because it was so like a such an under research topic and our purpose in doing this was that we found that children with selective mutism were very few in number. And we thought that may could be because you know it’s not something that a lot of people know about so these kids may be getting diagnosed with social anxiety disorder or another disorder that isn’t quite selective mutism and also in general the population one in 200 children are inflicted with selected mutism and that again there are so many misconceptions that prevent them from never giving the treatment that they need and that can affect them later in life.
Whether that’s finishing school going to college and maintaining a job or just a happy life and again selective mutism can affect school performance and possibly affect development in those areas of development that I talked about speech language motor social emotional and that social skills are important for school-aged children’s to adults so if children are not getting out socializing making friends then that can cause them to have you know a lot of issues later in life.
So to start out we kind of build a little survey to give to the graduate students and what’s kind of neat about this is that we found a thesis from a past individual who at Eastern Kentucky University who surveyed speech language pathologist only in the schools.
So we wanted to take her survey and kind of make it unique in saying that giving it to the graduate students to see if our programs are teaching it rather she already gave it to school-based speech pathologists who have already graduated so we had six questions that were laggard scale questions they’re rated one to five. They said that information about selected mutism should be taught more often and in greater depth in college slash university slp training program or clinical psychology training program and the second one was I feel that treatment and selective mutism I feel that treatment selective mutism is within my personal scope of expertise and then third I have located advocate adequate resources for referring a child with selective mutism to professionals within my community.
And then we also have five multiple choice questions and I’ve listed some of them here and they said have you ever provided services to a child with selective mutism and then which of the following best describes the population of your work location.
And then third have you ever attended a course or workshop focused specifically on selected mutism and our methods of doing so was that we surveyed both graduate cohorts clinical psychology and communication disorders and sciences from EKU using SurveyMonkey under irb approval we compare the averages to see if there are differences between the groups when providing therapy to children with selective mutism and then we computed statistical t-test and chi-square test to see if one graduate cohort is more confident or has more experience in treating selective mutism.
So here are our results so the question was have you ever provided services to children with selected mutism and something weird about this question was that there are 28 respondents to this question. And then the rest of the questions there are only 27 respondents so someone must have took this survey and only answered number one but it shows that only one person said yes they had and then 27 people said no they have never provided services to children with selective mutism.
Then second was have you ever attended a course or workshop focused specifically on selected mutism five had said yes and 22 had said no.
And then the third question was approximately how many children with selective mutism characteristics past or present have you encountered in your professional practice. So twenty said zero and seven said one to three.
And then we also asked a question kind of about demographics which of the following describes the population of your work location and you can see that a lot of them were in a small town or a large town. There weren’t there really wasn’t any large cities it was mostly small towns so that could also have an impact on our research because they may just have less children that they’re providing therapy to given that they’re in a smaller town so on.
The clinical psychology side there were 22 respondents to this survey and so four had said yes they have provided services to children with selected mutism and 18 said that they had not the second question was have you ever attended a course or workshop focused specifically on selecting mutism one said yes and then 21 said no.
And then this one was kind of interesting we asked approximately how many children with selected me to some characteristics past or present have you encountered in your professional practice? 14 had zero and seven had one to three and then there was one person who said they had four to six children with selective mutism that they’ve encountered.
So the demographics they were kind of different than the communication disorders demographics area so we asked which of the following describes the population of your work location and this is kind of a little bit more spread out they a lot of them lived in a large town or a large central city. So they may be getting more children in their clinics then they may just see you selecting you to some more.
And so our results were that participants were asked how many clients with selected mutism they had treated or encountered and psychology students had encountered. On average one a client with selective mutism and then speech language students they slightly less than one on average and then there’s no significant differences between numbers of clients treated.
You can see our results from our t-test there we also found that there is no association between graduate student groups so communication disorders versus psychology and history of direct experience or training events on selected mutism and you see the results of our chi-square test there.
And then results continued an independent samples t-test was conducted to compare responses to the six likert scale questions between the psychology and communication disorders graduate student groups. There were no significant differences in the scores between the two graduate students groups suggesting that there were equal ratings across the groups on questions measuring concepts such as confidence in treating selected mutism and feeling that their that there are enough journal and articles available about selective mutism.
And also too we found interesting was that the highest ranked item for both groups of students was the following information about selecting mutism should be taught more in college and university pre-service training programs and the means for the Israel psychology was 4.6 and then cvs was 4.7.
Sso one being that they’re less like needed to be taught less and then five being that they needed to be taught more. And our conclusions that we found too about all of this research was that of course selecting mutism needs to be taught more in programs for pre-service individuals, and that there needs to be more workshops or specific instruction for selecting mutism, and it needs to be just offered more and that many pre-service individuals have little to no experience with selective mutism.
I found it of course interesting surveying students from Eastern Kentucky University to see if our programs taught about selecting autism more and it was interesting to see the different responses and I hope that this research can be used to advocate that we need to provide more workshops specific instruction for these kids but we did have some limitations to our research.
And that was because each graduate cohort has a small sample size the ces respondees respondents were 27 and then the clinical psychology was only 22.
And we also didn’t take agent consideration so you know if someone was maybe older they could have more experience with children they may have more selected me working with selective mutism more often.
Something else we talked about my mentor was that graduate students are new at treating most types of disorders so in communication disorders and one of the most common is an articulation disorder. S so they start us out treating articulation disorders before they start us out with more complex disorders and for clinical psychology too. We felt that students or pre-service students are more than likely to treat like the generalized anxiety disorder rather than something extreme like selective mutism so it may just mean something that they hadn’t got to yet in our discussion.
We saw that both psychology and speech language students or communication disorder students reported relatively little direct experience with individuals with selecting autism, and while we didn’t find any significant differences in reported comfort in treating knowledge about available information about and locating resources for selecting mutism it is notable that the question endorsed most strongly by both groups of graduate students relates the need for more training about the specialized disorder.
And then you know our goals for my thesis was that I wanted to raise awareness. It is such an under research disorder and to me it just breaks my heart thinking that there are children out there who think that they’re just shy or that they’ll just grow out of it and they never get the treatment that they need. So I wanted to take the blame off the child too and this is not me saying that it’s the parent’s fault or the family’s fault or anything it’s just that we need to provide more information to educate parents and families about this disorder because I can’t imagine being so anxious that I couldn’t speak at all.
And most of the time you know the parents may get frustrated because they don’t understand why their child may be so anxious to speak so I wanted to take the blame off the child and realize that this isn’t actually a specialized anxiety disorder and that they need help they need treatment for this.
And so I just really wanted to give advice for the parents and the families to show them that you know there is help out there. I wanted to encourage cross-disciplinary practice because a speech language pathologist you know may be able to help and the clinical psychologist may be able to help too but if they work together then you know it may be more beneficial for the child rather the child just seeing one professional versus the other.
And every time that you know we work together I just feel like it’s so much more beneficial for the client and then like after you know a lot of people think that this may just affect children but really there’s effects throughout the lifespan so if selective mutism isn’t treated there may be worsening anxiety depression and other anxieties may occur social isolation and withdrawal can be very harmful to someone who’s going into adulthood you know making decisions getting jobs poor self-esteem and self-confidence can also affect that another one is school refusal poor academic performance and the possibility of even quitting school.
So the not getting treated for selected mutism may and make it worse and just continuously like a snowball effect really and that the child may just or the person may just kind of give up and then under achievement academically and in the workplace.
Like I said they may not be able to make peers or relationships in the workplace to make them you know have a good work experience which could contribute to just a happy life. And then also yeah I think you can be seen with a lot with anxiety disorders and depression that they may start to self-medicate and with drugs and or alcohol and it may contribute to suicidal thoughts and possible suicide if their anxiety disorder is not treated so yeah I really think that giving that awareness to selecting mutism that it deserves can really like maybe not cause these hopefully we can avoid that and treat them when they’re children and those are my references.