DIRFloortime® in Treating Selective Mutism
Selective Mutism has been described as a social communication anxiety disorder (The Selective Mutism Group, n.d.). Though its prevalence is considered rare in the DSM-IV (APA, 2004), research by Bergman et al (2002) showed that 1 in 143 elementary school-aged children met the diagnostic criteria for Selective Mutism.
Selective Mutism is documented to be associated with a number of co-morbid disorders that complicate a child’s profile. Given Selective Mutism’s relationship to anxiety, most consider these co-morbid disorders to be psychiatric in nature including depression, panic disorders, dissociative disorders, obsessive-compulsive behavior, and Asperger’s disorder (Sharp et al., 2006). Kopp and Gillberg (1997) found that 7.4 percent of children with Selective Mutism also met criteria for Asperger’s disorder. More recently, Stein et. al. (2010) found a partially shared etiology between Autism Spectrum Disorders and Selective Mutism.
However, speech and language disorders are also prevalent in children with Selective Mutism. Cleator and Hand (2001) estimate that 80% of children with SM also have speech and language disorders, while Steinhausen et al., (1996) suggest that about 38% have pre-morbid speech and language problems. These findings are consistent with theories that children with Selective Mutism avoid speaking out of fear of being teased for mispronouncing a word (Krysanski, 2003). McInnes et al. (2004) suggests that children with Selective Mutism have shorter, linguistically simpler narratives with less detail than children with social phobia. Children with Selective Mutism may also have normal receptive language and cognitive skills, but they show subtle expressive language deficits not attributable to social anxiety (McInnes et al., 2004).
In addition to the co-morbid psychiatric disorders and speech and language challenges, individuals with Selective Mutism may exhibit broader developmental delays. For example, a 2000 study by Kristensen highlights the way children with Selective Mutism may show developmental delay as often as they show anxiety disorders (68.5% for co-morbid developmental delay compared to 74.1% for co-morbid anxiety). Moreover, children with Selective Mutism may conceal their developmental delay in their silence (Kristensen, 2000) making intervention even more challenging.
Most models for assessment and intervention of children with Selective Mutism focus on cognitive behavioral therapy; however, the DIRFloortime® model is a perfect fit for remediating Selective Mutism. As a comprehensive framework, the DIRFloortime® Model described by Dr. Stanley Greenspan and Dr. Serena Wieder (2006), typically involves an interdisciplinary team approach including speech and occupational therapy, mental health professionals (e.g. social worker, psychologist, child psychiatrist), educational programs, and, where appropriate, biomedical intervention. After carefully assessing the child’s functional emotional developmental level, individual differences and challenges, as well as relationships with caregivers and peers, the interdisciplinary team will, together with the parents, develop an individualized functional profile that captures the child’s unique developmental features and serves as a basis for creating an individually tailored intervention program.
The child’s relationship with her family and surrounding community is the basis of her comfort within her environment. Family heredity and predisposition to anxiety play a key role in the relationship between the child and the adults in those relationships, so in addition to Relationships, taking into consideration the child’s Functional Emotional Developmental Levels (FEDLs) and the child’s Individual Differences has yielded success in 100% of our 37 cases in The Easter Seals NH, The Family Place Selective Mutism Clinic. Psychodynamic theories as well as theories from the disciplines of play, family systems, speech-language, sensory integration and occupational therapy are also incorporated within the therapy sessions.
Given the complexity of Selective Mutism, it requires a comprehensive treatment model, such as DIR/Floortime, which addresses all facets of the disorder: social emotional development, individual differences, including speech and language, motor and sensory processing, and relationships with others at home, school and in the community
Bergman, R. L, Piacentini, J., & McCracken, J. T. Prevalence and description of selective mutism in a school-sased sample. Journal of the American Academy of Child & Adolescent Psychiatry – August 2002. Vol. 41, Issue 8, Pages 938-946.
Cleater, H. & Hand, L. (2001). Selective mutism: How a successful speech and language assessment really is possible. International Journal of Language and Communication Disorders, 36 (Suppl.), 126-131.
Kopp S, Gillberg C. Selective mutism: a population-based study: a research note. J Child Psychol Psychiatry. 1997 Feb;38(2):257–262.
Kristensen H. Selective mutism and comorbidity with developmental disorder/delay, anxiety disorder, and elimination disorder. J Am Acad Child Adolesc Psychiatry. 2000;39(2):249–256.
Krysanski VL. A brief review of selective mutism literature. J Psychol. 2003;137(1):29–40
McInnes A, Fung D, Manassis K, et al. Narrative skills in children with selective mutism: an exploratory study. Am J Speech Lang Pathol. 2004;13(4):304–315.
Sharp WG, Sherman C, Gross AM. Selective mutism and anxiety: A review of the current conceptualization of the disorder. J Anxiety Disord. 2006 Aug 30.
Stein, M. B., B. Z. Yang, et al. (2010). A Common Genetic Variant in the Neurexin Superfamily Member CNTNAP2 Is Associated with Increased Risk for Selective Mutism and Social Anxiety-Related Traits. Biol Psychiatry, A 2010 Society of Biological Psychiatry. Published by Elsevier Inc
Steinhausen HC, Juzi C. Elective mutism: an analysis of 100 cases. J Am Acad Child Adolesc Psychiatry. 1996;35(5):606–614
SM Treatment Philosophy
My overall philosophy of SM stems from the DIRFloortime® framework developed by Dr. Stanley Greenspan and Dr. Serena Wieder. Utilizing the following graphic, (insert the FEDCs and SM graphic), I work from a bottom up perspective. Consider the analogy of building a house. One would want the strongest foundation to secure the walls, ceiling, and roof.
The priority is communication – talking will come as a child moves up the levels. I believe that anxiety at its foundation is related to one’s ability to regulate. If the child’s sensory systems are overloaded by sights, sounds, smells, tastes or touch, how could he possibly put forth effort to speak or attend or even engage. Therefore, it’s imperative intervention begins internally. I don’t use extrinsic rewards like stickers or toys. I prefer the child’s motivation comes from within and is a natural extension of our interaction and relationship. The following describes the hierarchy for my model of treatment for Selective Mutism
Functional Emotional Developmental Capacity 1: At the most foundational level, a child needs to be regulated (FEDC 1) in order to access the higher capacities. A child with SM at this level is typically non verbal and presents with little affect or facial expressions. Treatment focus is mostly on developing a relationship and rapport so that there’s trust between the clinician, child, and caregivers.
Functional Emotional Developmental Capacity 2: This level is where a child may begin to share attention and engage with his communication partner. He may gesture in response to a question with a head nod or shrug of the shoulders. Treatment focus at FEDC 2 is on both responding and initiating using gestural communication.
Functional Emotional Developmental Capacity 3: A child with SM demonstrating FEDC 3 often uses some sounds or laughs audibly while engaging in purposeful communication. He may mutter, “uh huh” or “mmmm” in response to a question. If this level is too challenging, children can use the Systematic Sound Sequencing Strategy to incorporate responding and initiating while using sounds or whispering.
Functional Emotional Developmental Capacity 4: Social problem solving is a skill necessary for interacting with peers and the focus of FEDC 4. Continuing to support both response and initiation at this level, while also incorporating pragmatics is the focus of intervention for children at FEDC 4.