Contrary to popular belief, people with selective mutism do not necessarily improve with age. Effective treatment is necessary for a child to develop properly. Without treatment, selective mutism can contribute to chronic depression, further anxiety, and other social and emotional problems. Consequently, treatment at an early age is important. If not addressed, selective mutism tends to be self-reinforcing. Others may eventually expect an affected child to not speak and therefore stop attempting to initiate verbal contact. Alternatively, they may pressure the child to talk, increasing their anxiety levels in situations where speech is expected. Due to these problems, a change of environment may be a viable consideration. However, changing school is worth considering only if the alternative environment is highly supportive, otherwise a whole new environment could also be a social shock for the individual or deprive them of any friends or support they have currently. Regardless of the cause, increasing awareness and ensuring an accommodating, supportive environment are the first steps towards effective treatment. Most often affected children do not have to change schools or classes and have no difficulty keeping up except on the communication and social front. Treatment in teenage or adult years can be more difficult because the affected individual has become accustomed to being mute, and lacks social skills to respond to social cues. The exact treatment depends on the person's age, any comorbid mental illnesses, and a number of other factors. For instance, stimulus fading is typically used with younger children because older children and teenagers recognize the situation as an attempt to make them speak, and older people with this condition and people with depression are more likely to need medication. Like other disabilities, adequate accommodations are needed for those with the condition to succeed at school, work, and in the home. In the
United States, under the
Individuals with Disabilities Education Act (IDEA), a federal law, those with the disorder qualify for services based upon the fact that they have an impairment that hinders their ability to speak, thus disrupting their lives. This assistance is typically documented in the form of an
Individualized Education Program (IEP). Post-secondary accommodations are also available for people with disabilities. Another federal law, the
Americans with Disabilities Act (ADA), provides protections for distinct civil rights regarding effective communication. Under another law in the US,
Section 504 of the Rehabilitation Act of 1973, public school districts are required to provide a free, appropriate public education to every "qualified handicapped person" residing within their jurisdiction. If the child is found to have impairments that substantially limit a major life activity (in this case, learning), the education agency has to decide what related aids or services are required to provide equal access to the learning environment. Social Communication Anxiety Treatment (S-CAT) is a common treatment approach by professionals and has proven to be successful. S-CAT integrates components of behavioral-therapy,
cognitive-behavioral therapy (CBT), and an insight-oriented approach to increase social communication and promote social confidence. Tactics such as systemic desensitization, modeling, fading, and positive reinforcement enable individuals to develop social engagement skills and begin to progress communicatively in a step-by-step manner.
Self-modeling An affected child is brought into the classroom or the environment where the child will not speak and is videotaped. First, the teacher or another adult prompts the child with questions that likely will not be answered. A parent, or someone the child feels comfortable speaking to, then replaces the prompter and asks the child the same questions, this time eliciting a verbal response. The two videos of the conversations are then edited together to show the child directly answering the questions posed by the teacher or other adult. This video is then shown to the child over a series of several weeks, and every time the child sees themself verbally answering the teacher/other adult, the tape is stopped and the child is given positive reinforcement. Such videos can also be shown to affected children's classmates to set an expectation in their peers that they can speak. The classmates thereby learn the sound of the child's voice and, albeit through editing, have the opportunity to see the child conversing with the teacher.
Mystery motivators Mystery motivation is often paired with self-modeling. An envelope is placed in the child's classroom in a visible place. On the envelope, the child's name is written along with a question mark. Inside is an item that the child's parent has determined to be desirable to the child. The child is told that when they ask for the envelope loudly enough for the teacher and others in the classroom to hear, the child will receive the mystery motivator. The class is also told of the expectation that the child ask for the envelope loudly enough that the class can hear.
Stimulus fading Affected subjects can be brought into a controlled environment with someone with whom they are at ease and can communicate. Gradually, another person is introduced into the situation. One example of stimulus fading is the
sliding-in technique,
Spacing Spacing is important to integrate, especially with self-modeling. Repeated and spaced out use of interventions is shown to be the most helpful long-term for learning. Viewing videotapes of self-modeling should be shown over a spaced out period of time of approximately 6 weeks. to decrease anxiety levels and thereby speed the process of therapy. Use of medication may end after nine to twelve months, once the person has learned skills to cope with anxiety and has become more comfortable in social situations. Medication is more often used for older children, teenagers, and adults whose anxiety has led to depression and other problems. Medication, when used, should never be considered the entire treatment for a person with selective mutism. However, the reason why medication needs to be considered as a treatment at all is because selective mutism is still prevalent, despite psychosocial efforts. But while on medication, the person should still be in therapy to help them learn how to handle anxiety and prepare them for life without medication, as medication is typically a short-term solution. Since selective mutism is categorized as an anxiety disorder, using similar medication to treat either makes sense. Antidepressants have been used in addition to self-modeling and mystery motivation to aid in the learning process. In one of them, Black and Uhde (1994) conducted a double-blind,
placebo-controlled study investigating the effects of
fluoxetine. By parent report, fluoxetine-treated children showed significantly greater improvement than placebo-treated children. In another, Dummit III et al. (1996) administered fluoxetine to 21 children for nine weeks and found that 76% of the children had reduced or no symptoms by the end of the experiment. This indicates that fluoxetine is an SSRI that is indeed helpful in treating selective mutism. ==History==