Selective Mutism in the Montessori Classroom

    Selective Mutism (SM), is a disorder usually first seen in preschool and school-aged children who possess the ability to speak, however they may not speak in certain situations or environments, and it may interfere with their social or academic functioning (Bergman, 2008). It is considered a rare, possibly genetic, condition, affecting only 1% of the general population, and up to 2% of elementary children (Busman, et al. 2018; McHolm, et al, 2005; Muris, et al., 2015). The purpose of this paper is to explore the main characteristics of SM to help give Montessori elementary teachers a basic understanding of the disorder, and some guidance on how to accommodate children with SM in their classrooms.

The definition of SM and its possible causes have been disputed among researchers, as it has been found to share qualities with several anxiety disorders, social phobias, and some developmental language disorders (Fisak Jr, et al., 2006; Martinez, et al., 2015; Muris, et al., 2015). Parents and teachers are usually the first to recognize symptoms of SM, though they may not seek early intervention due to thinking the child is just “shy,”or just transitioning into a new school or environment, especially if the child or family has just been immersed into a new place, and they have been trying to learn the language and/or culture (Fisak Jr, et al., 2006; Martinez, et al., 2015; Starke, 2018). In those cases, SM may be mistaken for the receptive, “nonverbal period” (Starke, 2018, p. 47) as seen in the earliest stage of acquiring anew language, and may contribute to the higher rates of SM reported for English Language Learners and “immigrant families” (Muris, et al., 2015, p. 159; Fisak Jr, et al., 2006; Martinez, et al., 2015; Starke, 2018).

Teachers may be the first to notice a child who doesn’t speak in class, and be the last one to hear the child speak; the child may speak only to close family or friends but not to other adults, or only to certain adults (Fisak Jr, et al., 2006; Martinez, et al., 2015). There are also variations in the way SM is observed in children; some children may eventually speak in class, but do so quietly it is impossible to hear them, or they may use no sound, and only gesture or point in substitution for words (McHolm, et al., 2005).

Initially, parents may not notice anything unusual because most symptoms of SM are observed at school or in new and unfamiliar situations and settings, or they may describe their child as a “completely different kid” at home than at school (McHolm, et al., 2005, p. 8) because their behaviors are so strikingly dissimilar in each environment (Martinez, et al., 2015).

Once the child is referred for an evaluation, as long it has been more than one month since the start of a new school or big move, SM is typically assessed by professionals using the Selective Mutism Questionnaire (SMQ), which has a total of 23 questions for parents to answer about their children in various settings: “school, home/family, in social situations (outside of school), interference/distress” (Bergman, 2013, Appendix B; Bergman, et al., 2008).

Children with SM may be affected in different ways: temperament, behavior, social exclusion, and mental health later on, though there has been disagreement about specific diagnoses, children with SM are thought to have some type of anxiety, with varying ranges of severity; “nearly half of the children with SM had one or more anxiety disorders, notably specific phobias, separation anxiety disorder, and overanxious disorder” (Muris, et al., 2015, p. 156). Starke (2018) found that, “Social Anxiety is one of the most common comorbid disorders in children with SM” (Starke, 2018, p. 46; Bergman, et al., 2008; McHolm, et al., 2005; Muris, et al., 2015).

Untreated anxiety experienced by a child with SM can have both short-term and long-term adverse effects, such as “excessive withdrawal” socially (Martinez, et al., 2015, p. 84), and is of concern to parents and teachers because communicating through speech is a large part of keeping up academically in class, socially with peers, and functionally in the community (Busman, et al., 2018; Starke, 2018). Some parents have reported their children with SM have shown signs of perfectionism or obsessive tendencies, and some children have a fear of using public restrooms or using the bathroom at school, while other parents describe their children as being oppositional at home, though their teachers did not describe them as oppositional or disruptive at school (McHolm et al., 2005).

Some children with SM have comorbid speech and language disorders –“30%-50%” (Starke, 2018, p. 46), which may be cause or symptom of SM, and should be investigated further by the child’s “management team” (McHolm, et al., 2005,p. 55-63). Treatment is a high priority for children with a suspected diagnosis of SM, with intervention recommended as early as possible; Rachel Busman, from the Child Mind Institute stated, “children with SM do not get better without treatment” (Busman, et al., 2018, p. S129). Although, some children have been reported to overcome their symptoms as they age (Bergman et al., 2008). McHolm et al., (2005) have created several record keeping charts and tables for parents and teachers to use in the different stages of identification, which are similar to the SMQ used by diagnosticians, along with step-by-step instructions for navigating the process of formal assessment and diagnosis.

Martinez, et al., (2015) has called for an evaluation and formalization of the teacher’s role in supporting children suspected of having communication problems, and have created “The Teacher Telephone Interview: Selective Mutism and Anxiety in the School Setting (TTI-SM)” (Martinez, et al., 2015, p. 83) for use by teachers to start a collaborative conversation about children in their classroom who are showing signs and symptoms of SM. They assert,“for childhood disorders, like SM, teachers are a key player in the assessment, diagnosis, and treatment process” (Martinez, et al., 2015, p. 86).

Once a child has been evaluated and diagnosed by a qualified team of professionals who have had experience with SM, there are many options for treatment, including certain behavior therapies, as well as medications and parent training (Bergman et al., 2013; Busman, et al., 2018). It should be noted that several studies of SM reported one of the complications of testing initially, is that the children sometimes do not respond to adults due to their condition, so assessments may need to be modified or postponed until the child is able to answer the questions (Bergman, et al., 2013;Fisak Jr, et al., 2006; Martinez, et al., 2015).

Medications, such as selective serotonin reuptake inhibitors (SSRI), have been used for successfully treating symptoms of anxiety, and phobias, as well as monoamine oxidase inhibitors (MAOI), but there can beside effects so they are used with discretion (McHolm, et al., 2005;Muris, et al., 2015). The most effective treatment for SM is a combination of both SSRI medication and behavioral therapy, with a priority on building skills and increasing successful experiences –and not to regard anxiety as “the sole target of treatment” (McHolm, et al., 2005;Muris, 2015, p. 165).

Non-pharmaceutical interventions include Cognitive Behavior Therapy (CBT), including strategies such as exposure therapy, which can also be thought of as “practice,” (Fisak Jr., 2015, p. 397) as the child must practice gradually being in situations and settings in order to increase their social and functional behaviors (Fisak Jr, et al., 2006; McHolm, et al., 2005). McHolm et al., (2005) have outlined a model for constructing “Your Child’s Ladder” (p. 83-102) by recommending parents identify, then record in a log, the “activities, locations, and people,”(p. 86) of the different areas of their child’s life to find out when and where they may be having difficulty, and then make a list according to how they can help support their child in building their skills gradually (McHolm, et al., 2005).

Integrative Behavior Therapy for Selective Mutism (IBTSM) is a method of “graduated exposure to the feared stimuli,” (Bergman et al., 2013, p. 683) and was offered in 1-hour increments over the course of 24 weeks to the child with SM and their teacher and parents.

Another treatment, used by Fisak Jr., et al, (2006), also resembled CBT strategies, and included the child, their parents, and teacher. They started out simply taking turns, each of them whispering a sound, and from there they would build on by getting louder and louder until they were all taking turns yelling their sound. Then, by extending the sounds to include a word, they would keep increasing more words to build a sentence–a type of exposure therapy in practice (Fisak Jr et al., 2006).

Parent training was mentioned in several studies; there is a suspected genetic component along with cultural adaptation, assimilation, and familial traits, which served to maintain some of the symptoms of SM in their child/ren (Fisak Jr, et al., 2006; Starke, 2018). One study mentioned observations of families with children with SM tended to have parents who were “significantly more controlling and overprotective” (Muris, et al., 2015, p. 159).

The recommended training for parents included direct involvement in the therapy practice procedures at home, such as: role-playing the new skills, and positively “reinforcing appropriate speech, while ignoring” (Fisak Jr., et al., 2006, p. 196) other, inappropriate speech (McHolm, et al., 2005). Audiotaping, videotaping, and incentive logs were some of the assistive technologies mentioned, however it seems there could be other methods of assisted communication, such as a Picture Exchange Communication System (PECS) that may help to transition the children from silence to gesturing to speaking (McHolm, et al., 2005).

For a child in elementary, the early intervention phase is over, so assessment and intervention should be priority while the child is still in their formative early elementary years (Bergman, et al., 2008; McHolm, et al., 2005; Muris, et al., 2015; Starke, 2018). Other interventions at the elementary level should be parent training, especially for immigrant families or bicultural/bilingual families, since they tend to have much higher rates of children with SM (Fisak Jr, et al., 2006; Martinez, et al., 2015; Muris, et al., 2015; Starke, 2018).

Weekly parent meetings, which include explicit parent guidance may have to become a priority for a few months until a child with suspected SM is able to speak to adults and peers in school (Fisak Jr, et al., 2006; McHolm, et al., 2005).

In-class accommodations for Montessori elementary classrooms would include building trust and connection between the child with signs of SM, and other adults and peers, by building on their inherent strengths and interests, and by using the behavioral tools recommended, so they can gradually work to overcome their inability to speak in a supportive environment (Bergman, et al., 2008; McHolm, et al., 2005; Muris, et al., 2015; Starke, 2018).

References:

Bergman, R. L. (2013). Treatment for children with selective mutism: An integrative behavioral approach. Oxford University Press.Bergman, R. L., Gonzalez, A., Piacentini, J., & Keller, M. L. (2013). Integrated behavior therapy for selective mutism: a randomized controlled pilot study. Behaviour Research and Therapy, 51(10), 680-689.Bergman, R. L., Keller, M. L., Piacentini, J., & Bergman, A. J. (2008). The development and psychometric properties of the selective mutism questionnaire. Journal of Clinical Child & Adolescent Psychology, 37(2), 456-464.Busman, R., & Koplewicz, H. S. (2018). 6.3 Talk the Talk: Intensive Behavioral Treatment for Children WithSelective Mutism. Journal of the American Academy of Child & Adolescent Psychiatry, 57(10), S129-S130.Fisak Jr, B. J., Oliveros, A., & Ehrenreich, J. T. (2006). Assessment and behavioral treatment of selective mutism. Clinical Case Studies, 5(5), 382-402.Martinez, Y. J., Tannock, R., Manassis, K., Garland, E. J., Clark, S., & McInnes, A. (2015). The teachers’ role in the assessment of selective mutism and anxiety disorders. Canadian Journal of School Psychology, 30(2), 83-101.McHolm, A. E., Cunningham, C. E., & Vanier, M. K. (2005). Helping your child with selective mutism: Practical steps to overcome a fear of speaking. New Harbinger Publications.Muris, P., & Ollendick, T. H. (2015). Children who are anxious in silence: a review on selective mutism, the new anxiety disorder in DSM-5. Clinical child and family psychology review, 18(2), 151-169.Starke, A. (2018). Effects of anxiety, language skills, and cultural adaptation on the development of selective mutism. Journal of communication disorders, 74, 45-60.