Selective Mutism (SM) Clinic

Selective Mutism (SM) is a childhood anxiety disorder defined by a child’s persistent inability to speak in certain social settings and with certain people. Children with SM are able to verbally communicate in settings where they feel secure, typically at home and around their parents and siblings. However, ‘‘they are unable speak at all or speak above a whisper in other social contexts, for example at school, in public or at extended family gatherings’’ (Child Mind Institute). It is important to note the inability to speak in specific contexts that characterises SM is explained independently from “an organic inability rooted in language ability, another communication disorder and concurrent diagnosis of pervasive development disorder” (DSM-IV-TR). The condition is termed as ‘selective’ to highlight the specific situations in which children fail to speak rather than the intentional withholding or reluctance to speak as previously conceptualized (Wong, 2010). The prevalence of SM is currently 0.7 – 2% of children and its onset is typically between the ages of three to six, as children are expected to verbally participate in school. It is common that children with SM report a history of being behaviourally inhibited and are also diagnosed with other impairing anxiety disorders such as social anxiety disorder, separation anxiety and phobias (e.g. Dummit et al., 1997).

Treatment for Selective Mutism

Treatment for Selective Mutism consists of two primary domains: behavioural therapy and medication-based interventions. Behavioral and Cognitive-Behavioral interventions for children with SM have been well-supported in the research literature (e.g. Cohan et al., 2006), and involves systematically and gradually building confidence in the settings where the child is unable to speak in. The child is consistently encouraged to speak using positive reinforcement, making treatment a time for children to practice talking bravely in a fun and safe environment. Therapists also teach parents specialised techniques in guiding their child’s exposures to these difficult situations as they begin to practice talking in real-life settings.

If a child’s SM behaviour present as severe, has been prolonged, or if they had not responded desirably to previous psychotherapy, they may be prescribed medication, such as a selective serotonin reuptake inhibitor (SSRI) to reduce symptoms of anxiety. Pharmacological intervention effectively complements behavioural-based treatments as it increases children’s tolerances to exposure tasks, creating more successful experiences rather than avoidance (e.g. Wright et al., 1995). Parent ratings of their children’s SM behaviours undergoing medication have been shown to be significantly lower than those whose children were under a placebo (Black & Uhde, 1994).

Group Intensive Interventions for children with SM

To prepare children with SM for talking in the school and community environments, an innovative group treatment delivery was designed to simulate a classroom-like setting to encourage children to practice speaking in a safe but more social space. Trained counselors guide children through the day with high rates of positive reinforcement for using their voices loud and proud. Not only do the children get exposed to other adults, they get a day full of opportunities for peer-to-peer interactions. Activities during the intensive program aim to elicit speaking in increasingly challenging scenarios, gradually moving toward real-life community-based situations. Behavioral intervention in a group has been shown to highly effective as children get an intense ‘dosage’ of guided practice at talking, and these skills are carried forward onto a variety of settings and activities.

Available Treatment Options at the CDT

  • Individual weekly small groups
  • Confident Crew Program
    • 1-day Intensive Program
    • 5-day Intensive Program
  • Individualized Intensive Programs

Dr. Melissa Ortega, U.S. Licensed Clinical Psychologist, and her SM team provide sensible, practical, and collaborative support to children with selective mutism and their families. Dr. Ortega is the one of the few psychologists in Hong Kong specializing in SM and Social Anxiety Disorders (SAD).

For more information on the assessment of SM and our SM Program, please contact the CDT’s SM Program Director.