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DIR / Floortime in Assessing and Treating Selective Mutism

By: Joleen Fernald, MS CCC-SLP, Doctoral Student

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 DIR/Floortime model is a perfect fit for remediating Selective Mutism. As a comprehensive framework, the DIR/Floortime 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
Featured Author and Organization: Joleen Fernald, CCC-SLP
We thank Joleen Fernald for allowing PediaStaff to reprint their article.
Joleen Fernald, CCC-SLP is currently a PhD student studying infant mental health and developmental disabilities with the Interdisciplinary Council on Developmental and Learning Disorders founded by Dr. Stanley Greenspan. She has a special interest in the social emotional development of young children. As a speech-language pathologist, Joleen works with children with a variety of communication disorders. She has partnered with Easter Seals NH to begin an assessment and treatment clinic specifically for selective mutism, a social communication anxiety disorder and is the immediate past Chair of the Selective Mutism Group, a non-profit organization specializing in the advocacy of Selective Mutism awareness. Joleen enjoys public speaking and has presented nationally on the topics of childhood apraxia of speech and selective mutism. To learn more about Selective Mutism visit the SMG website at To learn more about Joleen and her work, please visit her website at: Joleen

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