Editing Selective mutism (section)

==Treatment==
Contrary to popular belief, people with selective mutism do not necessarily improve with age.<ref name="Johnson">{{cite book |last1=Johnson |first1=Maggie |last2=Wintgens |first2=Alison |title=The Selective Mutism Resource Manual |date=2001 |publisher=Speechmark |isbn=978-0-86388-280-7 }}{{pn|date=December 2022}}</ref> 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.<ref>Selective Mutism Group: Ask the Doc archives: [http://www.selectivemutism.org/faq/faqs/when-do-i-need-to-seek-professional-help-for-my-child When do I need to seek professional help for my child?] {{Webarchive|url=https://web.archive.org/web/20120311180146/http://www.selectivemutism.org/faq/faqs/when-do-i-need-to-seek-professional-help-for-my-child |date=2012-03-11 }}</ref><ref>{{Cite web |url=http://www.selectivemutism.org/faq/faqs/what-about-adults-what-are-the-long-term-effects-of-sm |title=What about adults? What are the long-term effects of SM? |access-date=2008-05-09 |archive-date=2012-07-01 |archive-url=https://web.archive.org/web/20120701035438/http://www.selectivemutism.org/faq/faqs/what-about-adults-what-are-the-long-term-effects-of-sm |url-status=dead }}</ref><ref>{{cite news |last1=Ketteley |first1=Emma |title=Killer's history of social disorders |url=http://news.bbc.co.uk/2/hi/programmes/this_world/7336053.stm |work=BBC This World |date=8 April 2008 }}</ref>

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.{{fact|date=December 2022}}

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.<ref>{{cite web |url=http://www.selectivemutism.org.uk/wp-content/uploads/2017/08/Older_Children_and_Teens-Ricki-Blau.pdf |first1=Ricki |last1=Blau |title=The Older Child or Teen with Selective Mutism }}{{self-published inline|date=December 2022}}</ref>

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.{{fact|date=December 2022}}

Under another law in the US, [[Section 504 of the Rehabilitation Act|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.<ref>{{cite web |url=https://www.hhs.gov/sites/default/files/ocr/civilrights/resources/factsheets/504.pdf|title=Your Rights Under Section 504 of the Rehabilitation Act |date=June 2006 |access-date =2023-02-09}}</ref>

Social Communication Anxiety Treatment (S-CAT) is a common treatment approach by professionals and has proven to be successful.<ref>{{Cite journal |last1=Klein |first1=Evelyn R. |last2=Armstrong |first2=Sharon Lee |last3=Skira |first3=Kathryn |last4=Gordon |first4=Janice |date=January 2017 |title=Social Communication Anxiety Treatment (S-CAT) for children and families with selective mutism: A pilot study |journal=Clinical Child Psychology and Psychiatry |volume=22 |issue=1 |pages=90–108 |doi=10.1177/1359104516633497 |pmid=26940121 |s2cid=206708229 }}</ref>  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. There are many treatment plans that exist and it is recommended for families to do thorough research before deciding on their treatment approach.{{fact|date=December 2022}}

===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.{{fact|date=December 2022}}

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.<ref name="Kehle Madaus Baratta Bray 1998">{{cite journal |last1=Kehle |first1=Thomas J. |last2=Madaus |first2=Melissa R. |last3=Baratta |first3=Victoria S. |last4=Bray |first4=Melissa A. |title=Augmented Self-Modeling as a Treatment for Children with Selective Mutism |journal=Journal of School Psychology |date=September 1998 |volume=36 |issue=3 |pages=247–260 |doi=10.1016/S0022-4405(98)00013-2 }}</ref><ref name="Shriver Segool Gortmaker 2011">{{cite journal |last1=Shriver |first1=Mark D. |last2=Segool |first2=Natasha |last3=Gortmaker |first3=Valerie |title=Behavior Observations for Linking Assessment to Treatment for Selective Mutism |journal=Education and Treatment of Children |date=2011 |volume=34 |issue=3 |pages=389–410 |doi=10.1353/etc.2011.0023 |s2cid=143555332 }}</ref>

===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.<ref name="Kehle Madaus Baratta Bray 1998"/><ref name="Shriver Segool Gortmaker 2011"/><ref name=Anstendig1998>{{cite journal |last1=Anstendig |first1=Karin |title=Selective mutism: A review of the treatment literature by modality from 1980–1996. |journal=Psychotherapy: Theory, Research, Practice, Training |date=1998 |volume=35 |issue=3 |pages=381–391 |doi=10.1037/h0087851 }}</ref>

===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,<ref name="Johnson"/> where a new person is slowly brought into the talking group. This can take a long time for the first one or two faded-in people but may become faster as the patient gets more comfortable with the technique.

As an example, a child may be playing a board game with a family member in a classroom at school. Gradually, the teacher is brought in to play as well. When the child adjusts to the teacher's presence, then a peer is brought in to be a part of the game. Each person is only brought in if the child continues to engage verbally and positively.<ref name="Kehle Madaus Baratta Bray 1998"/><ref name="Shriver Segool Gortmaker 2011"/><ref name=Anstendig1998/>

===Desensitization===
The subject communicates indirectly with a person to whom they are afraid to speak through such means as email, instant messaging (text, audio or video), [[online chat]], voice or video recordings, and speaking or whispering to an intermediary in the presence of the target person. This can make the subject more comfortable with the idea of communicating with this person.

===Shaping===
The subject is slowly encouraged to speak. The subject is [[reinforcement|reinforced]] first for interacting nonverbally, then for saying certain sounds (such as the sound that each letter of the alphabet makes) rather than words, then for whispering, and finally saying a word or more.<ref>{{cite web |title=WHAT is Selective Mutism? |url=https://selectivemutismcenter.org/wp-content/uploads/2017/03/What_is_Selective_Mutism_2014.pdf }}{{rs|date=December 2022}}</ref>

===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.<ref name="Kehle Madaus Baratta Bray 1998"/><ref name="Shriver Segool Gortmaker 2011"/><ref name=Anstendig1998/>

===Drug treatments===
Some practitioners believe there would be evidence indicating [[anxiolytic]]s to be helpful in treating children and adults with selective mutism,<ref>{{cite web|url=http://www.mentalhelp.net/articles/treatment-of-selective-mutism|title=Treatment Of Selective Mutism|date=21 March 2019 }}{{rs|date=December 2022}}</ref> 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.{{fact|date=December 2022}} 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.{{fact|date=December 2022}}

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.{{explain|date=January 2018}}<ref name="Kehle Madaus Baratta Bray 1998"/><ref name="Shriver Segool Gortmaker 2011"/> Furthermore, [[Selective serotonin reuptake inhibitor|SSRIs]] in particular have been used to treat selective mutism. In a [[systematic review]], ten studies were looked at which involved SSRI medications, and all reported medication was well tolerated.<ref>{{cite journal|last1=Manassis|first1=Katharina|last2=Oerbeck|first2=Beate|last3=Overgaard|first3=Kristen Romvig|title=The use of medication in selective mutism: A systematic review|journal=European Child & Adolescent Psychiatry|date=June 2016|volume=25|issue=6|pages=571–8|pmid=26560144|doi=10.1007/s00787-015-0794-1|s2cid=5859770 }}</ref> 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.<ref>{{cite journal |last1=Dummit |first1=E Steven |last2=Klein |first2=Rachel G. |last3=Asche |first3=Barbara |last4=Martin |first4=Jacqueline |last5=Tancer |first5=Nancy K. |title=Fluoxetine Treatment of Children with Selective Mutism: An Open Trial |journal=Journal of the American Academy of Child & Adolescent Psychiatry |date=May 1996 |volume=35 |issue=5 |pages=615–621 |doi=10.1097/00004583-199605000-00016 |pmid=8935208 |doi-access=free }}</ref> This indicates that fluoxetine is an SSRI that is indeed helpful in treating selective mutism.