Learning to Work with Mute Patients in Your Speech-Language Pathology Practice

One of the more disconcerting situations you might run into as a speech-language pathologist is working with someone who simply doesn’t speak.

Mutism can be a tricky diagnosis to make. Sometimes the culprit is purely physical: damage to the brain and/or speech muscles can leave a person mute. Sometimes the culprit appears to be emotional or mental. Other times, you’ll run into some combination of the two.

Neurogenic Mutism

Neurogenic mutism is a lack of speech due to underlying damage to the brain. The mutism can be short or long term, static or progressive—it all depends on the region of the brain affected and the level of damage sustained.

As a speech-language pathologist, you may find yourself working with patients like 6-year old Xavier, who woke up after brain surgery unable to communicate with his family.

“He didn’t eat or drink and the worst part [was that] he didn’t speak,” writes Xavier’s mom, Bec, on the Facebook page she created to follow his journey.

The form of neurogenic mutism Xavier faced is known as cerebellar mutism. Researchers aren’t exactly sure what specific damage causes cerebellar mutsim, but current thinking is that surgery to remove tumors may result in lesions on the cerebellum that affect speech.

While Xavier woke up from surgery unable to speak, some patients with this form of mutism don’t lose their ability to speak until 1-6 days post-operation, something that could be even more troubling to parents and family.

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Causes of Neurogenic Mutism

Neurogenic mutism can be caused by:

  • Surgery
  • Dementia
  • Traumatic Brain Injury
  • Seizures
  • Other nervous system diseases
  • Medications

Neurogenic mutism is often a manifestation of extreme forms of other speech disorders, including:

  • Aphasia
  • Apraxia
  • Dysarthria

Treatment of Neurogenic Mutism

When treating someone with neurogenic mutism you will be one of multiple healthcare professionals that make up the team of therapists and specialist, so expect to work along side other therapists, including PTs and OTs, as well as a neurologist.

Initial treatment often involves medication to support brain function, and  speech therapist might not be called in until the individual shows solid attempts at trying to speak.

From there, you will need to assess whether or not the individual’s speech problems fall into one of the standard categories such as extreme dysarthria or extreme aphasia and make your treatment plan accordingly. Depending on the situation, you may also be called on to treat swallowing issues.

Long-Term Results

It’s difficult in the early days to know what sort of recovery an individual will make; the type and severity of brain damage can influence this, as well as whether or not the damage is due to a progressive, degenerative disease like dementia.

With some patients your goal will be to get them back to being able to speak as well as they did before their injury or the on-set of the causal disorder. For others, your goal will be to help them find ways to communicate even as their speech continues to deteriorate.

For those like Xavier, who suffer from cerebellar mutism, simply recovering simple words and phrases can take weeks or months. These patients often show signs of apraxia or aphasia and need continuing treatment for months or years.

“It took almost 5 months before Xavier started making real progress,” writes Bec. “[It] made us extremely happy to hear his beautiful voice again.”

Psychogenic Mutism, Also Known as Selective Mutism

Twenty-six-year-old Hannah is only able to speak with her parents. In other situations like school, where she’s interacting with a larger group of people who she is less familiar with, her words get stuck, and even though she wants to speak, nothing comes out.

“It isn’t me. I know who I am and I’m not shy or quiet,” Hannah shared with researchers at the University of Huddersfield during a recent study. “When I’m with my parents I can be myself but around everyone else it’s like it [selective mutism] takes over. I can get the words in my head but something won’t let me say them and the harder I try the more of a failure I feel like when I can’t.”

With selective mutism, a person suddenly stops speaking, but without any injury to the brain. These individuals can speak in some circumstances but not others, or with some people but not others. Psychogenic mutism most often shows up in children, but it can also appear later in life.

Unlike small children who are simply shy in certain circumstances, psychogenic mutism is a pervasive problem that interferes with someone’s ability to lead a normal life and without intervention, most won’t simply grow out of it.

Types of Psychogenic Mutism

Over the years, the way psychogenic mutism has been classified, and the terms used to describe these classifications and different aspects of the disorder, have shifted and evolved. Even today there isn’t total agreement across fields regarding how to classify psychogenic mutism. The most common “types” of classifications you will hear of include:

  1. Elective Mutism: A person chooses not to speak as a result of psychological issues.
  2. Selective Mutism: A person wants to speak, but in certain circumstances finds that they can’t
  3. Total Mutism: A person doesn’t speak under any circumstance.

In older literature, you’ll find that selective mutism was essentially considered elective mutism, but we now understand they are two distinct issues.

As a speech language pathologist your focus will be on those in the second category, selective mutism. You may, however, work with patients in the selective mutism category who go through periods of total mutism.

Causes of Psychogenic Mutism

It’s hard to pin down one specific root cause for psychogenic mutism, and experts disagree (sometimes passionately) on this question. Some of the more common triggers suggested include:

  • Stress
  • Sudden life change
  • Feeling threatened

There are some common risk factors, however, that seem to show up among these patients:

  • History of Anxiety or Anxiety Disorders
  • Extreme Shyness
  • Social Anxiety Disorder
  • Sensory Processing Disorder
  • Auditory Processing Disorder
  • Obsessive Compulsive Disorder
  • Reduced Opportunities for Social Interaction
  • Bilingual or Multilingual Environment

In the past researchers thought that trauma caused selective mutism. Current research, however, suggests that while trauma may induce total mutism it doesn’t relate to selective mutism.

Traumatic mutism generally looks more like a child who witnesses a death or experiences other trauma and then stops speaking in all circumstances.

Bilingualism and Selective Mutism

You might find yourself working with a child who has lived overseas or lives in a bilingual family. When acquiring a new language it’s common for young children to go through a “silent period”, and this isn’t something to worry about.

However, incidents of selective mutism tend to be higher among bilingual children and those with immigrant backgrounds. Diagnosing selective mutism can be a little tricky when working with a bi- or multi-lingual child, but experts suggest looking for the following markers:

  • Mutism is prolonged
  • Mutism isn’t proportionate to the level of second language knowledge and exposure
  • Mutism is present in both languages
  • Mutism is concurrent with shy or anxious behavior

Treating Selective Mutism

The first and primary treatment  for children with selective mutism is behavioral. Their primary treating practitioner will likely be someone from the behavioral health sciences, however you as an SLP play an important role as a member of the child’s recovery team.

Usually, SLP’s will focus on the following areas:

  • Augmentative and Alternative Communication (AAC) – Providing technology or other simple tools and devices that a child uses to help them communicate their needs. AAC also includes teaching gestures that the child can use to communicate.
  • Shaping – Reinforcing any attempts the child makes at communication. This might involve using AAC, pointing, gesturing, whispering or sound production. As the child moves up the ladder of communication towards speaking, larger positive reinforcers are given.
  • Self-Modeling – Taking video of the child speaking in one of their familiar, comfortable settings (maybe at home, with family) and then showing them the video to help increase their confidence in their ability to speak.
  • Stimulus Fading – When a child masters each level of communication (i.e., speaking with you, the SLP), SLP’s gradually increase the number of individuals in the room, and then slowly increase their proximity to the child and involvement in the conversation.

Keys to Remember

Professors Ruiz, Klein, and Armstrong of LaSalle University offer the following suggestions for working with children diagnosed with selective mutism:

  • Initially don’t direct speech to the child.
  • Reduce eye-contact and focus on the child.
  • Don’t call attention to talking or not talking.
  • Don’t talk about the child to parents or other therapists in front of the child.
  • Never coerce or trick the child into speaking.
  • Reduce the amount of people around and the expectations placed on the child.
  • Any type of communication, including whispering, is better than no communication.
  • When asking a question, wait 5 seconds, and then if there is no reply ask again by providing direct choice options or yes/no questions.

Co-occurring Disorders

Your patient may have lapsed into selective mutism in part because of anxiety over an undiagnosed speech problem. It’s important in working with the child to watch for signs of other speech disorders and begin treating those as well as the mutism. In these cases, as the child overcomes the co-occurring disorder (i.e., apraxia, aphasia, etc.) their confidence will increase and the selective mutism may naturally begin to decrease.

Specializing in Treating Mutism

There is no one governing body that certifies practitioners in treating mutism, but there are a handful of options you can pursue if you want to improve your ability to treat those with various forms of mutism.

Specializing in Neurogenic Mutism

Because neurogenic mutism is a neurological disorder you may want to consider pursuing board certification from the Academy of Neurologic Communication Disorders and Sciences (ANCDS).

In order to be eligible for this certification, you’ll need to fulfill the following requirements:

  • Be a fully certified CCC-SLP
  • Have five years of clinical experience with neurologic communication disorders
  • Submit your CV or resume with three letters of recommendation from health care professionals familiar with your skills
  • Complete the Board Certification Candidacy Application and pay applicable fees

The certification process involves submitting two case studies, giving an oral presentation, and taking part in a discussion following your presentation. The reviewers will then give you a “Pass” or notify you that your work “Does not meet standards”.

Specializing in Treating Selective Mutism

There is no industry standard certification for treating selective mutism, but there are a handful of organizations that offer information, webinars, and educational opportunities to grow in this area.