Selective Mutism

Selective Mutism Summer Seibert, M.S., CCC-SLP Adapted from information presented by Dr. Elisa Shipon-Blum, President & Director of Selective Mutism Anxiety Research and Treatment Center (Smart-Center)

Research Indicates • Individuals who develop Selective Mutism: • Have strong family history of social anxiety • 90% have social anxiety • There are other reasons besides ‘timidity’ as to why a child develops SM • Children with SM produce shorter, linguistically simpler, less detailed narratives than non SM kids. Subtle expressive language skill deficits may play a roll in SM. (Fung, Manassis, et al 2004)

Quick and Easy Diagnosis Criteria • Child is MUTE in at least one setting • Child SPEAKS in at least one setting

Influential Factors • Genetics • Neurorphysiologic • Ex. Hyper-active amygdala (responsible for feelings) • Environment • Parents or school misunderstanding & enabling • Family stress and ‘troubles’ • Child modeling

Precipitating Factors • Social anxiety (over 90%) • Bilingual/Multilingual (silent period) • Speech-Language factors • Developmental Delay (sensory motor, language, social, emotional) • Personality traits (controlling, stubborn, assertive, bright, heightened perceptions)

Propagating Factors • Mutism REINFORCED by: • Misinterpretation of symptoms (others respond for the child when he/she hesitates) • Misinterpretation of testing/assessments • Misdiagnosed (autism, ODD) • Mistreated • Environmental stressors (Too much attention to speaking)

Interesting Facts about SM • Many children suffering in silence are unable to communicate nonverbally as well as verbally, and many cannot communicate at all when anxious • Just pointing or nodding can illicit anxious feelings • Many cannot acknowledge that people exist • Their anxiety changes from setting to setting and from person to person. It is related to expectation.

Change our Perspective! • Individuals with SM have difficulty with social engaging, nonverbal communication NOT just MUTISM. • Selective Mutism is a Social-Communication Anxiety Disorder

How can we evaluate if a child does not speak or interact? • The evaluation period is necessary to determine the reasons WHY a child is Selectively Mute. • Evaluation period should answer 3 KEY questions: • What is the CAUSE (causes) for why a child developed SM? • What are the REASONS why SM continues to exist? (propagating factors) • What stage or stages of social-communication is the child in within a variety of settings?

Evaluation –Gather History- pg 1 • History is Important! (Medical, developmental, social, academic, family) • What is Parental/Teacher understanding of SM and how do they approach the child? • Parent and School misunderstanding is a huge contributing factor to propagating SM! • Assessment forms are available on her website.

Interview Questions • When did parents first notice mutism? • Was child shy/timid as a baby • Where is child mute and with whom? • Has child ever commented about ‘voice’? (speak funny, others don’t understand?) • Does child speak at home? (If not, for how long?) • Did Mutism begin suddenly?

Evaluation • Golden Rules of Evaluating • Minimize eye contact • Talk ‘around’ child • No direct questioning at first • Focus on something other than the child: PROPS! • Have NO expectations! Act as if you have no interest in whether they speak or not. • PLAY with the child without asking open ended questions • Respond to child’s gestures as if he/she is speaking

Stages of Selective Mutism • Stage 0 • Non-Communicative (neither verbal or non verbal communication…not socially engaging another • No responding, no initiating, child stands motionless, expressionless or blank look, frozen looking • When is a child in Stage 0? • Senses setting is unsafe, in a new/unfamiliar setting, feelings of high expectations, younger children

Stages of Selective Mutism • Stage 1 • Nonverbal Communication • 1A Responding (via pointing, nodding, writing, using sign language, etc. • 1B Initiating (via getting someone’s attention, handing a note, raising a hand, pulling on person, etc.) • When is a child in Stage 1? • After a warm up period in most social settings, within school, as school year progresses, as nonverbal communication becomes easier and easier, with family/friends • (As years progress, child may remain in STAGE 1 unless they LEARN coping skills to communicate -> professional mime)

Stages of Selective Mutism • Stage 2 • Verbal Communication • 2A Responding (any sounds i.e., grunts, baby talk, animal sounds, moans, soft whispering, speaking, laughing out loud) • 2B Initiating (via getting someone’s attention via making any sound) • When is a child in Stage 2? • At home, with immediate family and SELECT others)

Need to Determine: • What stage of communication is the child in in each setting: • Home- with immediate family, extended family, adult friends, peers, answering phone, making phone calls • School- within classroom, playground, throughout school, school personnel • Out of home- at other’s home, friends, family, in public places, restaurants, stores, parties (Pay attention to warm up time)

SLP’s Role in the School Setting With Students with Selective Mutism • SLPs should be involved in assessment. • SI should NOT be the child’s only eligibility. • Student can qualify for direct services if it is determined that the child also has a speech and language disorder. • If no speech/language disorder is present, ED may be the child’s only eligibility but Speech can be added as a Supplemental Aid and Service • Can see child on consult and work with the teacher/counselor

Treatment Approach • Social Communication Anxiety Therapy (SCAT) • Lower anxiety • Build self esteem • Increase confidence and communication in social settings • Don’t treat to speak! Address the factors of shut down and the reinforcers. Un-learn ‘learned’ behaviors and build coping skills.

Goal of School Accommodations & Interventions • Increase comfort and ability to engage, socialize and communicate in social settings to move from nonverbal to verbal.

Help Child Acknowledge/Assess • Feelings charts • Heights of building blocks for younger kids • Using hands/fingers to gage feelings - Where child can “RATE” feelings of being scared, uncomfortable and/or where it is difficult to communicate - Give them example situations with the emotion scale and have them compare to an easy situation.

Emotion Chart • Give the child time to assess their feelings. • How do you feel about making these sounds with me? • Proceed if the child is responding positively. • Pull back if the child is very resistant. • Trust their feelings! They don’t fake it!

Use Choice and Control Using Sounds Yes/No Game Interview Game Mr./Mrs. Handover Mr./Mrs. Takeover Waving Game Clockwatcher Hi/Bye Game Eye-Spy Trophy Games Ritual Games Phone Game E-mail Verbal Intermediary Desensitization Fading Countless Methods:

Use of Control and Choice • Direct questions • Yes/No questions • Use visual choices • Ask questions that the child knows the answer to. • Allow for hesitations • Give child choices to give them control. But don’t take “no” for an answer. • Find a way for them to communicate without pressuring them to speak. (pointing, eye blinks, eye gaze) • Giving these children control helps lower anxiety. These kids are always being told what to do.

Use of Sounds- pg 2(Transferring into Verbal communication via the back door) • Good method for child who already makes sounds (grunts, groans, laughs, etc.) • Begin making tapping noises, finger snap noises. • 2 snaps/taps = YES & 1 snap/tap = NO • Progress to mouth popping sounds • 2 pops = YES & 1 pop = NO • Have the child write out the alphabet first. ** Give LOTS of wait time for response at first.

Use of Sounds Cont. • When child can make ‘Pop’ sound, let them know they make a ‘P’ sound. • Can begin crossing off letters of the alphabet/animal sounds • Write simple words on paper with P sound • Use ‘P’ sound and SHAPE into other sounds (i.e., ‘b’, then ‘bbbbb’ = bye • Eventually: “hhhh” = hi • As you work through sounds, ‘sssssssssss’ = YES, ‘nnnnn’ = NO • Put beginning and ending sounds together ‘yyyyy’ + ‘ssssssss’ = YES & ‘nnnnn’ + ‘ooooo’ = NO • Don’t make a big deal out of it when they make sounds. Let them know you’re not pressuring them.

Hi/Bye Game- pg 3 • The child collects stickers, stars, etc each time they : • WAVE • Hand a card that says “hi” or “bye” • Use sounds or a verbal intermediary, • Copying hi/bye • Saying hi/bye independently • Children who respond to hi/bye get one sticker; Children who initiate hi/bye get two stickers.

Yes/No Game- pg 4 • Do you like donuts? • Do you like ice cream? • Do you like dogs? • Do you like chocolate covered spiders? • Do you like rats? • Keep up with who the child plays the game with and the date.

Interview Game- pg 5 • Stage 1 A: Other person asks questions, child answers with point, nod, written response • Stage 1 B: Child goes up to person and hands her a card/journal with question. Person responds. • Transition to verbal: Person asks questions, child answers through intermediary or child uses intermediary to ask questions. Can also use tape recorder • Stage 2A: Person asks questions. Child answers via whispers, words, reading answers off card • Stage 2B: Child goes up to person to ask question via whispering, sounds, reading off cards.

Interview Game Sample Questions • What’s Your Favorite Game • Color? Ice cream flavor? Pet? Holiday? TV show? Book? • Color Game: “What color is….” • Grass? The ocean? An Apple? • “A book about my teacher” pg 6

Verbal Intermediary – pg 7 • Use a person or object (whisper buddy/ puppet) who the child can speak to: • Whisper close up • Whisper at fist length away • Whisper at half arm length away • Whisper at full arm length away • Whisper across table • Look in direction of person * The other person should NOT make a big deal out of the child talking!!

Mr./Mrs. Handover / Mr./Mrs. Takeover • Handing things onto the conveyer belt at the grocery store • Handing the credit card/money to the cashier • Taking the change back from the cashier • If this is too hard, parents can hold her hand • Also, can allow the child to place the item in front of the store clerk rather than handing something to them. *Non-Verbal communication is the KEY to social engagement and is the precursor to communication.

Waving Game • Change the connotation of “waving.” • Don’t tell the child to “Wave!” or “Say hi!” • Instead: • Hand twist • Flopping • Wash the window • Hand rock • Give an “Man's” when they wave.

Clock-watcher • “Tell me when it’s lunch time.” • Student can tap desk or hand teacher a note.

Eye-Spy • Many kids shut down when they see someone they know in public. (Emotion goes to amygdala and evokes fear). • This game helps bypass the amygdala and shoot the response to the cortex by cognitively thinking about it. • Make a list of people we might see. • Make a list of observations we will make: What color shoes are they wearing? Etc. • After the outing, check off the people we saw and see if our predictions were correct.

Plan Ahead • Anticipate what will be asked / talked about in certain situations. • Prepare the child for what will be asked and how they can respond. • Keep a list of questions. • After the event, check off what questions were asked. • This will lower anxiety.

E-mail • Have child e-mail with the teacher from home or therapy room to get used to communicating with her. • They can attach pictures to make it more interesting to the child. • Younger children can sit in the parent’s or therapist’s lap and “dictate” the e-mail.

Photo Album • Provide child with a 24-page tape-record picture album. • Select pictures of events in the child’s life that she might like to tell someone about. • In a comfortable environment, she can record “captions” for each of the pictures • She can share the book with people she is uncomfortable speaking around.

Desensitization • Spend one-on-one time with the child within the school. Practice Communicating. • One-on-one time with teacher. • Classmates: Playdates (one new child at a time, then increase to a few at a time) • Bring friends to school before/after hours. • Practice on playground/eating/bathroom • Small groups: introduce one child at a time.

Fading • School: • Parent interacts with the child in the small group • When child is verbalizing, add another child • When child continues to verbalize, parent gets up and teacher moves in. • Next, parent leaves the group and the teacher stays.

Fading • Home • Playdates: Parent interacts with child and new friend. • When child begins talking, mom slowly goes away.

The Phone (start young) • Answering Phone Calls: • Answer knowing its mom or dad. • Add grandparents, close friend, etc (plan phone calls) • Mystery caller between 3 or 4 people. • Making phone calls in the same progression. • To ease the stress: • Play phones, walkie talkies with friends, use of cell phone in own home. • Set sayings reading off cards. (Great for answering machines) • Older kids can leave script by phone

The Phone • Call and order pizza • Write script and rehears • Emotion chart • Rehearse with phone in hand • Emotion chart • Open cell phone and rehearse • Emotion chart • Put phone to ear and rehearse • Emotion chart • Make the phone call • Emotion chart

Phone Game • Can play with home phone & cell phone or with walkie talkies • Friend tries to guess where the child with SM is ‘hiding’ • Is there a sink in the room? • Is there a tv in the room? • Friend Goes home and calls the child with SM and plays the game again.

Trophy Games – pg 8 - 11 • Helps child develop inner control by emphasis on incremental progression of communication. • The child must have at least one person present who she can speak to. • Prior to beginning, the child should have a reward system in place for positive reinforcement • After so many stickers/tokens/play money, the child receive a reward/privilege/item • Example Games: • Restaurant • Handover/Takeover • Hi/Bye • Finish the Sentence • Interview Game

Ritual Games – pg 12-13 • Can be used for children in ALL stages of communication. • Helps child feel in control over their communication progress. • Difference between trophy games and ritual games: Trophy games help the child DEVELOP inner control while Ritual games USE the child’s need for inner control to help the child progress communicatively. • Similar to Trophy Games: the child should have a reward system in place (positive reinforcement) to help the process along.

Ritual Game • Ritual Games are contrived and individual-based ‘rituals’ the child goes through as they progress communicatively. • Have the child help you develop the ritual: ex. 5 favorite sounds, all the alphabet, yes/no questions, etc. • Do this out of the classroom first, then move to the back of the room, then to the desk, etc. • The child will not speak in front of people who they haven’t done the ritual with. • Every child has a different ritual. • May need a trigger question to be able to start talking in different settings.

Signs of Lowered Anxiety • Relaxed body language • Excellent eye contact • Smiling more • Child laughing (with or without sounds) • Initiating without effort • Responding rapidly and freely

Things to Keep in Mind • Don’t make a big deal out of the child making sounds/talking • Don’t stare at the child when you ask a question. • Don’t let them think you “give a darn” so they don’t feel anxious • Act like your attention is divided: play on the computer, clean your desk, etc. • Never work on eye-contact! It will come as comfort comes. Eye-contact is very invasive. You can work on looking toward someone.

Things to Keep in Mind • Allow for time to respond. Children with SM hesitate when anxious. Do not jump in with the response if the child is not communicating. • Praise and support the child’s efforts: “You did so well!” • Help child to “express” feelings: comfort journal, bedtime snuggle time, etc. • Prepare child for changes/transitions: substitute, going to parties, outings • Arrive to places early, bring a friend. • Increase independence at home (chores / responsibilities) to build self esteem • Strengthen strengths to build self-esteem,

I also have more information about: • SM and Medication • Why, When, & How • Accommodations to set up at school • IEP goals • Case Studies

Selective Mutism