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Selective Mutism Summer Seibert, M.S., CCC-SLP Adapted from information presented by Dr. Elisa Shipon-Blum, President & Director of Selective Mutism Anxiety.

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Presentation on theme: "Selective Mutism Summer Seibert, M.S., CCC-SLP Adapted from information presented by Dr. Elisa Shipon-Blum, President & Director of Selective Mutism Anxiety."— Presentation transcript:

1 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)

2 Research Indicates Individuals who develop Selective Mutism: Individuals who develop Selective Mutism: 1) Have strong family history of social anxiety 2) 90% have social anxiety 3) There are other reasons besides ‘timidity’ as to why a child develops SM 4) 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)

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

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

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

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

7 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 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 Just pointing or nodding can illicit anxious feelings Many cannot acknowledge that people exist Many cannot acknowledge that people exist Their anxiety changes from setting to setting and from person to person. It is related to expectation. Their anxiety changes from setting to setting and from person to person. It is related to expectation.

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

9 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. The evaluation period is necessary to determine the reasons WHY a child is Selectively Mute. Evaluation period should answer 3 KEY questions: Evaluation period should answer 3 KEY questions: 1. What is the CAUSE (causes) for why a child developed SM? 2. What are the REASONS why SM continues to exist? (propagating factors) 3. What stage or stages of social-communication is the child in within a variety of settings?

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

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

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

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

14 Stages of Selective Mutism Stage 1 Stage 1 Nonverbal Communication Nonverbal Communication 1A Responding (via pointing, nodding, writing, using sign language, etc. 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.) 1B Initiating (via getting someone’s attention, handing a note, raising a hand, pulling on person, etc.) When is a child in Stage 1? 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 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) (As years progress, child may remain in STAGE 1 unless they LEARN coping skills to communicate -> professional mime)

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

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

17 SLP’s Role in the School Setting With Students with Selective Mutism SLPs should be involved in assessment. SLPs should be involved in assessment. SI should NOT be the child’s only eligibility. 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. 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 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 Can see child on consult and work with the teacher/counselor

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

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

20 Help Child Acknowledge/Assess Feelings charts Feelings charts Heights of building blocks for younger kids Heights of building blocks for younger kids Using hands/fingers to gage feelings 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.

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

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

23 Use of Control and Choice Direct questions Direct questions Yes/No questions Yes/No questions Use visual choices Use visual choices Ask questions that the child knows the answer to. Ask questions that the child knows the answer to. Allow for hesitations Allow for hesitations Give child choices to give them control. But don’t take “no” for an answer. 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) 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. Giving these children control helps lower anxiety. These kids are always being told what to do.

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

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

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

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

28 Interview Game- pg 5 Stage 1 A: Other person asks questions, child answers with point, nod, written response 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. 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 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 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. Stage 2B: Child goes up to person to ask question via whispering, sounds, reading off cards.

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

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

31 Mr./Mrs. Handover / Mr./Mrs. Takeover Handing things onto the conveyer belt at the grocery store Handing things onto the conveyer belt at the grocery store Handing the credit card/money to the cashier Handing the credit card/money to the cashier Taking the change back from the cashier Taking the change back from the cashier If this is too hard, parents can hold her hand 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. 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.

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

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

34 Eye-Spy Many kids shut down when they see someone they know in public. (Emotion goes to amygdala and evokes fear). 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. 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 people we might see. Make a list of observations we will make: What color shoes are they wearing? Etc. 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. After the outing, check off the people we saw and see if our predictions were correct.

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

36 Have child with the teacher from home or therapy room to get used to communicating with her. Have child 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. 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 . Younger children can sit in the parent’s or therapist’s lap and “dictate” the .

37 Photo Album Provide child with a 24-page tape-record picture 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. 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 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. She can share the book with people she is uncomfortable speaking around.

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

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

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

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

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

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

44 Trophy Games – pg Helps child develop inner control by emphasis on incremental progression of communication. 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. 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 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 After so many stickers/tokens/play money, the child receive a reward/privilege/item Example Games: Example Games: Restaurant Restaurant Handover/Takeover Handover/Takeover Hi/Bye Hi/Bye Finish the Sentence Finish the Sentence Interview Game Interview Game

45 Ritual Games – pg Can be used for children in ALL stages of communication. Can be used for children in ALL stages of communication. Helps child feel in control over their communication progress. 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. 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. Similar to Trophy Games: the child should have a reward system in place (positive reinforcement) to help the process along.

46 Ritual Game Ritual Games are contrived and individual-based ‘rituals’ the child goes through as they progress communicatively. 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. 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. 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. The child will not speak in front of people who they haven’t done the ritual with. Every child has a different ritual. Every child has a different ritual. May need a trigger question to be able to start talking in different settings. May need a trigger question to be able to start talking in different settings.

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

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

49 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. 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!” Praise and support the child’s efforts: “You did so well!” Help child to “express” feelings: comfort journal, bedtime snuggle time, etc. Help child to “express” feelings: comfort journal, bedtime snuggle time, etc. Prepare child for changes/transitions: substitute, going to parties, outings Prepare child for changes/transitions: substitute, going to parties, outings Arrive to places early, bring a friend. Arrive to places early, bring a friend. Increase independence at home (chores / responsibilities) to build self esteem Increase independence at home (chores / responsibilities) to build self esteem Strengthen strengths to build self-esteem, Strengthen strengths to build self-esteem,

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

51 For More Information:


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