1 Selective Mutism Summer Seibert, M.S., CCC-SLP Adapted from information presented byDr. Elisa Shipon-Blum, President & Director ofSelective Mutism Anxiety Research and Treatment Center (Smart-Center)
2 Research Indicates Individuals who develop Selective Mutism: Have strong family history of social anxiety90% have social anxietyThere are other reasons besides ‘timidity’ as to why a child develops SMChildren 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 settingChild SPEAKS in at least one setting
4 Influential Factors Genetics Neurorphysiologic Environment Ex. Hyper-active amygdala (responsible for feelings)EnvironmentParents or school misunderstanding & enablingFamily stress and ‘troubles’Child modeling
6 Propagating Factors Mutism REINFORCED by: Misinterpretation of symptoms (others respond for the child when he/she hesitates)Misinterpretation of testing/assessmentsMisdiagnosed (autism, ODD)MistreatedEnvironmental 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 anxiousJust pointing or nodding can illicit anxious feelingsMany cannot acknowledge that people existTheir 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.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.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?
10 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.
11 Interview Questions When did parents first notice mutism? Was child shy/timid as a babyWhere 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?
12 Evaluation Golden Rules of Evaluating Minimize eye contact Talk ‘around’ childNo direct questioning at firstFocus 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 questionsRespond to child’s gestures as if he/she is speaking
13 Stages of Selective Mutism Non-Communicative (neither verbal or non verbal communication…not socially engaging anotherNo responding, no initiating, child stands motionless, expressionless or blank look, frozen lookingWhen is a child in Stage 0?Senses setting is unsafe, in a new/unfamiliar setting, feelings of high expectations, younger children
14 Stages of Selective Mutism Nonverbal Communication1A 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)
15 Stages of Selective Mutism Verbal Communication2A 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)
16 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 callsSchool- within classroom, playground, throughout school, school personnelOut 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.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 ServiceCan see child on consult and work with the teacher/counselor
18 Treatment Approach Social Communication Anxiety Therapy (SCAT) Lower anxietyBuild self esteemIncrease confidence and communication in social settingsDon’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.
20 Help Child Acknowledge/Assess Feelings chartsHeights of building blocks for younger kidsUsing 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. 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!
22 Countless Methods: Use Choice and Control Using Sounds Yes/No Game Interview GameMr./Mrs. HandoverMr./Mrs. TakeoverWaving GameClockwatcherHi/Bye GameEye-SpyTrophy GamesRitual GamesPhone GameVerbal IntermediaryDesensitizationFading
23 Use of Control and Choice Direct questionsYes/No questionsUse visual choicesAsk questions that the child knows the answer to.Allow for hesitationsGive 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.
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.)Begin making tapping noises, finger snap noises.2 snaps/taps = YES & 1 snap/tap = NOProgress to mouth popping sounds2 pops = YES & 1 pop = NOHave 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.Can begin crossing off letters of the alphabet/animal soundsWrite simple words on paper with P soundUse ‘P’ sound and SHAPE into other sounds (i.e., ‘b’, then ‘bbbbb’ = byeEventually: “hhhh” = hiAs you work through sounds, ‘sssssssssss’ = YES, ‘nnnnn’ = NOPut beginning and ending sounds together‘yyyyy’ + ‘ssssssss’ = YES & ‘nnnnn’ + ‘ooooo’ = NODon’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 3The child collects stickers, stars, etc each time they :WAVEHand a card that says “hi” or “bye”Use sounds or a verbal intermediary,Copying hi/byeSaying hi/bye independentlyChildren 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 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.
28 Interview Game- pg 5Stage 1 A: Other person asks questions, child answers with point, nod, written responseStage 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 recorderStage 2A: Person asks questions. Child answers via whispers, words, reading answers off cardStage 2B: Child goes up to person to ask question via whispering, sounds, reading off cards.
29 Interview Game Sample Questions What’s Your Favorite GameColor? 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
30 Verbal Intermediary – pg 7 Use a person or object (whisper buddy/ puppet) who the child can speak to:Whisper close upWhisper at fist length awayWhisper at half arm length awayWhisper at full arm length awayWhisper across tableLook 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 storeHanding the credit card/money to the cashierTaking the change back from the cashierIf this is too hard, parents can hold her handAlso, 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.” Don’t tell the child to “Wave!” or “Say hi!”Instead:Hand twistFloppingWash the windowHand rockGive an “Man's” when they wave.
33 Clock-watcher “Tell me when it’s lunch time.” Student can tap desk or hand teacher a note.
34 Eye-SpyMany 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.
35 Plan AheadAnticipate 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.
36 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.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. 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 picturesShe can share the book with people she is uncomfortable speaking around.
38 DesensitizationSpend 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/bathroomSmall groups: introduce one child at a time.
39 Fading School: Parent interacts with the child in the small group When child is verbalizing, add another childWhen child continues to verbalize, parent gets up and teacher moves in.Next, parent leaves the group and the teacher stays.
40 Fading Home Playdates: Parent interacts with child and new friend. When child begins talking, mom slowly goes away.
41 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
42 The Phone Call and order pizza Write script and rehears Emotion chart Rehearse with phone in handOpen cell phone and rehearsePut phone to ear and rehearseMake the phone call
43 Phone GameCan play with home phone & cell phone or with walkie talkiesFriend 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.
44 Trophy Games – pgHelps 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 reinforcementAfter so many stickers/tokens/play money, the child receive a reward/privilege/itemExample Games:RestaurantHandover/TakeoverHi/ByeFinish the SentenceInterview Game
45 Ritual Games – pg 12-13Can 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.
46 Ritual GameRitual 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.
47 Signs of Lowered Anxiety Relaxed body languageExcellent eye contactSmiling moreChild laughing (with or without sounds)Initiating without effortResponding rapidly and freely
48 Things to Keep in MindDon’t make a big deal out of the child making sounds/talkingDon’t stare at the child when you ask a question.Don’t let them think you “give a darn” so they don’t feel anxiousAct 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.
49 Things to Keep in MindAllow 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, outingsArrive to places early, bring a friend.Increase independence at home (chores / responsibilities) to build self esteemStrengthen strengths to build self-esteem,
50 I also have more information about: SM and MedicationWhy, When, & HowAccommodations to set up at schoolIEP goalsCase Studies
51 For More Information: www.selectivemutismcenter.org