Selective Mutism

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
• 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)

3
Quick and Easy Diagnosis Criteria

• Child is MUTE in at least one setting
• Child SPEAKS in at least one setting

4
Influential Factors

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

5
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)

6
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)

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
• 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.

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 baby
• Where is child mute and with whom?
• Has child ever commented about voice?
• (speak funny, others dont 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 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 childs gestures as if he/she is
  speaking

13
Stages of Selective Mutism

• Stage 0
• Non-Communicative (neither verbal or non verbal
  communicationnot 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

14
Stages of Selective Mutism

• Stage 1
• Nonverbal Communication
• 1A Responding (via pointing, nodding, writing,
  using sign language, etc.
• 1B Initiating (via getting someones 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 -gt
  professional mime)

15
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 someones 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 calls
• School- within classroom, playground, throughout
  school, school personnel
• Out of home- at others home, friends, family, in
  public places, restaurants, stores, parties
• (Pay attention to warm up time)

17
SLPs Role in the School Setting With Students
with Selective Mutism

• SLPs should be involved in assessment.
• SI should NOT be the childs 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 childs only eligibility but Speech can be
  added as a Supplemental Aid and Service
• Can see child on consult and work with the
  teacher/counselor

18
Treatment Approach

• Social Communication Anxiety Therapy (SCAT)
• Lower anxiety
• Build self esteem
• Increase confidence and communication in social
  settings
• Dont 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 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.

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 dont fake it!

22
Countless Methods

• 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

23
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
  dont 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 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.

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 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
• Dont make a big deal out of it when they make
  sounds. Let them know youre not pressuring
  them.

26
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.

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 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.

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Interview Game Sample Questions

• Whats 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

30
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!!

31
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.

32
Waving Game

• Change the connotation of waving.
• Dont tell the child to Wave! or Say hi!
• Instead
• Hand twist
• Flopping
• Wash the window
• Hand rock
• Give an Man's when they wave.

33
Clock-watcher

• Tell me when its lunch time.
• 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).
• 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 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.

36
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 parents or
  therapists lap and dictate the e-mail.

37
Photo Album

• Provide child with a 24-page tape-record picture
  album.
• Select pictures of events in the childs 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.

38
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.

39
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.

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 hand
• Emotion chart
• Open cell phone and rehearse
• Emotion chart
• Put phone to ear and rehearse
• Emotion chart
• Make the phone call
• Emotion chart

43
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.

44
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

45
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 childs 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 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 havent 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 language
• Excellent eye contact
• Smiling more
• Child laughing (with or without sounds)
• Initiating without effort
• Responding rapidly and freely

48
Things to Keep in Mind

• Dont make a big deal out of the child making
  sounds/talking
• Dont stare at the child when you ask a question.
• Dont let them think you give a darn so they
  dont 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.

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.
• Praise and support the childs 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,

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I also have more information about

• SM and Medication
• Why, When, How
• Accommodations to set up at school
• IEP goals
• Case Studies

51
For More Information

• www.selectivemutismcenter.org
• www.selectivemutism.org
• sminfo_at_selectivemutism.org
• SMartCenter_at_selectivemutism.org
• 215-887-5748