Title: Selective Mutism
1Selective 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)
2Research 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)
3Quick and Easy Diagnosis Criteria
- Child is MUTE in at least one setting
- Child SPEAKS in at least one setting
4Influential Factors
- Genetics
- Neurorphysiologic
- Ex. Hyper-active amygdala (responsible for
feelings) - Environment
- Parents or school misunderstanding enabling
- Family stress and troubles
- Child modeling
5Precipitating 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)
6Propagating 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)
7Interesting 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.
8Change our Perspective!
- Individuals with SM have difficulty with social
engaging, nonverbal communication NOT just
MUTISM. - Selective Mutism is a Social-Communication
Anxiety Disorder
9How 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?
10Evaluation 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.
11Interview 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?
12Evaluation
- 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
13Stages 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
14Stages 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)
15Stages 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)
16Need 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)
17SLPs 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
18Treatment 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.
19Goal of School Accommodations Interventions
- Increase comfort and ability to engage, socialize
and communicate in social settings to move from
nonverbal to verbal.
20Help 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.
21Emotion 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!
22Countless 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
23Use 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.
24Use 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.
25Use 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.
26Hi/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.
27Yes/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.
28Interview 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.
29Interview 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
30Verbal 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!!
31Mr./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.
32Waving 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.
33Clock-watcher
- Tell me when its lunch time.
- Student can tap desk or hand teacher a note.
34Eye-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.
35Plan 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.
36E-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.
37Photo 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.
38Desensitization
- 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.
39Fading
- 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.
40Fading
- Home
- Playdates Parent interacts with child and new
friend. - When child begins talking, mom slowly goes away.
41The 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
42The 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
43Phone 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.
44Trophy 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
45Ritual 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.
46Ritual 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.
47Signs of Lowered Anxiety
- Relaxed body language
- Excellent eye contact
- Smiling more
- Child laughing (with or without sounds)
- Initiating without effort
- Responding rapidly and freely
48Things 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.
49Things 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,
50I also have more information about
- SM and Medication
- Why, When, How
- Accommodations to set up at school
- IEP goals
- Case Studies
51For More Information
- www.selectivemutismcenter.org
- www.selectivemutism.org
- sminfo_at_selectivemutism.org
- SMartCenter_at_selectivemutism.org
- 215-887-5748