Posts for: August, 2017
How We Treat Selective Mutism at Child Achievement Center
by Shari A. Gross, M.A., CCC-SLP and Rachel Shapiro, M.S., CCC-SLP
"Lauren" is in third grade. Her family is bilingual. She attended kindergarten twice. She does not act out, but she has never spoken in school, and is always highly reluctant to participate. Any school work she does is far below grade level, but her teachers and child study team have not achieved any true skill assessment. All staff at her school are bewildered about how to work with her.
Selective mutism is a highly frustrating disorder to experience for children, parents, and school personnel. Children with Selective Mutism communicate in a relaxed manner in comfortable environments, most typically at home. However, in environments which are uncomfortable to the child, most notably school, the children do not speak. At Child Achievement Center, we have used a direct therapy approach for fifteen years to successfully treat pediatric clients with Selective Mutism. Initially, at pre-school and primary ages, anxiety directly causes children to “shut down”. However, as children grow older, their silence additionally becomes a learned behavior, as it is the mechanism that has already worked for the child in coping with the social environment of school. In turn, the selective mutism becomes a more engrained part of the child’s self-concept, making it more difficult to overcome.
More than any other aspect of communication disorders we treat, the approach required for remediating selective mutism is both an art and a science. We call our technique the “communication confidence” approach, and it works consistently with the pre-school and primary grade population. We focus on developing children’s communication confidence at our clinic, and then transferring the skills into each child’s school. Sometimes, the child transfers the skills on their own. Other times, the children require therapist consultation with their teachers and school therapists, or direct in-school treatment.
Therapy starts with an initial evaluation to ascertain as closely as possible the student’s speech-language skills and pragmatic skills, and determine the whether co-morbid disorders are present. Although we have treated numerous children with selective mutism as their only difficulty, we also frequently treat children presenting with selective mutism who display additional disorders. We have encountered selectively mute children in whom we have observed symptoms of Asperger’s syndrome: their communication and behavioral characteristics were hiding behind their silence and reluctance to participate in school. (These children were referred to medical professionals and subsequently diagnosed.) Similarly, referrals to mental health professionals have been made for suspected and confirmed social anxiety disorders, generalized anxiety disorders, obsessive-compulsive disorders, and Attention Deficit Hyperactivity Disorder. Importantly, we also have treated children with selective mutism who definitively have additional language, articulation, and learning disorders, including severe disorders. For example, Lauren, now verbal, presents with multiple language test scores one standard deviation below the mean, as well as dyslexic symptoms. Thus, we consider it crucial that we recognize the characteristics of presenting communication and learning disorders, as well as mental health disorders, and that we provide proper referrals when necessary.
Treatment then begins with individual therapy, focused on shaping and desensitizing communication experiences in steps. This involves providing the child with opportunities to experience positive success using all types of communication in our setting. Activities utilized when targeting a child's goals are motivating and non-anxiety provoking, engaging and fun. We offer options such as crafts, board games, active games, block building, cars, or Legos, focused on the child’s interest each session, to build communication in a hierarchy. This hierarchy may include non-verbal/non-oral communication activities such as nodding, pointing to yes/no cards, writing responses to concrete questions, shaking head yes or no, pointing. Then, oral/verbal communication behaviors are shaped, including blowing whistles at different levels of intensity to “answer”, mouthing words, making oral sounds, whispering phonemes, whispering words, reading single word and then sentence responses, and then building up to vocalizing responses in an audible voice. Each treatment plan requires constant adjustment depending on the child's reaction to the new demands. Success is observed with increased communication and relaxation observed on a child's face and in overall body composure.
Once a child has experienced verbalization in individual therapy we then continue the child's communication success in a small group setting. Throughout the period of exposing the child to "new friends", we continue to reinforce how "brave" they are as they participate, communicate, inevitably verbalize consistenly in the group. This verbal praise and reinforcement is essential in boosting each child's self-esteem and self-confidence while reassuring them that "it is not scary" to interact with new friends. Activities such as blowing whistles to respond to peers or making books about "being brave in new places" are crucial in continuing the child's forward movement with verbal communication. As a child's anxiety about verbal communication in group settings decreases, they display more communicating in school and the community.
Although some children will begin to communicate independently in school, close coordination with school personnel is the next critical step for others. Although in many cases we prefer involvement of speech-language professionals in schools, we have also successfully collaborated with classroom and special education teachers, guidance counselors, and other child team members. In Lauren’s case, she participated in a course of individual and group therapy at our center, as well as in-school therapy. We collaborated successfully with teachers, as well as a caring and motivated paraprofessional. She eventually acted as a main staff member providing daily practice of routine school verbalization to Lauren, while her teachers could focus on integrating skills she was practicing into their instruction and interactions. Lauren benefitted tremendously although she had not previously spoken for four years in school.
Successfully treating children with selective mutism in our practice has been a challenge. It has also rewarded us with the thanks of schools and many parents.
Child Achievement Center, Professional Therapy Associates, is located in Manalapan, NJ. The majority of our fifteen therapists have significant experience treating selective mutism. We can be reached at c[email protected] or 732-617-8255.
Shari A. Gross, M.A., CCC-SLP is Director of Child Achievement Center. Rachel Shapiro, M.S., CCC-SLP is Assistant Director of Child Achievement Center. Children with Selective Mutism have been treated successfully at our practice for twenty years.
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