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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.
© 2017 Child Achievement Center
Selective Mutism and Communication Anxiety in Children
Shari A. Gross, M.A., CCC-SLP,
Director of Child Achievement Center
Originally Published in Advance for Speech-Language Pathologists and Audiologists,
February 11, 2002. All rights reserved.
Selective mutism is a challenge that often is highly frustrating for children, parents and professionals. In the public school setting, often at the preschool and elementary levels, speech-language pathologists may encounter children presenting with selective mutism due to their complete lack of communication in school. Other children may demonstrate some verbalizations but still have a significant reluctance to speak.
Although selective mutism was assumed to be primarily a behavioral disorder in the past, a multitude of recent research, such as that conducted at the UCLA Child & Adolescent Anxiety Program, in Los Angeles, CA, has demonstrated that selective mutism is a childhood manifestation of social anxiety disorder.
According to the DSM-IV-TR, the Text Revision to the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000), a diagnosis of selective mutism is indicated by a persistent failure to talk in one or more social settings, including school, despite speaking in other social situations.
Unfortunately, in practice some school personnel, physicians and psychologists frequently have equated this lack of speech with a behaviorally-based refusal to speak. However, many professionals contend that, in the large majority of cases, children with selective mutism are not refusing to speak at all but rather are extremely anxious about verbalizing.
They are anxious to the point that "they actually exhibit a physical reaction and Iiterally cannot talk," stated Elisa Shipon Blum, DO, executive/medical director of the Childhood Anxiety Network and clinical professor of psychology and family medicine at Philadelphia College of Osteopathic Medicine in Pennsylvania.
Furthermore, some children with selective mutism are not only totally silent in school, but they may lack typical facial expressions because they are overwhelmed with fear and unable to participate in any way. Other children with this diagnosis may be able to participate in activities while remaining silent. Some anxious children may speak only when required, but do not volunteer to speak and do not initiate interaction.
Sometimes children with selective mutism may have receptive or expressive language disorders, articulation disorders or leaming disabilities. They may be bilingual or come from bilingual homes. It is crucial that school personnel realize that in many cases these children have fully developed to age expectations in all respects and may in fact be particularly bright, even though this may only be apparent in the home or other very comfortable settings.
Because selective mutism is anxiety-based, it is important to recognize that the condition stands apart from any other characteristic of a child's learning and language skills. Some children who are selectively mute benefit from treatment with selective serotonin reuptake inhibitors (SSRI). These medications are monitored by knowledgeable physicians and psychologists.
Other children gradually overcome selective mutism with step-by-step treatment plans but without the aid of mediciltions. However, if left untreated, selective mutism can lead to underachievement in school, poor social skill development, low self-esteem, social withdrawal and possibly psychiatric complications.
How can the speech-language pathologist help these children? The first step to helping children with selective mutism is to view them with a completely open mind. Although similarities may exist between cases, each child who is selectively mute is unique.
Although the child must be observed in the classroom, it is imperative that the parents be questioned about their child's behavior and speech-language use at home and in other comfortable settings. This information must be fully acknowledged and accepted by all professionals working with the child.
By definition, parents will report that their child is verbal and animated at home and often loud and boisterous. Ideally, observing the child at home or viewing a videotape of the child at home, provided by the parents, offers tremendous insight into the potential abilities and/or possible weaknesses of the child.
After the speech-language pathologist has received enough information to begin approximating the child's level of function, a therapy eligibility plan can be formulated and presented to the parents so the child can begin to be seen by the clinician. The child's eligibility could be based on the need for improvement in pragmatics, with goals written accordingly. Individual goals can include nonverbal interaction with the speech-language pathologist, teacher and peers; one-word answering of the teacher and then peers; eventual one-word initiation, such as a greeting, to members of Ihe school community; or speaking in simple sentences to the speech-language pathologist in the context of a board game.
If it is possible and the parents agree, a full child study team evaluation may not be appropriate at the onset because test scores can be skewed if the child is fully mute. What is most important is for the child to begin to feel comfortable communicating in school, even if that communication is nonverbal at first. Even the slightest successes from the child - including looking at the speech-language pathologist or coming to a speech room- should be calmly but fully praised by the therapist. Each individual step is often a huge leap because the child who is selectively mute often feels that "the words just won't come out," even though they want them to.
Techniques that have been successful in getting preschool and primary grade children with selective mutism to feel comfortable initially and interact both nonverbally and verbally are, by design, fun and motivating.
One technique is arts and crafts. After proceeding well into a project, the child has to communicate a choice, such as color, or a part, like a hat or a scarf for a snowman. Many children also react well to playing with playhouse-type figures or puppets and will allow their figure or puppet to interact with the therapist's figures before they themselves directly interact with the clinician.
Children with selective mutism also can play on a computer alongside the speech-language pathologist, with the clinician operating the mouse. In this way they are not forced to maintain eye contact at first, which can provoke anxiety. The speech-language pathologist might play a game while the child watches but should later encourage the child to communicate choices about the game, nonverbally at first with gestures and then verbally as the child demonstrates strong interest.
When children with selective mutism begin to display comfort and increased communication, they can benefit from participating in a social skills group with well-matched peers. Regardless of the specific activity offered, accepting the child fully, communicating a positive affect toward the child, and rewarding all communication attempts by providing logical outcomes are the first steps the speech-language pathologist can take to lessen the child's anxiety and build communication confidence in the school setting.
Shari A. Gross is a speech-language pathologist and certified elementary educator in private practice in Manalapan, NJ, and served as a member of the Professional Advisory Board and the Executive Committee of the Selective Mutism Group, Child Anxiety Network. In addition to serving as director of Child Achievement Center, she was the director of speech-language pathology at the Selective Mutism Anxiety Center. She can be reached at 732-617-8255.