Treating Selective Mutism as a Speech-Language Pathologist 2021035623, 2021035624, 9781635502817, 1635502810

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TREATING SELECTIVE MUTISM as a

SPEECH-LANGUAGE PATHOLOGIST

TREATING SELECTIVE MUTISM as a

SPEECH-LANGUAGE PATHOLOGIST

EMILY R. DOLL, MA, MS, CCC-SLP

5521 Ruffin Road San Diego, CA 92123 e-mail: [email protected] Web site: https://www.pluralpublishing.com Copyright © 2022 by Plural Publishing, Inc. Typeset in 11.5/14 Minion Pro Flanagan’s Publishing Services, Inc. Printed in the United States of America by McNaughton & Gunn, Inc. All rights, including that of translation, reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, including photocopying, recording, taping, Web distribution, or information storage and retrieval systems without the prior written consent of the publisher. For permission to use material from this text, contact us by Telephone: (866) 758-7251 Fax: (888) 758-7255 e-mail: [email protected] Every attempt has been made to contact the copyright holders for material originally printed in another source. If any have been inadvertently overlooked, the publisher will gladly make the necessary arrangements at the first opportunity. Library of Congress Cataloging-in-Publication Data: Names: Doll, Emily R. author. Title: Treating selective mutism as a speech-language pathologist / Emily R. Doll. Description: San Diego, CA : Plural Publishing, [2022] | Includes bibliographical references and index. Identifiers: LCCN 2021035623 (print) | LCCN 2021035624 (ebook) | ISBN 9781635502817 (paperback) | ISBN 1635502810 (paperback) | ISBN 9781635502886 (ebook) Subjects: MESH: Mutism--therapy | Mutism--diagnosis | Child | Speech-Language Pathology--methods Classification: LCC RJ496.S7 (print) | LCC RJ496.S7 (ebook) | NLM WS 350.7 | DDC 618.92/855--dc23 LC record available at https://lccn.loc.gov/2021035623 LC ebook record available at https://lccn.loc.gov/2021035624

Contents Preface vii Acknowledgments xi Reviewers xiii Introduction xv

1 Overview of Anxiety 2 History of Selective Mutism and Etiological Factors 3 Characteristics of Selective Mutism 4 Assessment and Diagnosis of Selective Mutism 5 Treatment Techniques for Selective Mutism 6 Meaningful Goals and Therapy Activities

113

Resources Case History Sample Letter to New Classmates/Friends Selective Mutism at School Handout (Teacher Tip Sheet) Sample Talking Map Classmates and Friends Rating Form Teachers and Adults Rating Form Playdate Log Sample Ritual Sound Approach Chart Brave Talking Practice Assignment Sheet Feelings Rating Chart Brave Talking Questions Brave Talking Goals Brave Talking Ladder (5 Steps) Brave Talking Ladder (10 Steps) Find-A-Friend Bingo

135 137 152 154 155 156 157 158 161 162 164 165 167 168 169 170

1 7 23 39 71

v

vi  Treating Selective Mutism as a Speech-Language Pathologist

Brave Talking Chart (10 Spaces) Brave Talking Chart (80 Spaces With Row Markers) Brave Talking Chart (80 Spaces) Brave Talking Weekly Chart (for Classroom) Pets Survey Birthday Survey Seasons Survey Siblings Survey Ice Cream Survey Challenge Cards for School Nature Walk Scavenger Hunt Bookstore/Library Scavenger Hunt Grocery Store Scavenger Hunt Department Store Scavenger Hunt Additional Resources

171 172 173 174 175 176 177 178 179 180 181 182 183 184 185

References 189 Index 199

Preface As a high school student, my first job was teaching at a local preschool. I spent my days working on language, math, science, and social-emotional concepts with 2- to 5-year-olds, engaging in creative play, laughing at funny antics, watching friendships being formed, engaging in silly dances, singing catchy songs, and inventing elaborate dramatic play games. Throughout the years, I watched many children grow from toddlers to almost-kindergarteners in the program, and I watched as their personalities and skills continued to develop. One year, I met “Caleb.” He entered our “Twos Turning Three” classroom and he didn’t speak a word. His mom reported that he had selective mutism (SM), an anxiety disorder that prevented him from speaking in most situations. He was able to speak to her at home, and sometimes in a whisper in other places, but that was it. Throughout the next 3 years, Caleb and I grew very close. I was so intrigued by this creative, funny, artistic little boy and determined to find ways for him to communicate with the people around him. We developed hand signals and used drawings and nonverbal communication and he slowly began to make friends, laugh silently at silly moments, and paint picture after picture at the easel, but he still was not able to speak at school. His speech-language pathologist (SLP) would come to school after the other students had left and work one-on-one with him in the classroom, helping him to get comfortable speaking there. After a few months of this, she invited me to be part of their sessions, so they could practice generalizing his speech to a new conversation partner. As we played “Hi Ho Cherrio,” she asked him, “Whose turn is it next?” and for the first time, I heard his voice as he said my name. I thought his SLP was magic. I was captivated by the work that she was doing with Caleb, how she was helping him to find his voice, and by the small steps forward we were starting to see. I wanted to learn how to help children like this, too. I spent the next few years earning a BA and MA in applied developmental psychology, and then returning to graduate school for a vii

viii  Treating Selective Mutism as a Speech-Language Pathologist

second time to earn my MS in speech-language pathology. I learned about anxiety and I learned about speech and language. I read everything I could about selective mutism and looked for chances to learn more. I found that the American Speech-Language-Hearing Association makes it clear that treating SM is within the SLP’s scope of practice. I was able to find training programs and opportunities to work with children with SM at the Child Mind Institute and the SMart Center. I joined the Selective Mutism Association Board of Directors and became engaged in the work they were doing to promote awareness and provide resources for SM. And, children with SM began showing up on my speech therapy caseload at an elementary school. Suddenly, SM was everywhere—I was being invited to present on the topic at conferences and to graduate and undergraduate classes; it was becoming a topic of discussion and debate among teachers and SLPs on social media groups; parents were recognizing the signs in their children and looking for help and guidance, but finding that there were not enough trained professionals available to provide support and treatment. Over the years, my experiences with these children and teenagers have been that they are an incredibly brave, resilient, creative, witty, kind, thoughtful, and wonderful group to work with, who simply need help finding their voice and practicing using it in new situations and with new people. As SLPs, our knowledge about treating pragmatic disorders and our understanding of how to elicit language in an intentional and scaffolded manner makes us prime candidates to work with these children and families. However, many SLPs hear that SM is an “anxiety disorder” and incorrectly conclude it is outside of their scope. This book is designed to dispel those myths, and to be a manual for SLPs who are looking for information about how to work with children with SM. It provides information regarding how to assess and treat children with this disorder using evidence-based practices and provides a number of resources for SLPs to utilize with their own clients. It is my hope that the information in this book will empower SLPs to use their knowledge and skills to help this group of children find their “brave voice.” When Caleb was in second grade, I ran into him one weekend at a soccer tournament. He excitedly ran up to me and told me about the

Preface   ix

game he had just won and his plans for the rest of the weekend. Gone was the hesitant whisper; he no longer avoided eye contact or turned away from interactions. I marveled at how easily and comfortably he was able to interact with me after so many years of silence, and how beautiful it was to see this version of himself and witness so much more of his personality, now that his words were no longer restricted by anxiety. Our work as SLPs can make all the difference for children like Caleb, by helping them to break out of their silence and share the true versions of themselves with the world around them.

Acknowledgments I am forever grateful to my family for supporting me throughout the process of writing this book—from taking the initial steps, to encouraging me when I needed a boost, to supporting me through all the late nights and weekends full of writing and researching. Thank you to Debbie, Ed, Eliza, Kiersten, Isaac, Christy, Kraig, Elena, Alex, Simon, Aaron, LuAnn, and Bob for your endless faith in me, patience as I had to talk things out with you, ideas and suggestions, and encouragement to keep moving forward. I am so thankful to Rachel, Elianna, Alisa, and the Child Mind Institute team; Elisa and the SMart Center team; and my colleagues on the Selective Mutism Association Board of Directors, for all they have taught me about SM through trainings, conversations, and participating in treatment programs. Each of you has helped to make me the clinician I am today and contributed to my knowledge and skills. Thank you to Lily, Lucy, Connor, and their parents for being so willing to share their experiences. Your perspectives are so vital in helping others to have hope and to promote understanding of SM. Finally, I am extraordinarily grateful to my team at Plural Publishing for reaching out to me with this initial opportunity and all the support and guidance they provided to me throughout this writing and publication process. I am so thrilled and thankful to have had this opportunity to write about this topic that is so near to my heart.

xi

Reviewers Plural Publishing and the author thank the following reviewers for taking the time to provide their valuable feedback during the manuscript development process. Audrey E. Boggs, PsyD Psychologist in Private Practice Selective Mutism Specialist Los Angeles, California Annie DiVello MS, CCC-SLP Founder of Annie DiVello Consulting, LLC Newmarket, New Hampshire Catherine Eckel, PhD Psychologist in Private Practice San Jose, California Jemma Helfman, PsyD, CPsych Clinical Psychologist Kidcrew and The Feelings Place Toronto, Ontario, Canada Lisa Kovac, PhD, BCBA Executive Director Selective Mutism Association School Psychologist Seminole County Public Schools Seminole County, Florida Rebecca Laptook, PhD Clinical Psychologist Associate Professor of Psychiatry and Human Behavior Alpert Medical School of Brown University Providence, Rhode Island xiii

xiv  Treating Selective Mutism as a Speech-Language Pathologist

Rebecca Lulai, MA, CCC-SLP Speech-Language Pathologist Director of Clinical Program in Speech-Language Pathology University of Minnesota Minneapolis, Minnesota Angela N. McLeod, PhD, CCC-SLP Clinical Associate Professor University of South Carolina Columbia, South Carolina Brenda Ray, MS, CCC-SLP Speech-Language Pathologist Seattle Children’s Hospital Seattle, Washington Mona Ryan, MS, CCC-SLP Clinical Associate Professor Speech-Language Pathologist Clinical Coordinator University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Introduction “When I had selective mutism it was really hard to talk to anyone besides my mom, dad, and sister. I couldn’t ask to go to the bathroom at school, tell a friend to stop bothering me, or ask the teacher for help. I couldn’t tell someone what my name was if they asked. I wanted to, but I couldn’t. It was like my lips were stuck together with superglue and the words couldn’t come out.”  —Lily, age 13

Foundations of Social Language Developing appropriate social language skills (also known as “pragmatics”) is crucial for building and maintaining meaningful relationships throughout the lifespan. As such, deficits in these skills can have extensive detrimental effects on a child’s mental health and social-emotional functioning, as well as their academic functioning. Speech-language pathologists (SLPs) are well-trained experts in the area of assessing and treating pragmatic language disorders. Therefore, it clearly falls within the SLP’s scope of practice to treat students who are experiencing difficulty engaging in social language tasks or interactions. One group of children who exhibit difficulty in this area are children with selective mutism (SM). Selective mutism is an anxietybased disorder in which the child is able to communicate appropriately in at least one setting (often, the home or with familiar family members) but is unable or struggles to communicate in other settings (i.e., school, community settings, etc.) or with other communication partners (i.e., peers, less familiar adults, teachers, community members, etc.). Children with SM may not demonstrate appropriate social language skills for a number of reasons. They may have had limited opportunities to develop and practice these skills, due to xv

xvi  Treating Selective Mutism as a Speech-Language Pathologist

avoidance of social interactions, or they may know when to use the skills (i.e., know when it’s appropriate to greet a conversation partner) but be unable to do so due to their level of anxiety. Social language skills can be divided into three primary categories of skills. The first skill is using language for different reasons, also known as “pragmatic functions.” This includes greetings and farewells, making requests for objects or actions, requesting continuation or cessation, providing comments or descriptions, making promises, and engaging in humor. Deficits in this area may look like omission of greetings and farewells, difficulty formulating questions to ask for things they want or need, difficulty knowing when and how to tell someone “no” or “stop,” difficulty providing detailed and meaningful explanations of things (i.e., retelling a story, making a comment about something in the environment), and difficulty telling or understanding jokes and teasing. Children may struggle with multiple pragmatic functions or may specifically struggle with one or two areas. A description of when various pragmatic functions develop can be found in Table 0–1. The second primary social language skill is the ability to change language based on the listener. This includes altering the tone, register, length of utterance, and/or vocabulary used to talk to a younger child versus a peer or an adult. Another related skill is understanding the listener’s perspective and being able to omit redundant information or add additional information in order to aid in the listener’s understanding of the content. If the child is discussing the trip they took to the grocery store with the parent they went with, certain details are unnecessary because the parent was present in the shared experience and has the requisite background knowledge. If the child is explaining the trip to his grandmother, who was not there, he may need to add additional information such as where they were, who was with him, what they were doing, and so forth, in order to make his story meaningful and provide appropriate context. Also included in this skill set is the ability to modify language based on the situation. Children must be able to understand that how they talk to their friend on a playdate requires a different set of linguistic parameters than how they would talk to their teacher at school, whom they see regularly, versus their pediatrician, whom they see infrequently. Deficits in this

Introduction   xvii

area typically manifest as difficulty interpreting the social situation and knowing what is appropriate (i.e., telling jokes in the middle of a religious service) or not being able to take the listener’s perspective and therefore giving too much or too little background information. Additionally, it may look like engaging in “baby talk” at inappropriate times or difficulty shifting gears from more informal to formal conversations, such as knowing when to use polite versus more relaxed conversation, or knowing when to make direct requests (“Give me that blanket,”) versus indirect requests (“It’s really cold in here, I wish I had something to keep me warm.”). The final skill is following culturally appropriate rules for conversation. This includes allowing appropriate turn-taking with the conversation partner, initiating conversations appropriately (i.e., getting the partner’s attention appropriately, informing partner of the topic to be discussed), maintaining the topic throughout the conversation, revising and repeating language to clarify when the meaning was misunderstood by the listener, utilizing and understanding nonverbal language (i.e., gestures, facial expressions, eye contact), demonstrating awareness of appropriate personal space, and using and understanding how tone of voice affects the message and intent. Deficits in this area may look like children who monopolize conversations and do not allow time and opportunities for others to talk, or who continually draw the topic back to preferred topics instead of shifting topics with the partner. It can also look like difficulty using or understanding nonverbal language, including not noticing or interpreting it at all and therefore missing cues such as when a partner wants to end a conversation or when they are uninterested versus invested in the topic. Additionally, children with deficits in this area may have difficulty maintaining appropriate personal space (ASHA, n.d.). Social language begins to develop as early as the newborn to 3 months stage, when infants engage in turn-taking with caregivers through smiling and cooing, attending to eyes and mouths, and demonstrating preferences for faces (Peters, n.d.). From there, social language continues to develop and be refined through adolescence (see Table 0–1). Clearly, children are working hard to develop a variety of skills throughout both the early and later childhood years. Developing these

xviii  Treating Selective Mutism as a Speech-Language Pathologist

skills and continuing to practice them across a variety of situations and with a variety of communication partners is crucial in the refinement of these skills and to the success of social interactions. Children who cannot practice these skills or do not have the opportunity to do so are at a significant disadvantage compared to their peers, and with every instance of avoiding practice, fall further and further behind in development of appropriate social language skills. Therefore, it is critical for SLPs to identify children who have difficulty with social language skills and provide appropriate intervention as early as possible, in order to ameliorate current deficits and avert potential negative long-term consequences. Students with SM are at particular risk for these negative longterm consequences. However, research is clear that children with SM who receive appropriate treatment can and do make significant progress, and can go on to form strong, meaningful friendships; participate and be contributing members of teams and groups; assert and defend their opinions appropriately; and demonstrate all other age-appropriate social language skills. Students with this disorder require intervention that integrates components of cognitive-behavioral therapy geared towards treating anxiety disorders coupled with the knowledge of language development and complexity that SLPs possess. As such, with a little training, SLPs are in a unique position to serve as members of a treatment team and provide vital, life-changing intervention to these students who so desperately need it. The purpose of this book is to provide adequate background information regarding anxiety disorders, specifically SM; information about diagnosis and assessment of children with SM; and a clear overview, with examples, strategies, and ideas, of how to provide evidencebased treatment for children with selective mutism. Ideally, this book can serve as a manual for SLPs working with students with SM and enable them to make a tremendous difference in the lives of children who desperately want to use their voice effectively. “I am really happy that I can use my voice in all settings now. I can stand up for myself and talk to my friends just like all the other kids.”  —Lily, age 13

Table 0–1.  Development of Social Language Skills 0–3 months

Smiles/coos responsively Attends to eyes/mouth; shows preference for faces Demonstrates turn-taking

3–6 months

Laughs during social interactions Maintains appropriate eye contact Takes turns with vocalizing Follows gaze of communication partner Mimics facial expressions

6–9 months

Vocalizes to get attention Demonstrates attachment Shows self in “Peek-a-boo” Reaches/points to request

9–12 months

Begins directing others Participates in verbal routines Repeats actions that others laugh at Tries to restart play Uses play routines (give and take, build and knock over) Pragmatic functions (vocalizations/gestures): protest/ reject, request objects or action, call, express feelings, notice/comment, respond to others, and refuse

12–18 months

Imitates routines Imitates older children Pragmatic functions (words): protest/reject, greet/call, respond to others, label/comment, request objects/ actions, express feelings/wants Controls behavior of self and others Responds to adult conversational attempts Pragmatic functions closer to 18 months (words): request information, initiate pretend play, comment/tell information, acknowledge/answer

18–24 months

Pragmatic functions (2–3 words): protest/reject, greet/ call, respond to others, label/comment, request object/ action, express feelings, request information, initiate pretend play, tell information, acknowledge/answer Practices familiar conversational routines (book-reading, going to restaurant, etc.) continues

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Table 0–1.  continued 24–30 months

Uses “please” for requests Engages in symbolic play Able to talk about absent objects Misrepresents reality (lies, teases) Narratives comprised of labels and descriptions Announces intentions Engages in conversations of two turns each Introduces and changes topics Verbally expresses emotions Begins to give descriptions to aid listener’s understanding Clarifies by repeating Requests clarification

30–36 months

Speaks in sentences Attempts to control situations verbally Uses polite “nice” intonation patterns Responds to requests to clarify Apologizes with “I’m sorry” Able to maintain topics ~50% of the time Maintains topics by adding new information Increases use of language in play Narratives begin to include sequences with theme but no plot Understands that others can want different things

36–42 months

Engages in/maintains conversation of 4–5 conversational turns each Uses filler words to acknowledge Begins to shift tone with younger children Makes choices Requests permission Uses language for teasing/jokes/fantasy Consistently uses descriptions to clarify; gives description of objects wanted Expresses specific personal needs Requests help

xx

Table 0–1.  continued 36–42 months

States problems

continued

Corrects others Uses pronouns Gives directions to play a game or make something Identifies and explains feelings (“I’m sad because it broke.”) Provides excuses or reasons Offers an opinion with support Complains Blames others Disagrees with others Compliments others Can provide personal information (name, age, address, birthday, etc.) Uses appropriate social rules for greetings, farewells, getting attention Requests through yes/no questions Asks questions out of curiosity Begins to role play as different characters Makes polite requests; uses permission directives (“Can you . . . ?”) and indirect requests (“Would you . . . ?”) Less direct requests and more indirect requests Narratives have theme and some temporal organization

42–48 months

Has long, detailed conversations Initiates a topic of conversation (vs. starting to talk in the middle) Tells two events in correct order Tells story mixing real and unreal components Uses pronouns across sentences New pragmatic functions: reporting on past events, reasoning, predicting, expressing empathy, creating imaginary roles and props, and maintaining interactions Understands that others can have different beliefs continues

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Table 0–1.  continued 4–5 years

Uses hints that do not mention the intention in the request Increased ability to address specific requests for clarification Correctly uses and changes references terms this/ that, here/there, go/come Uses this/that/these/those from listener’s perspective Initiates easily Ends conversations (may be abrupt) Changes topics appropriately Uses apposition to cue the listener Revises/repairs an incomplete message Interjects appropriately into established conversations with others Apologizes and/or explains behavior Requests clarification Criticizes others Asks questions to systematically gather information (i.e., 20 questions) Explains relationship between two objects, actions, or situations Correctly retells a story that was told to them May begin to tell lies Expresses humor/sarcasm Original narratives are “chains” with some plot but no high point or resolution Understands that he/she can know something that others don’t know

5–6 years

Uses focused chains for narratives Gives threats/insults Issues promises May give praise Maintains topic of conversation for 10 turns each Self-monitors speech for errors Engages in negotiations (play roles, turns, ending of play)

xxii

Table 0–1.  continued 5–6 years continued

Understands that a person can feel something but may not demonstrate it (“hidden emotions”)

6–8 years

Can give multiple-step directions Creates well-formed narrative Uses multiple-sentence descriptive language (creates riddles, describes characters) Makes and responds appropriately to evaluative comments/corrections Checks listener’s comprehension Produces full explanations Responds appropriately to compliments Apologizes and responds to apologies appropriately

8–9 years

Uses language to establish and maintain social status Demonstrates increased perspective-taking, more successful persuasion Provides conversational repairs by defining terms or giving background information Begins to understand jokes and riddles based on sound similarity

9–12 years

Narratives include complex, embedded, interactive episodes Understands jokes and riddles based on lexical ambiguity

12–14 years

Uses expository texts in school-based writing Most academic information is presented in expository format Understands jokes and riddles based on deep structure ambiguity

14–18 years

Language is used to maintain social bonds Persuasive and argumentative skills reach near-adult levels

Source:  Adapted from Peters (n.d.) and Goberis (1999).

xxiii

1

Overview of Anxiety

Fear is a normal, healthy response to threatening stimuli. All humans experience fear, and fear serves an adaptive purpose. From an evolutionary perspective, fear serves the purpose of stopping us from entering dangerous environments and preventing us from engaging in unsafe activities. When a person is confronted by a fear-evoking stimulus, a complex neurobiological response, including a cascading physiological and hormonal process, is initiated in the brain. First, the eyes and/or ears communicate the information about the stimulus to the amygdala, the part of the brain responsible for managing emotional responses and processing, specifically fear and anger. When the amygdala receives the signal, it triggers a second signal, alerting the hypothalamus of the danger. The hypothalamus is often known as the “control center” of the brain, as the signals that travel to the rest of the body’s nervous system are usually directed through the hypothalamus. The hypothalamus is responsible for regulating the body’s autonomic nervous system, which is comprised of the sympathetic and parasympathetic nervous systems. The autonomic nervous system governs the operation of many involuntary bodily functions, including respiration, heart rate and blood pressure, and the dilation or constriction of airways in the lungs. When the hypothalamus receives the “danger” signal from the amygdala, it activates the sympathetic nervous system. This, in turn, triggers the fight, flight, or freeze response. The signal passes through the adrenal glands which release a burst of epinephrine (also known as adrenaline), so that the body is equipped to handle the dangerous situation. Epinephrine 1

2  Treating Selective Mutism as a Speech-Language Pathologist

triggers responses throughout the body, including increasing heart rate; directing blood flow to muscles, heart, and vital organs; increasing pulse rate and blood pressure; and opening up airways in the lungs to allow for the person to breathe heavily. This allows more oxygen to be sent to the brain which in turn increases the brain’s level of alertness to the dangerous stimulus. Additionally, the senses of sight and hearing are enhanced. This initial activation of the sympathetic nervous system happens so rapidly that people are not aware of it; in fact, the entire cascade effect is triggered and complete before the brain is able to fully process what the dangerous stimulus is (Harvard Health Publishing, 2018). Fear responses can usually be categorized into one of three types, and are colloquially referred to as “fight, flight, or freeze.” “Fight” responses can be seen in nature in the form of animals that engage in an altercation to protect themselves or their offspring from a dangerous stimulus. In modern-day human society, a “fight” response can manifest as physical or verbal aggression, such as a desire to hit, rip, or punch something; a desire to stomp or kick; a clenched jaw or fists; grinding teeth; feelings of anger or rage; and using metaphors that indicate aggression, such as talking about bombs or erupting volcanoes. In extreme circumstances the individual may also experience homicidal or suicidal feelings. However, the “fight” response can also manifest as less obvious symptoms. Anxious people experiencing a “fight” response may demonstrate crying, tense or flexed muscles throughout the body, and/or a “knotted” or burning stomach feeling or nausea. “Flight” responses get their name from animals in the wild that flee the dangerous situation in order to maintain safety. In some cases, the “flight” responses in humans may look similar—people may attempt to leave the situation that is triggering their fear, whether it is getting away from a certain person, getting out of a certain environment, or actually running away from the dangerous stimulus. Less obvious signs of a “flight” response include feelings of restlessness or numbness in the feet or legs; shallow breathing; enlarged pupils; fidgety movements, especially of the legs and feet; feelings of being trapped or tense; or the need to engage in excessive exercise.

1.  Overview of Anxiety   3

The “freeze” response originates from animals in nature who become motionless when confronted by danger in an attempt to be unnoticed, so that the dangerous stimulus will pass by. People experiencing a “freeze” response may physically or mentally “freeze” in place and have difficulty moving or thinking about ways to manage the situation. They may also report feeling “stuck” in some part of their body; feeling cold or numb; having paleness of skin; holding their breath or experiencing restricted breathing; feeling a sense of dread; feeling their heart pounding; and/or a decreased or increased heart rate (Trauma Recovery, 2013). After the initial burst of epinephrine, which triggers the flight, flight, or freeze response, the hypothalamus activates the pituitary glands in addition to the adrenal glands. Together, these three structures (known as the HPA axis) continue to keep the sympathetic nervous system activated. If the source of danger is still present, the hypothalamus and pituitary glands continue to release hormones, which in turn trigger the adrenal glands to release cortisol. Cortisol keeps the physiological alertness of the body intact until the threat has been managed or is no longer present. At this point, the parasympathetic nervous system is activated in order to subdue the stress response (Harvard Health Publishing, 2018). However, fear can become overactive and can signal an emergency at inappropriate times. Fear can be triggered not only by an immediate event but also by one’s thoughts about a future or past event, which is often referred to as “anxiety.” Just like fear, some level of anxiety is normal and important for appropriate everyday functioning. However, when anxiety becomes too frequent, lasts for too long, or is impairing one’s ability to complete everyday tasks, this signifies that an anxiety disorder may be present. The Diagnostic and Statistical Manual, 5th edition (DSM-5; American Psychiatric Association, 2013) categorizes many disorders under the heading of “anxiety disorders.” These include social phobia, generalized anxiety disorder, specific phobias, separation anxiety, selective mutism, and others. Anxiety disorders are incredibly prevalent in the worldwide population, with recent estimates suggesting that as many as 1 in 5 individuals experience anxiety disorders

4  Treating Selective Mutism as a Speech-Language Pathologist

at some point in their lives (Kessler et al., 2009; Whiteford, Ferrari, Degenhardt, Feigin, & Vos, 2015; Wittchen et al., 2011). Treatment methods for anxiety disorders span a large spectrum of options. This includes psychological interventions, such as cognitive-behavior therapy, psychoanalysis, supportive counseling, brief psychotherapy, and group psychotherapy (Mangolini, Andrade, Lotufo-Neto, & Wang, 2019). For social anxiety/phobia, and selective mutism specifically, evidence-based treatment methods include social skills training, relaxation, exposure-based methods, cognitive behavioral therapy, group therapy, and systematic desensitization (Chambless & Ollendick, 2001; Nathan & Gorman, 2002). Additionally, in place of or in addition to psychological interventions, pharmacological interventions may be used. These include antidepressants, buspirone, benzodiazepines, beta-blockers, and in some cases, antipsychotic medication (Mangolini et al., 2019). Furthermore, some clients may choose to supplement these interventions with alternative therapies such as aromatherapy, acupuncture, exercise, herbal medicine, homeopathy, massage therapy, mindfulness, yoga, and other relaxation techniques. A review of these treatment methods indicates that while many clinicians are supportive of these therapies in a supplemental role, there is not enough evidence to suggest that alternative therapies alone are effective at managing anxiety disorders (Craske, Stein, & Hermann, 2016). Throughout this book, the term “clinician” is used to refer to a treatment provider, which may include a psychologist, social worker, or speech language pathologist (SLP). In cases where more specific aspects of a treatment provider’s work or scope of practice is being discussed, the provider’s title (i.e., psychologist) is used. In many cases, there may be more than one type of clinician working with the child and family. Clinicians, doctors, parents, and children must work together to determine the most effective treatment methods for their individual needs and situation. In many cases, it may take a trial-anderror process with more than one treatment technique before the right one is discovered and implemented. At the same time, it is important to give each treatment method a reasonable amount of time to work, to determine if there is improvement in the child’s skills or lessening of their anxiety symptoms.

1.  Overview of Anxiety   5

It is important to have an understanding of anxiety and the responses that it can cause, as selective mutism (SM) is an anxiety disorder at its core. However, it is a unique disorder that requires collaboration from multiple fields (i.e., psychology, psychiatry, and speech-language pathology, etc.) because the effects of the anxiety can be seen in the child’s social language skills and abilities—an area that is within the SLP’s scope of practice. It is critical that treatment teams address both the underlying anxiety component of the disorder (i.e., through medication, therapy, or both) as well as work on teaching the child appropriate social language skills and providing many opportunities to practice using these skills across multiple people, places, and activities. Additionally, understanding the etiological factors that contribute to the development and maintenance of SM can help the team decide how to progress with treatment. The next chapter includes an overview of the history of SM and etiological factors.

2

History of Selective Mutism and Etiological Factors

What Is Selective Mutism? Selective mutism (SM) is an anxiety-based childhood disorder that prevents a child from speaking in specific situations—often this is anywhere outside the home, or to anyone other than immediate family members (American Psychiatric Association, 2013). The severity of this disorder can range from mild, such as a child who is able to speak to teachers and a few peers at school, but does so at a low volume and has difficulty speaking to new or unfamiliar people; to severe, such as a child who struggles to communicate at school or in public, even with extended family members, and may even appear “frozen” or have difficulty with nonverbal communication (e.g., nodding, shrugging, pointing) (Kotrba, 2015). Consider each of the following scenarios: n Jayden’s grandparents come over to visit to celebrate his little

sister’s birthday. As everyone sings “Happy Birthday,” Jayden is silent and stares at the ground. Later, as the family sits in the living room, his grandmother asks him what he’s been learning about in school. Jayden looks to his mom, up at the ceiling, and then back to the ground, and isn’t able to respond. n Manuel wakes with a start and looks around. He had fallen asleep on the bus, which is now almost empty. Manuel looks out the window and does not recognize where he is. The bus 7

8  Treating Selective Mutism as a Speech-Language Pathologist

stops and the last remaining children get off, so now Manuel is the only student left on the bus. The bus driver looks in the rearview mirror and calls out to him, “Hey, did you miss your stop? What’s your name?” Manuel looks back out the window to avoid looking at the driver and is not able to answer. n Elena is sitting in the “morning meeting” circle with the rest

of her preschool class. Her teacher, Miss Claire, goes around the circle one by one, asking the students what they did over the weekend, and Elena wants to talk about her trip to pick strawberries. As her classmates enthusiastically share stories of their activities and trips, Elena sits rigidly, fists clenched, not making eye contact with anyone. When Miss Claire gets to her, she asks, “Elena, did you go somewhere this weekend?” Elena is not able to respond. Miss Claire, trying to help, suggests, “You can shake your head ‘yes’ or ‘no’. ” Elena remains frozen and Miss Claire moves on to the next student. The next day, Miss Claire skips over Elena, hoping that she will feel better if she is not put on the spot.

n Aaron is playing on the playground at recess when he falls

and hits his head on a metal post. He looks around for help, but no one seems to have noticed. Aaron has a headache, is dizzy, and is experiencing nausea, but is unable to approach a teacher to explain what happened or ask to go to the nurse. Instead, he tolerates the symptoms for 5 more hours until he arrives home and can tell his mother what happened.

n Deirdre is at an airport with her family. As they walk through

the crowded terminal to get to their gate, a hurried passenger pushes in front of her and she gets separated from her family. Deirdre stops and looks around but doesn’t see them anywhere. An airport security guard sees her and asks, “Are you lost, sweetie? Do you need help?” Deirdre remains frozen in place and is unable to nod or answer.

In each case, the child is demonstrating characteristics of SM, which are inhibiting their ability to participate fully in the interaction and environment around them. In some cases, this makes the situation unpleasant or uncomfortable; in others, it places the child

2.  History of Selective Mutism and Etiological Factors   9

at significant risk or in danger. In many situations, however, teachers may not recognize these symptoms for what they are, instead characterizing these students as “behavior problems” or merely “shy and quiet.” Parents may have no idea that these symptoms are occurring, because these children are able to talk and interact typically at home and may even be “chatterboxes” or described as “outgoing.” Upon hearing about concerns from teachers about their child not responding, ignoring questions, not participating in group projects, and not asking for help, they may assume their child is being “defiant” or “difficult” or may brush off the concerns as simply a “shy phase.” In fact, SM is neither a defiance issue nor is it the same as shyness—it is a diagnosable anxiety disorder which, with the right intervention and follow-through, can be successfully treated, allowing children to be successful communicators throughout all of their social interactions.

History of Selective Mutism Our understanding of selective mutism has evolved significantly throughout the past century. Although not considered a well-known diagnosis, SM is a concept that can be found in the literature dating as far back as 1877. German physician Adolph Kussmaul first encountered the disorder and named it “aphasia voluntaria,” emphasizing that the individuals with this diagnosis were “voluntarily” choosing not to speak (Krysanski, 2003; Kussmaul, 1877). Decades later, Tramer (1934) coined the term “elective mutism,” thus furthering the belief that these individuals were “electing” not to speak or engage in social interactions. The term was picked up by early versions of the Diagnostic and Statistical Manual (DSM; American Psychiatric Association, 1975, 1980), including the second and third editions. The diagnostic criteria included a “persistent refusal” to speak which lasted a few weeks to a few months. This description highlights the belief that practitioners believed SM was a temporary disorder, one that would resolve on its own or that a child would grow out of after a month or so. It is now known that SM does not typically resolve on its own and can persist for many years and even have lasting effects into adulthood.

10  Treating Selective Mutism as a Speech-Language Pathologist

It wasn’t until 1994 that the DSM-IV introduced the term “selective mutism,” which, for the first time, represented a shift in thinking about the nature of SM—changing from the belief that individuals “chose” not to speak to the belief that individuals could not speak in select environments. The diagnostic criteria included a “consistent failure” to speak in social situations and noted that the course of the disorder could be several weeks to several years. In addition, the inclusion of the fact that “chronic anxiety symptoms” may be present further underscored the role of anxiety in this disorder. In 2013, the DSM-5 introduced the current definition of SM. The diagnostic criteria include: n Consistent failure to speak in specific social situations in

which there is an expectation for speaking (e.g., at school) despite speaking in other situations.

n The disturbance interferes with educational or occupational

achievement or with social communication.

n The duration of the disturbance is at least 1 month (not

limited to the first month of school).

n The failure to speak is not attributable to a lack of knowledge

of, or comfort with, the spoken language required in the social situation.

n The disturbance is not better explained by a communication

disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder. (APA, 2013)

Etiological Factors A number of theorists have proposed etiologies of selective mutism throughout the years, and it is important to understand these theories in order to make sense of the ways various professionals have viewed (and continue to view) and have treated SM.

2.  History of Selective Mutism and Etiological Factors   11

Psychodynamic The psychodynamic view of psychology has posited that SM develops in children who remain “fixated” at certain stages of development and have unresolved conflicts within these stages. Psychodynamic theory states that individuals move through five distinct stages throughout the lifetime, with each stage characterized by a primary conflict that must be resolved successfully (i.e., without excessive frustration or overindulgence), or else unhealthy and negative behaviors, obsessions, or “fixations” will develop later in life. The successful resolution of each stage comes when the individual is able to adequately fulfill the specific pleasure-seeking needs of that stage. Children move through the oral phase from infancy through the age of one. The primary conflict in this stage is resolving the tension of desiring oral stimulation, which is fulfilled through feeding, sucking, swallowing, etc. The anal stage, which the child moves through from approximately ages 1 to 3 years, revolves around the necessity of anal stimulation. Increasing independence through the process of potty-training is a primary focus during this time period (McLeod, 2017). Proponents of the psychodynamic theory believe that unresolved conflict in either of these stages (i.e., due to frustration or overindulgence) can lead to the child’s desire to “punish” the parent, which is achieved through choosing not to speak in certain situations or when demands are placed on the child. Other etiologies of SM that stem from the psychodynamic theory include that the child is holding and refusing to share a family secret, that the child is maintaining anger towards one or both parents and acting on this anger in the form of refusal to speak, or that the child is regressing to a previous stage of nonverbal development (Giddan, Ross, Sechler, & Becker, 1997). Such suggestions build off the notion that the child is choosing not to speak or acting out in a form of willful defiance. Practitioners subscribing to a psychodynamic theory of etiology will typically use play therapy as a treatment approach, rather than an intervention focused specifically on eliciting verbal behavior. The goal of psychodynamic treatment typically revolves around the belief that helping the child to develop adequate symbolic play to demonstrate or act out the underlying conflict will result in healing of the “internal world.” It is important to

12  Treating Selective Mutism as a Speech-Language Pathologist

note that there is little empirical evidence to support these etiological ideas (Krysanski, 2003), and it does not fit well into current theories regarding underlying anxiety causing the child to be unable to speak, rather than deciding not to out of defiance.

Behavioral Behavioral psychologists have attempted to explain the development of SM through the lens of reinforcement. Such theorists believe that SM occurs when negative behaviors are repeatedly reinforced over time. In other words, the mutism is a learned response in which the refusal to speak is a method of manipulating the environment (Friedman & Karagan, 1973). As such, the behavior is thought to serve some type of function and therefore is purposeful and fills a need for the child. The environment, which includes not only the setting but also the people in the environment and their reactions to the child’s behavior, serves to reinforce the behavior, which increases the likelihood that it will continue to occur. The behavioral viewpoint brings to the table the acknowledgment that the environment—specifically, the responses of those within the environment—plays a significant role in the course of SM’s development and the progression of symptoms. However, strict behavioral theorists will argue that the mutism behavior of SM is “adaptive,” rather than a disorder in need of treatment (Powell & Dalley, 1995). Given what we know now about how the negative consequences of SM can, when left untreated, persist throughout the lifetime, this argument does not hold up against current empirical evidence.

Social Phobia Still others argue that SM is an extension of social phobia/social anxiety disorder. Black and Uhde (1995), studied a sample of children with SM and found that social phobia was present in all participants in their study, suggesting that it may be a “universal characteristic” of this population. They proposed that selective mutism may be

2.  History of Selective Mutism and Etiological Factors   13

the most extreme form of social anxiety, characterized by an excessive inability to speak, which may be displayed to a lesser degree by adults and children diagnosed with social anxiety (but not SM). Other researchers have supported this viewpoint (Dummit et al., 1997; Kristensen, 2000). However, Hassan, Taha, Mahmoud, and Azzam (2013) examined the differences between children with selective mutism and children with social anxiety disorder. They found that, while some children with SM did meet the criteria for social anxiety disorder (38% of the sample), not every child with SM could be diagnosed with it. Such findings suggest that, although there is a high level of comorbidity between the two disorders, SM is indeed a distinct diagnosis separate from social anxiety disorder, and it is possible to have SM without having social anxiety. Similarly, the DSM-5 treats social phobia/social anxiety disorder and SM as two distinct and unique diagnoses.

Family Systems The family systems theory, conceptualized by Bowen (Brown, 1999) and others, revolves around the idea that an individual’s development does not occur in a vacuum, but rather is significantly influenced by factors within the family and relationship dynamics between family members. Those who subscribe to the family systems theory believe that SM results from faulty family relationships (Anstendig, 1998), particularly between the parent and child or between the parents themselves. Such families are typically characterized by intense attachments and interdependency, fear and distrust of the outside world, fear and distrust of strangers, language and cultural assimilation difficulties, marital disharmony, or withholding of speech practiced by one or more of the parents in the home (Meyers, 1984). The family systems theory contributes to our current understanding of SM by underscoring that family dynamics do influence the development and maintenance of SM. Certainly, the factors described by Meyers (1984) are seen as risk factors for developing SM, but are not seen as typical patterns across all families whose children present with SM. Treatment from a family systems perspective

14  Treating Selective Mutism as a Speech-Language Pathologist

typically focuses on addressing the larger discordant dynamics present within the family, and repairing overall relationships among family members, rather than specifically on eliciting and improving speech from the child. Current evidence-based treatment methods for SM take this into account by including a parent training component to treatment, which acknowledges that parents’ behaviors can (unknowingly and unintentionally) impact children’s ability to overcome SM.

Multifactorial The current, most widely accepted etiology of selective mutism is the multifactorial viewpoint (Cohan, Chavira, & Stein, 2006; Muris & Ollendick, 2015; Viana, Beidel, & Rabian, 2009; Figure 2–1), also sometimes referred to as the biopsychosocial model. SM is thought to develop due to a combination of genetic, temperamental, environmental, and neurodevelopmental factors. Genetics

A number of studies have examined the similarities between parents and their children with SM. Remschmidt, Poller, Herpertz-Dahlmann, Hennighausen, and Gutenbrunner (2001) reviewed family histories of 45 children with SM and found that 9% of fathers, 18% of mothers, and 18% of siblings had histories of SM. Additionally, 51% of fathers and 44% of mothers showed signs of “extreme reticence” in social situations. Kristensen and Torgersen (2001, 2002) analyzed personality traits of parents of children with SM and those with typically developing children. Findings include that parents of children with SM were more likely to have higher levels of shyness, social anxiety, and prefer solitary activities, compared to the parents of typically developing children. Of course, similarities between parents and children may be explained by genetics, but may also be explained by behavioral factors (i.e., children mimicking behavior they see their parents engaging in). As such, there is a need for further study of the influence of genetics (Rice, 2008).

2.  History of Selective Mutism and Etiological Factors   15

Phobias

Social anxiety disorder

Anxiety disorders Genec

Speech/Lang disorder

Shy

Anxiety disorders Neurodevelopmental

Child

Temperamental

Inhibited

Social anxiety disorder

Reserved Phobias

Environmental Reduced opportunies for social interacon

Reinforcement of not talking

Observing anxious behaviors

Avoidance

Figure 2–1.  Multifactorial etiology of SM.

Temperament

Although not all children diagnosed with SM demonstrate behavioral inhibition, there is significant overlap between the indications of this temperament and the typical presentation of SM. Children who are behaviorally inhibited repeatedly demonstrate fearfulness and avoidance in situations with unfamiliar people, objects, or other stimuli (Kagan, 1994), which are all characteristic behaviors of children with

16  Treating Selective Mutism as a Speech-Language Pathologist

SM. Among preschool-age children, one of the primary manifestations of behavioral inhibition is a decreased level of spontaneous speech around the novel stimuli or environment. Some studies have examined the overlap between “shyness” and children with SM and have found that between 68% (Kumpulainen, Rasanen, Raaska, & Somppi, 1998) and 85% (Steinhausen & Juzi, 1996) of children who are diagnosed with SM can be categorized as “shy” according to clinical temperamental rating scales. Similarly, parents of children with SM are significantly more likely to rate their children as being “shy” on a behavioral rating scale compared to parents of control children (Buss & Plomin, 1984). Given the significant overlap between the manifestations of shy and inhibited temperaments and symptoms of SM, more research is needed in this area, particularly prospective studies, to determine the relationship between temperament and SM symptomology. Environmental

Early theories regarding the environmental nature of the etiology of SM revolved around the concept that problems within families (i.e., divorce, abuse, etc.) were the causal factor. However, multiple studies investigating the validity of these beliefs have found no evidence to support these notions (Black & Uhde, 1995; Ford, Sladeczek, Carlson, & Kratochwill, 1998; Kumpulainen et al., 1998; Steinhausen & Juzi, 1996). Similarly, studies investigating the role of trauma (i.e., moving, death of a family member, extended hospitalizations of the child, etc.) have not found evidence of a causal link with developing SM (Black & Uhde, 1995; Kopp & Gillberg, 1997; Kumpulainen et al., 1998; Steinhausen & Juzi, 1996). In general, there are no significant differences between the parenting styles of parents of children with and without SM. However, Edison and colleagues (2011) found that when parents of children with SM were engaged in free play activities as well as a structured activity (i.e., preparing a speech about a favorite birthday), these parents were less likely to give their children autonomy and more likely to make “power remarks” compared to parents of children without SM. Further analysis found that parents

2.  History of Selective Mutism and Etiological Factors   17

with higher levels of anxiety were also more likely to be more controlling, which fits with what is known about children with SM being more likely to have anxious parents. Another environment that has been explored in the literature is children’s experiences at school, since this is most often the place, or one of the places, that children with SM most struggle to speak. Researchers have questioned which aspects of the school environment might contribute to children’s development of SM. One suggestion is that, due to the very verbal nature of most academic activities that occur at school, children with low intelligence or low verbal skills may have difficulty with these skills and, therefore, be less likely to participate or more likely to “shut down” in the face of such pressure to perform. Regarding intelligence, in a study by Kolvin and Fundudis (1981), the majority of children with SM were found to have an IQ that fell within the average range. However, other studies have found that children with SM are significantly more likely to be referred for special education evaluation or services. Usually, this is due to concerns regarding speech and language skills. Beyond academic pressures to speak and engage verbally, another significant part of the school experience is engaging in peer relationships. Children with SM are frequently rated as less social by both parents and teachers, including being less confident during interactions with peers and less able to successfully join peer groups and form and maintain friendships (Cunningham, McHolm, & Boyle, 2006; Cunningham, McHolm, Boyle, & Patel, 2004; Levin-Decanini, Connolly, Simpson, Suarez, & Jacob, 2013). Kolvin and Fundudis (1981) found that students with SM were more withdrawn around peers compared to typical students, and Brown and Lloyd (1975) found that students with SM were more withdrawn around adults compared to their non-SM peers. Similarly, Kumpulainen et al. (1998) found that, in a sample of second grade students who met diagnostic criteria for SM, approximately 40% of these students did not actively participate in group activities in class. Additionally, teachers rated 16% of these children as being rejected by peers in the classroom, 13% as being rejected by peers during breaks or transitional times, and 5% as experiencing identifiable bullying from peers. Of course, when

18  Treating Selective Mutism as a Speech-Language Pathologist

discussing the influence of environment on children’s development of SM, it is important to consider directionality. To date, not enough information is known about whether the environment (i.e., pressure to perform verbally, poor peer relationships) causes the development of SM, or if students who have SM then experience negative consequences in various environments. As such, longitudinal studies that examine the directionality and causality of these factors are needed to gain more information (Muris & Ollendick, 2015). Neurodevelopmental

A number of studies have found evidence of neurodevelopmental differences between children with and without SM. One of the most well-established differences is the presence of speech or language disorders, which has been reported to occur in 35% to 75% of children with SM (Cohan et al., 2008; Kristensen, 2000; Muris & Ollendick, 2015). In addition to articulation and/or expressive and receptive language deficits, children with SM have also been found to have lower pragmatic language skills compared to same-age peers. Carbone et al. (2010) found that children with SM were rated by both parents and teachers as having lower “social assertion” (i.e., initiating conversations or play interactions) and verbal social skills compared to peers with other anxiety disorders and controls without any other diagnoses. It is unclear at this point if decreased social language skills are a causal factor in the development of SM, as children experience difficulty in this area, thus leading to anxiety or embarrassment, and therefore become more anxious or attempt to avoid these situations; or, if poorer social skills are an outcome of SM, as avoiding such situations leads to less opportunities to practice and develop these skills, thus causing these children to perform lower than peers on these measures. Beyond speech/language and specifically social language skills, other neurodevelopmental factors have been postulated to play a role in the manifestation of SM. Many authors have found evidence of more general developmental delays in children with SM. In one study, Kristensen (2000) found that children with SM were more likely to

2.  History of Selective Mutism and Etiological Factors   19

have complications during the prenatal and perinatal periods, as well as more likely to have fine motor and gross motor delays compared to controls. Similarly, Steinhausen and Juzi (1996) found that 43% of children with SM had complications occur during delivery and an additional 20% had at least one complication during the neonatal period. Children with SM were also more likely to have motor delays (18%) and delays in toilet training (24%) compared to controls. Taken together, these findings suggest that SM may be linked to neurodevelopmental immaturity which can manifest in a number of different ways.

Immigration Status and Bilingualism Some literature suggests that immigration status and/or bilingualism may serve as contributing factors to the development of SM. Elizur and Perednik (2003) had mothers of immigrant children and mothers of native children complete questionnaires regarding the children’s and families’ functioning. They found a higher incidence of SM among immigrant children (2.2%) compared to the general population (.76%). Furthermore, immigrant children with SM had higher rates of social anxiety/phobia compared to native children with SM. In another study, Bradley and Sloman (1975) found that the rate of SM was 10 to 13 times higher in immigrant children compared to children who were not immigrants. Such findings indicate that immigration status may be a risk factor for developing SM, although further research is necessary to determine the mechanism that underlies this factor. Regarding bilingualism, Toppelberg, Tabors, Coggins, Lum, and Burger (2005) explored when and how SM should be diagnosed in bilingual children. Their research indicated that children who are bilingual are three times more likely to have SM than monolingual children. The DSM-5 states that SM should not be diagnosed in cases where the child has limited proficiency with the language in question, as it is typical for second-language learners to go through a “silent period.” This nonverbal period usually lasts up to 6 months, is most

20  Treating Selective Mutism as a Speech-Language Pathologist

common in 3- to 8-year-olds, and typically lasts longer with younger children (Tabors, 1997). Given that this silent period is a normal and appropriate part of second-language acquisition, it can be difficult to determine if a bilingual child has reached a level of proficiency and comfort with the new language in order to meet qualification criteria for the diagnosis of SM. There are several important factors that must be considered when differentially diagnosing SM from normal second-language development. Children who are developing a second language normally will progress from a completely silent period to using limited words and phrases, often at a lower volume, to then “going public” and using more complex language more freely. Children with SM, however, can get “stuck” at earlier stages and not progress past pervasive silence or speaking at a very low volume. With typical secondlanguage acquisition, children are typically “mute” in situations in which the second language is expected to be used, but use appropriate social communication skills in environments and with audiences who speak the familiar, comfortable language. By contrast, children with SM have difficulty speaking in specific situations, not necessarily those in which the new language is expected, but rather those with unfamiliar audiences or settings. Additionally, and perhaps most obviously, children with SM will present with symptoms (i.e. lack of speech or limited speech) in both languages, lasting for a significant period of time, whereas the typically developing bilingual child will only demonstrate lack of speech in the new language, and only temporarily. It is critical for clinicians to understand and communicate to families that bilingualism or multilingualism is not to blame for the development of SM and is not a negative thing; rather, it is an important part of culture that is to be encouraged and celebrated. Families should be encouraged to continue speaking to children in their native language to facilitate the development of strong language skills. When working with culturally diverse families, clinicians should educate themselves regarding the social norms of the culture and the customs surrounding language and communication, in order to ensure that they are providing the most appropriate and responsive treatment.

2.  History of Selective Mutism and Etiological Factors   21

Conclusion Understanding the various theories regarding the reasons that SM develops is important for clinicians who work with children with this disorder. Members of the treatment team may have differing backgrounds or understandings of the etiological factors that underlie SM, and it may be important for one team member to provide education to other members of the team about what does—and does not—contribute to the development of SM. Ensuring that all team members have a working understanding of the components that can put children at risk for SM and contribute to the maintenance of not talking, helps inform treatment decisions and keeps all team members working together cohesively to address the specific needs and challenges of each child’s situation.

3

Characteristics of Selective Mutism

Selective mutism (SM) is estimated to affect between 0.71% and 2% of school-age children, or about 1 in 140 children (Bergman, Piacentini, & McCracken, 2002; Kumpulainen et al., 1998), however prevalence rates vary and are often thought to underestimate the true rate of occurrence. SM occurs more frequently in girls than in boys, by a ratio of about 2:1. However, there is some question whether this is a true gender difference, or if gender biases regarding cultural and societal expectations of each gender may play a role. In some cultures, it may be more expected that girls converse with adults and peers appropriately and interact in social ways, while this expectation may be lower for boys; such expectations could mean that difficulties in talking or socializing are more obvious or more readily noted in girls, whereas they are dismissed with boys. This could cause an underidentification of SM in boys. The onset of SM most commonly occurs between the ages of 3 to 6, and it is typically diagnosed between the ages of 5 to 8, or when the child begins formal schooling (Sharp, Sherman, & Gross, 2007). There are many reasons why delays can occur between the time of onset of SM and the time of diagnosis. Often, it is teachers who first note concerns about the child’s lack of speech in the school setting. Prior to beginning school, the child may not have been in situations that caused the SM to manifest, so in some cases, parents may be totally unaware of the child’s difficulty speaking in unknown or unfamiliar contexts. In these cases, it is particularly vital that school personnel contact families immediately and maintain communication regarding the child’s progress, so that if the mutism lasts for more than 23

24  Treating Selective Mutism as a Speech-Language Pathologist

a month, an evaluation, diagnosis, and further intervention can occur. In other cases, parents may already have concerns about their child’s difficulty speaking to unfamiliar people or in community settings, but may have been told by other parents or medical personnel that their child will “outgrow” it or that this is “just a phase.” Unfortunately, research does not support that children will “outgrow” SM; rather, it suggests that, in most cases, children require some form of intervention in order to overcome the disorder (Johnson & Wintgens, 2017). Symptoms of SM are most commonly seen in the classroom but may also occur in community settings or even with extended family members, who the child is not very familiar or comfortable with. Symptoms can vary depending on the situation and the severity of the SM, and not every child will demonstrate every symptom of SM consistently. Table 3–1 lists some common symptoms of SM. While the spectrum of severity and presentation of SM is quite broad and diverse, certain characteristics are common among children with this diagnosis. Research has examined a number of characteristics of children with SM, which include biological components, familial/parenting characteristics, comorbidities, and long-term impacts of the disorder if not treated appropriately.

Biological Components As discussed previously, the amygdala is the area of the brain responsible for modulating responses to emotional stimuli, specifically fear-inducing stimuli. Research has found that children with SM consistently have a decreased threshold of excitability in the amygdala. In other words, children with SM require less stimuli—whether in frequency or intensity—to trigger a fearful or anxious response. Additionally, children with SM typically have difficulty assessing situations and determining the appropriate level of threat that is present. These children have a tendency to overestimate the level of threat or danger in a specific circumstance, thus causing the sympathetic nervous system to activate and produce a response much stronger than what the situation actually warrants. Research has shown that children with

3.  Characteristics of Selective Mutism   25

Table 3–1.  Common Symptoms of SM At Home

At School

In the Community

• Usually able to speak comfortably and appropriately with at least one immediate family member

• Limited or nonexistent speech in certain settings (i.e., classroom) and/or with certain people (i.e., peers, teachers, or both)

• Difficulty speaking with unfamiliar or less familiar people

• Difficulty speaking with extended family members • Difficulty speaking to visitors or even speaking to immediate family members when visitors are present • May have emotional meltdowns after coming home from school or other environment with social demands • May try to avoid or refuse leaving the house in order to avoid social demands

• Lack of volunteering to perform verbal or nonverbal tasks • May look “frozen” or expressionless • May have difficulty with nonverbal communication • Lack of initiation of conversations or questions • Lack of responses to questions • Does not ask for help/clarification; may do things wrong if directions are not understood • May appear distracted • May appear withdrawn/separate self from social interactions; prefers to be alone • May avoid eye contact, especially when spoken to

• May have difficulty talking to immediate family members in settings outside the home or if other people are around • May look “frozen” or expressionless • Lack of initiation of conversations or questions • Lack of responses to questions • May avoid eye contact • May be resistant to going new places or to places where there are social demands

26  Treating Selective Mutism as a Speech-Language Pathologist

SM demonstrate more activity in the amygdala when confronted with threatening stimuli and, once the fear response is activated, the amygdala takes longer to “reset” and return to baseline levels of arousal after that threating stimuli has been removed. Additionally, research indicates that these children have higher levels of arousal at baseline compared to children who do not have SM (Kotrba, 2015). Taken together, this means that children with SM have more reactive fear response systems (which are already at a higher level of arousal than typical children), are more likely to interpret situations as more dangerous than they are (thus triggering a more powerful response than necessary), and take longer than typical children to calm themselves and return to baseline. These factors contribute to the understanding of why these children experience such strong reactions to circumstances that require communication, which they interpret as being fear-inducing and threatening. Research by Ruiz and Klein (2013) indicates that there may be a link between anxiety and physiological tension in the larynx. In an interview with a young adult who had overcome SM, the participant reported that he felt a “sudden pressure in the throat” whenever he was prompted to speak. In a study employing surface electromyography (sEMG), preliminary data suggested that children with SM demonstrated increased levels of laryngeal tension as the demands of the speaking tasks increased. They had the lowest levels of tension at rest, moderate levels when phonating vowel sounds, and the highest levels of laryngeal tension when asked to engage in speech. Additionally, higher levels of vocal tension were associated with higher ratings of internalizing behavior (anxiety and withdrawal) by parents, more difficulty answering questions about stories, and weaker vocabulary knowledge (Klein & Ruiz, 2018).

Negative Reinforcement Cycle An important concept for both team members and families to be aware of is the role of the environment in shaping inhibitory behaviors. This primarily occurs through the process of the negative reinforcement

3.  Characteristics of Selective Mutism   27

cycle. “Reinforcement” is a behavioralist concept which states that a consequence that occurs after a behavior will strengthen the likelihood of that behavior occurring again in the future. “Negative reinforcement,” then, occurs when something aversive is removed from the situation, thus the individual learns that by engaging in this same behavior, future aversive stimuli will be removed or resolved, resulting in relief from the negative stimuli. The more times this cycle occurs, the more the behavior is likely to occur in the future, thus making the behavior harder and harder to change (that is, more ingrained and automatic). Team members and parents may not be aware of the role they play in negatively reinforcing a child’s nonspeaking behavior. While it is crucial to not assign blame to any members of the team, particularly families, regarding this cycle, it is also vital that those who interact with the child understand the process in order to prevent themselves from engaging it in the future, and therefore strengthening the undesired avoidant behaviors. The negative reinforcement cycle (Figure 3–1) begins when the child is prompted to engage verbally. This may occur when the child and parent are shopping in a grocery store and encounter one of the parent’s coworkers. The parent introduces the child to the coworker and the coworker says, “Hi there! How old are you?” When this occurs, the child experiences immediate distress as a response to being prompted to talk. The child may start to hide behind the parent, look down at the floor, and does not respond to the question, thus demonstrating inhibitory and avoidant behaviors. The people in the environment then observe this distress. Both the parent and the coworker are aware that the child is uncomfortable. The adults in the environment experience an empathetic response to the child’s discomfort, and therefore want to alleviate it, which is a natural and expected response from a caring adult in such a situation. The parent will most likely answer the question for the child, stating, “Oh, she just turned seven last week” and the adults will continue engaging in conversation. At this point, the pressure to speak has been lifted, because the parent has answered the question directed at the child. This is known as “rescuing” the child from the speaking situation. The child may show outward signs of relief, such as coming out from behind the parent, increasing eye contact, or demonstrating

28  Treating Selective Mutism as a Speech-Language Pathologist

Child is prompted to engage verbally

Negave reinforcement has occurred

Child experiences distress and inhibits

Everyone feels relief

Environment observes distress

Environment has empathic response and removes demand

Figure 3–1.  Role of environment in negative reinforcement cycle.

less tension in the body. The adults feel relief because they no longer have to observe the child in distress and sit in the “awkwardness” of the situation. The problem, however, is that the negative reinforcement cycle has occurred. Whether consciously or not, the child has learned that when they are put in a stressful situation in which there is pressure to speak, if they engage in avoidant and inhibitory behaviors, their parent will come to the rescue and respond for them, thus allowing them to escape the anxiety-inducing task. Imagine that this happens at least once a day, every day, for multiple years of the child’s life— each of these instances strengthens the “avoidance loop.” One of the primary focuses of treatment for SM refines this process by seeking to

3.  Characteristics of Selective Mutism   29

strengthen the “bravery loop” instead, by providing repeated opportunities for children to engage in brave behavior, thus eventually making it more likely that the child will engage in the brave behavior—because this loop will be stronger—rather than the avoidant one.

Rescuing Versus Riding It Out While it may seem, in the moment, that “rescuing” (also called “accommodating”) a child from an anxiety-provoking situation is the kind and compassionate thing to do, in reality, rescuing has many negative consequences. When children experience an anxious response to a stimulus, such as being prompted to talk, the physiological anxious response follows a predictable routine. As discussed previously, the sympathetic nervous system activates the adrenaline, the body engages in fight, flight, or freeze until the stimulus is removed, and then the parasympathetic nervous system is activated to calm the physiological response and help return the body and brain back to baseline. This can be pictured in a normal curve formation, with the level of anxiety starting off low, increasing to a peak, and then decreasing back to baseline. When an adult rescues a child from an anxious situation, they typically intervene at the peak, or height, of the anxious response. By taking the pressure off the child to speak (such as by providing an excuse or speaking for the child), the child’s anxiety level immediately lowers and returns to baseline. This means the brain and body are deprived of the opportunity to practice calming itself naturally. The consequences of this process are that what the child remembers about the experience is the peak of anxiety, the height of the fear response. The child does not get the chance to habituate to anxious responses and learn to manage them, and they do not feel a sense of mastery or accomplishment. This, in turn, negatively reinforces the construct that they are not a good or capable speaker, that they “can’t” speak, or that they need others to talk for them. It also negatively reinforces escape and avoidance behaviors, making those responses more likely to occur in the future (Figure 3–2).

30  Treating Selective Mutism as a Speech-Language Pathologist

Figure 3–2.  Rescue process (Chansky, 2014). Reproduced with permission from Tamar Chansky, PhD, author of Freeing Your Child from Anxiety.

By contrast, allowing children to “ride out” manageably anxious situations has a host of benefits—although it is certainly much harder for adults to tolerate. Instead of rescuing children by handling the situation for them, adults can be most helpful by providing scaffolding to allow children to handle the situations themselves. For example, when a child is asked a question by an unfamiliar adult and they are struggling to answer, the parent could re-ask the

3.  Characteristics of Selective Mutism   31

question and have the child say the answer to the parent, who then relays it to the unfamiliar adult. Giving children the opportunity to successfully complete these types of social interactions is vitally important in the journey to overcome SM. When children engage in the social interaction to the best of their ability, they learn to ride out the entire anxiety cycle. Rather than being “rescued” and experiencing immediate relief from anxiety, the child experiences the feelings of the parasympathetic nervous system working to calm and regulate the body and feels the process of “calming down.” As a result, the child remembers the feeling of calming down from the interaction, rather than focusing on the peak of anxiety. Children learn that anxiety can and does pass on its own, and that even when they are most anxious or afraid, the feeling does not last forever—it can end, and they can feel better again. This leads to children being more willing to approach appropriately challenging situations in the future, which facilitates practice reinforcing the bravery loop instead of the avoidance loop. This also results in children feeling a sense of mastery and accomplishment, which in turn reinforces the belief that they are competent, capable communicators who can handle situations on their own. Overall, the process of riding out the anxiety cycle results in positive reinforcement— children experiencing positive internal feelings as well as receiving positive external praise—for accomplishing something difficult, thus increasing the likelihood that the bravery response will be used again in the future. Figure 3–3 illustrates the process of “riding it out.” When the child first has an opportunity to engage in an anxiety-provoking situation, they will experience an increase in anxiety which peaks at a rather high level. However, when the child is exposed to similar opportunities over and over again, the anxious response becomes lessened—this is the process of habituation. In Figure 3–3, by the fourth opportunity to engage in a speaking task, the child’s anxiety does not reach the same peak height as the initial opportunity. By the eighth exposure, the child’s anxiety peaks at only a fraction of what it was initially. In short, anxious responses decrease in intensity with repeated practice.

32  Treating Selective Mutism as a Speech-Language Pathologist

Figure 3–3.  Riding out the anxiety response (Chansky, 2014). Reproduced with permission from Tamar Chansky, PhD, author of Freeing Your Child from Anxiety.

3.  Characteristics of Selective Mutism   33

Comorbidities Although SM can occur in isolation, children often present with one or more comorbidities. The most common comorbidities include: n Generalized anxiety disorder n Separation anxiety n Social anxiety/social phobia n Other specific phobias n Obsessive-compulsive disorder/characteristics n Speech/language disorders n Defiance/oppositional defiant disorder n Enuresis/fear of toileting n Sensory processing/regulation difficulties n Food/eating anxiety or sensitivity to certain tastes or textures

of food

In one study, Kristensen (2000) found that when reviewing the records of children diagnosed with SM, 17% of children had a developmental coordination disorder, 32% had an elimination disorder (i.e., enuresis and/or encopresis), 8% had mild intellectual disability, and 7% had an autism spectrum disorder (including Asperger’s disorder). In all cases, the prevalence rates for the comorbid diagnoses among children with SM were higher than the prevalence rates for the same diagnoses in the control group of children who did not have SM. In another study, Steinhausen and Juzi (1996) reviewed a sample of 100 children diagnosed with SM. They found that 40% of these children also met criteria for relationship (i.e., attachment) problems, 30% for separation anxiety, 27% for sleep disorders, 21% for eating disorders, 5% for opposition/defiance and/or aggression, and 1% for hyperactivity. In total, 72% of children in the sample had at least one comorbidity.

34  Treating Selective Mutism as a Speech-Language Pathologist

Long-Term Impacts Research indicates that there are significant detrimental long-term impacts for children who suffer from SM and do not receive appro­ priate intervention. Throughout adolescence and adulthood, individuals with SM are more likely to experience increased anxiety, depression, and decreased self-esteem and self-confidence (Kotrba, 2015). They have poorer peer relationships and social skills compared to agemates without SM, which leads to increased isolation (Kotrba, 2015). In one study, Giddan and colleagues (1997) found that children with SM were more likely to be bullied than their peers without SM. Kumpulainen and colleagues (1998) reported that 5% of children with SM were victims of bullying, according to teacher report. This number is likely an underrepresentation of the bullying that children with SM experience, however, as many forms of bullying occur outside of the teacher’s awareness; this is particularly true in cases of cyberbullying. As a direct result of their difficulty advocating for themselves, children with SM are unlikely to report instances of bullying to school personnel or stand up for themselves in situations where they feel victimized. Additionally, some students report that they become known among peers as “the kid who doesn’t talk,” and the idea of breaking out of this perceived role—and all the subsequent attention it may draw to the child—leads to yet another layer of anxiety and fear about speaking. Certainly, these deficits in self-esteem, peer relationships, and social skills can have significant impacts on work performance in the job setting, making it more difficult for adolescents and adults with SM to complete the duties of their jobs effectively and appropriately (Kotrba, 2015). Additionally, this population displays higher rates of psychiatric disorders in adulthood (Remschmidt et al., 2001; Steinhausen, Wachter, Laimböck, & Metzke, 2006). Sadly, the very nature of the negative reinforcement cycle means that in every situation where the child with SM avoids communicating, the avoidance loop is strengthened. This means that more instances of avoidance lead to stronger and stronger reinforcement

3.  Characteristics of Selective Mutism   35

of the avoidance behaviors, making them even harder to change as the child gets older. Thus, the importance of providing intervention early cannot be overstated.

Speech and Language Disorders Current research suggests that the rates of comorbid speech and language disorders in children with SM ranges from 35% to 75% (Cohan et al., 2008; Kristensen, 2000; Muris & Ollendick, 2015). Many studies have found that children with SM perform worse on measures of language ability compared to children without SM (Manassis et al., 2007; Nowakowski et al., 2009; McInnes, Fung, Manassis, Fiksenbaum, & Tannock. 2004). In one study, Kristensen (2000) found that 17% of children with SM met diagnostic criteria for a mixed receptive-expressive language disorder, 12% for expressive language disorder, and 43% for a phonological disorder. In another study, Manassis and colleagues (2007) administered a number of nonverbal language assessments to children with SM, as well as children with other anxiety disorders and a control group of children without any diagnoses. Findings indicated that children with SM scored significantly lower on measures of receptive vocabulary, phonemic awareness, and grammar, compared to both the group with anxiety disorders and the control group. Such findings indicate that it is not merely the presence of anxiety that accounts for decreased performance on these measures. Additionally, Kristensen and Oerbeck (2006) found that children with SM performed worse on measures of auditory-verbal memory compared to children without SM. Often, speech-language pathologists (SLPs) may be the first person that a child with SM is referred to. Teachers or parents may assume that since the child has been observed to have difficulty with talking, there is an underlying speech or language issue. Even for children who do not qualify as having comorbid speech or receptive or expressive language disorders, the SLP still plays an important role in addressing social language skills for children with SM. This

36  Treating Selective Mutism as a Speech-Language Pathologist

may include teaching skills that the child was unable to develop due to avoidance, or giving the child a safe space to practice pragmatic skills through exposures to increasing numbers of people, places, and activities. Thus, it is critical that SLPs have a working knowledge of how to treat SM.

What Does SM Feel Like? Children diagnosed with SM vary in their ability to describe the experience and how it makes them feel. Some are able to give specific details to describe their experiences and related emotions, while others give more vague responses. Consider the following comments from children who have been diagnosed with SM and are in varying stages of recovery: “I do not like talking. When someone asks me a question that I can’t answer, I wish they would leave me alone. I do not like being asked questions.” —Connor, age 11 “I wish my teachers knew that I wasn’t choosing not to speak. That I wanted to speak to them really bad, but I would freeze, and the words couldn’t come out. I wish they knew that I really liked it when they talked to me, even though I looked frozen and couldn’t talk back. It really helps when teachers make comments instead of asking a lot of questions because questions are what made me freeze. The hardest part of talking to my friends was making small talk. I remember I always wanted to tell my friends that I really liked their shirt or haircut, but I couldn’t. “It was also really hard to me to tell my friends that I didn’t like something or to stop. One time my classmate bit me on the arm in line because she wanted to hear my voice. She thought I would say stop if it hurt, but I couldn’t. I couldn’t tell the teacher or say stop, so I went home with huge bite marks on my arm.” —Lily, age 13 “It is scary. And I want to be a talking kid, but sometimes my voice is frozen. I am scared people will be mad and sad at me

3.  Characteristics of Selective Mutism   37

when I don’t talk. I don’t think people will be my friend if I’m not a talking kid.” —Lucy, age 6 Interviews with adults who had SM as children can also provide some insight into what the disorder feels like. Omdal (2007) interviewed six adults who had experienced SM in their childhood and/ or adolescence, although none of them were formally diagnosed by a professional. The semi-structured interviews discussed the participants’ experiences with not talking, social interactions and other people’s reactions, self-image and personality, and the recovery process and current adjustment to adult life. Some participants discussed how others’ acceptance of their mutism further reinforced their anxiety regarding speaking. They stated that it was difficult for them if they spoke or behaved in a new way and received excessive attention for those actions. One participant noted that after years of not talking, it felt “impossible” to start talking again because that would undermine her sense of self. The respondents all noted that they felt anxious in situations where they did not know what was expected of them, and that even as adults, if they were expected to speak in unfamiliar situations, it could cause them to shut down and have difficulty talking. Regarding the recovery process, some participants remembered making a conscious decision to begin talking, while others could not remember a specific decision and instead remembered beginning to speak as a gradual process that happened over time. In some cases, the participants noted that it was easier to begin talking in new environments (e.g., moving to a new city, working at a new job, etc.) where there were no preconceived notions from others about their ability or inability to speak. The participants stated how independent they felt when they were able to start talking again. None of the participants received therapy or intervention services in childhood, although four of the six sought out therapy as adults. All of the participants stated that there were still impacts of SM they experienced as adults, such as avoiding situations that provoked anxiety or where they were the focus of attention. In another study, Remschmidt and colleagues (2001) interviewed 45 children with selective mutism (mean age of 8.7 years old) and then conducted a follow-up interview with 41 of them 12 years

38  Treating Selective Mutism as a Speech-Language Pathologist

later. At the follow-up, the authors found that 39% of participants were considered to be “in remission” from SM, while the rest still experienced some degree of impairment in communication skills. The participants described themselves as being less independent, less motivated (regarding academic achievement), less self-confident, less mature, and less healthy compared to a control group that did not have SM. These results suggest that the experience of having SM is one characterized by feelings of isolation, frustration, and, of course, anxiety. Individuals with SM want to communicate with the people around them, but often feel trapped or paralyzed by fear. This underscores that the very nature of SM is not a choice made out of defiance or in an attempt to control, but rather an inability due to significant levels of anxiety. Additionally, the comments from adult participants highlight the importance of early identification and appropriate intervention for children, in order to help ameliorate or prevent the negative long-term effects.

4

Assessment and Diagnosis of Selective Mutism

Team Contributions The pervasive and complex nature of selective mutism (SM) requires an interdisciplinary approach to effectively provide treatment. Depending on the specifics of the case, various combinations of these (and potentially other) professionals may be involved in both the treatment and diagnostic process, in addition to the speech-language pathologist (SLP). Regardless of the number of team members involved in the case, it is important to establish a “key worker” early on in the process. This key worker is someone who has been trained in what SM is and how to work with the child appropriately, and is most commonly a professional who can work with the child at school and serve as a point person for keeping track of the child’s progress and exposing them to new situations. A key worker may be a school counselor, school psychologist, SLP, social worker, teacher, paraprofessional, or other staff member who has been trained and can work with the child regularly.

Physician/Pediatrician The physician is a key member of the differential diagnosis team. They are able to assess and rule in or out other physical or neurological disorders and may provide referrals to other practitioners as 39

40  Treating Selective Mutism as a Speech-Language Pathologist

needed. Some physicians may be comfortable prescribing anti-anxiety medications, which may be helpful in some courses of treatment.

Psychologist Psychologists specialize in the diagnosis and treatment of psychological symptoms and disorders. Psychologists are able to make the diagnosis of SM as well as rule in or out any accompanying anxietyrelated disorders (i.e., obsessive-compulsive disorder, social phobia, separation anxiety, etc.) and address other mental health needs that may be present. Most psychologists offer both the initial diagnostic services as well as follow-up therapeutic services. Therapy sessions may focus on working with the child individually, or with the family unit as a whole, or both, depending on various factors of the situation.

Psychiatrist Psychiatrists have medical degrees specializing in the field of psychiatry. They are specifically trained in diagnosing mental health disorders and in prescribing any necessary medication. Psychiatrists typically provide follow-up services to manage medications, including dosage changes or adjustments, addressing side effects, changing medications if needed, and weening off medications when the time is right.

School Psychologist School psychologists are typically the professionals in school settings who are responsible for evaluating students to determine if they qualify for special education services and an Individualized Education Plan (IEP). If the student is receiving a school-based evaluation, the school psychologist will likely be the point person and may conduct assessments with the child; conduct interviews or gather input from families and teachers; review records, including previous/current

4.  Assessment and Diagnosis of Selective Mutism   41

diagnoses and therapies from any outside agencies or services the child has received; and conduct school-based observations of the child’s skills.

School Counselor In many school settings, school counselors can provide one-on-one counseling or skill-building sessions with students. They may also run small groups focused on building social skills or enhancing peer relationships (i.e., “lunch bunches” to facilitate socialization among a small group of peers). Depending on the school setting, school counselors may provide short-term services for students or may be able to serve as a key worker and work with the student long-term. Additionally, in some school settings, school counselors oversee the process of receiving Section 504 accommodations.

Social Worker A social worker, whether connected to the family from within the school or outside of it, is a beneficial partner in this process. Social workers can provide recommendations, resources, and support to families in a number of ways. Depending on the agency, social workers may provide, refer to, or help families to locate appropriate counseling or other needed services; provide support in completing documentation related to obtaining services; and serve as a liaison between families and other service providers, both within and outside of the school.

Teachers Classroom teachers are a significant part of the student’s support network, as they spend the largest amount of time during the school day directly interacting with the student and are responsible for much of the classroom culture and environment that the student

42  Treating Selective Mutism as a Speech-Language Pathologist

experiences. Teachers can provide specific input about what the student is able to do, and what they struggle to do, within the classroom context, including in both small and large group settings as well as with different audiences (i.e., peers, the classroom teacher, paraprofessionals in the classroom, visitors, etc.). With training, teachers can utilize treatment strategies and the agreed-upon reinforcement plan to increase communication skills on a daily basis. Teachers are also in the best position to monitor students’ progress within the regular education classroom and provide feedback about gains and needs.

School Staff Other members of the school staff may also play a role in the course of the child’s treatment. “Special” (i.e., art, library, music, physical education, etc.) teachers, regular substitute teachers, custodians, cafeteria personnel, paraprofessionals, office administration staff, even the principal or assistant principal may all have interactions with the student on a daily or weekly basis. Providing training to these staff members about appropriate expectations and ways to interact with the student (i.e., how to “greet” the student without using formal greetings that provide pressure to respond; what types of questions to ask or not ask, etc.) can make a significant difference in how the student relates to these adults and how the student is perceived by them.

Families Certainly, families play an incredibly important role in the course of the child’s diagnosis and treatment process. Families can provide detailed input regarding the child’s medical, psychological, educational, and developmental histories, as well as provide insight into the situations in which the child is able to communicate successfully and instances where they struggle. Such input is key in both making an accurate diagnosis and designing an appropriate treatment plan. Additionally, families can be advocates for their child’s educational

4.  Assessment and Diagnosis of Selective Mutism   43

needs at school, and can be taught to use strategies and support the child in making progress outside of school (i.e., with extended family members or in community settings) in which other clinicians or school-based personnel may not be able to adequately address.

Speech-Language Pathologist Finally, the speech-language pathologist (SLP) plays a crucial role in the assessment, diagnosis, and treatment of SM. SLPs are trained experts in the areas of communication as a whole and pragmatic skills specifically. SLPs can contribute by educating or providing resources to the rest of the team regarding age-appropriate skills and milestones that should be expected of the child. They may conduct evaluations of the student’s speech and language skills for the purposes of assessing social language skills specifically and determining if there are additional or underlying speech and language deficits present, in addition to or instead of SM. SLPs can also provide direct or consultative treatment for students with SM and provide counseling and education to the student and family regarding the speaking process and emotions surrounding speaking.

Scope of Practice The American Speech-Language-Hearing Association (ASHA, 2020) describes 12 ways that SLPs are expected to be involved in the assessment and treatment of individuals with SM. These include: 1. Educating other professionals on the needs of persons with selective mutism and the role of the SLP in diagnosing and managing selective mutism; 2. Screening individuals who present with language and communication difficulties to determine the need for further assessment and/or referral for other services;

44  Treating Selective Mutism as a Speech-Language Pathologist

3. Conducting a comprehensive, culturally and linguistically appropriate assessment of speech, language, and communication; 4. Aiding in diagnosing the presence or absence of selective mutism with an interdisciplinary team; 5. Referring to other professionals to rule out other conditions, determine etiology, and facilitate access to comprehensive services; 6. Making decisions about the management of selective mutism; 7. Developing treatment plans, providing treatment, documenting progress, and determining appropriate dismissal criteria; 8. Counseling persons with selective mutism and their immediate and extended families regarding communication-related issues and providing education aimed at preventing further complications relating to selective mutism; 9. Consulting and collaborating with other professionals, family members, caregivers, and others to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate; 10. Remaining informed of research in the area of selective mutism and helping to advance the knowledge base related to the nature and treatment of selective mutism; 11. Advocating for individuals with selective mutism and their families/caregivers at the local, state, and national levels; and 12. Serving as an integral member of an interdisciplinary team working with individuals with selective mutism and their families/caregivers.

Why Should an SLP be Involved? Selective mutism has a direct, detrimental impact on functional communication and pragmatics. Children who are unable to initiate and respond to communication from peers and adults appropriately will,

4.  Assessment and Diagnosis of Selective Mutism   45

by definition, have difficulty with a number of key communication skills. The ability to initiate communication is impacted, such that students may have difficulty or a complete inability to ask for help, request needed items, describe problems, request clarification, utilize humor, and initiate both social and academic conversations. Additionally, responsive communication can be impacted, such that the student has difficulty answering questions or making relevant comments and responses; this in turn impacts their ability to demonstrate knowledge and contribute to social and academic conversations. In addition, successful, age-appropriate communication is a foundational part of initiating and engaging in play, which creates and maintains relationships, which then provide the catalyst for pragmatic skills to continue to develop and progress. It is considered a critical skill for building happiness, social relationships, and creativity (Brown & Vaughan, 2010). Furthermore, for children who struggle with social skills, teaching children appropriate play skills has been found to lead to increased socially appropriate behaviors with peers (Coplan, Schneider, Matheson, & Graham, 2010). This finding has been replicated with children with disabilities, children with low social skills but without other disabilities/diagnoses, and typically developing children (Szumski, Smogorzewska, & Karwowski, 2016), suggesting that there are universal benefits to children’s use of appropriate play skills as a foundation and catalyst for developing appropriate social skills. Giddan and colleagues (1997) provide some general guidelines for SLPs working with students with SM: n If there is no speech in the school environment within two

months of beginning school, an SLP should collaborate with parents and teachers and begin some form of intervention

n If there is no speech in the school environment in the context

of speech therapy, the SLP should make a referral to a mental health professional (ideally one with experience with SM, or at least with childhood anxiety disorders). This professional should observe or evaluate the child and become part of the treatment team.

46  Treating Selective Mutism as a Speech-Language Pathologist n When the child begins to speak within the school environ-

ment, treatment should expand to integrate more environments and more people, including peers, other teachers, secretaries, bus drivers, cafeteria workers, and other people the child may encounter through the school day n A “concerted effort” should be made by all team members to elicit speech as early on as possible, as the longer the child is silent, the harder it is for them to break the avoidance cycle and begin speaking

Academic Impact SM can have many significant impacts on children’s academic progress. Overall, children who struggle to communicate in the classroom setting are at a disadvantage as they may not be able to ask for help or clarification if they do not understand the instructions being presented. They may not be able to participate fully in partner or group activities, thus missing out on the benefits of this form of instruction and interaction. They may also have difficulty explaining their reasoning behind their work or answers, therefore making it difficult for teachers to assess their understanding appropriately and provide the necessary support. Beyond these general difficulties, some children with SM have negative impacts on specific academic skills. One study found that children with SM have decreased word attack skills and poorer oral reading compared to peers without SM. Children with SM are also significantly more likely to demonstrate other speech and language deficits, with prevalence estimates ranging from 35% to 75%. Research indicates that children with SM produce shorter, simpler sentences and less detailed narratives (McInnes et al., 2004), have weaker auditory memory skills (Kristensen & Oerbeck, 2006), and have lower receptive language scores (Nowakowski et al., 2009) compared to children without SM. Kolvin and Fundudis (1981) found that children with SM spoke their first words significantly later (5 months or more) compared to a control group of children. Children with

4.  Assessment and Diagnosis of Selective Mutism   47

SM were also more likely to demonstrate delayed expressive language throughout childhood. Additionally, children with SM demonstrated lower scores in measures of mathematics skills compared to control groups (Nowakowski et al., 2009). Research is unclear as to the nature of the relationship between speech and language deficits and selective mutism. It could be that the two conditions develop independently of each other, or it could be that one influences the development of the other. Underlying speech and language deficits, such as producing shorter utterances or having difficulty comprehending language, could lead to increased anxiety regarding speaking tasks, which may play a causal or contributing role in the development of SM. By contrast, SM may develop separately of speech and language deficits, but these deficits may exacerbate the condition and lead to more severe presentations of SM. Further research on the directionality of influence of speech and language deficits on the development of SM is needed to parse out the specifics of this relationship.

Assessment Considerations The primary goal of the assessment process is to get a comprehensive understanding of the child’s current communication abilities while also establishing a positive rapport. Building positive rapport is crucial, because as the child’s comfort level increases, the clinician is better able to determine the intricacies of their communication abilities. Building rapport with children with anxiety disorders can be a long process that requires patience and repeated exposure to the assessor, materials, and assessment environment, but there are steps that can make this process easier. Building rapport begins by introducing yourself to the student in a familiar environment or with familiar people prior to the start of testing. In the school setting, this may look like stopping by the student’s classroom and introducing oneself to the student and surrounding peers. In a clinical setting, this may look like introducing oneself to the student while they sit in the waiting room with a parent,

48  Treating Selective Mutism as a Speech-Language Pathologist

and then leaving them to complete intake paperwork. When possible, and depending on the child’s baseline level of anxiety and comfort, it can be helpful to have the child come with the clinician to a neutral location to engage in a nonverbal task. The entirety of this first interaction should be nonverbal for the child—with no expectations or pressure to talk. Nonverbal tasks might include drawing, completing a puzzle, playing with Play-Doh, playing tic-tac-toe, or playing a card or board game that does not require talking. The clinician may make comments, using self-talk or parallel talk to describe what they and the child are doing, and may offer directions (e.g., “It’s your turn, go ahead and make your ‘X’ in the spot you want.”) or praise of the child’s efforts (e.g., “Wow, you’re really good at drawing.”), but no questions should be asked in this first session and no pressure to talk or engage verbally should be placed on the child. If the child is unable to come with the clinician for this initial meeting, it may be helpful to utilize a “fade-in.” Fade-ins are a gradual introduction of a new person (i.e., the clinician) while a familiar person (i.e., a parent) is still present. The child and parent may start off in a room alone, playing together with the parent encouraging speech, and the clinician will gradually enter the setting and become increasingly engaged with the child. Once the child is engaged with the clinician, the parent can then begin to “fade out” of the interaction. This process is described in more detail in Chapter 5. A second key part of building rapport with the child is to establish trust. One way to establish trust is to explain expectations in an age-appropriate way. For younger children, this may be as simple as stating, “We’re going to sit at this table and color some pictures together, while your mom completes paperwork, and then she’ll come in with us.” For older students, especially those who may be hesitant about coming with the clinician or be particularly behaviorally inhibited, it can be helpful to explain both what is going to happen and what is not going to happen (i.e., “I thought we could sit here and play a card game while we wait for your mom to finish the paperwork. You don’t have to talk while we play, and I won’t ask you any questions.”) In general, as the situation allows, testing students in smaller chunks rather than one large chunk is preferable. Of course, this may vary depending on the setting that the assessment is taking place in. In

4.  Assessment and Diagnosis of Selective Mutism   49

a school environment, the SLP may be able to spread the assessment out over several days or weeks in 20- to 30-minute testing sessions. In a clinical setting, it may be necessary to extend testing beyond the initial session, or break the initial session(s) up into smaller parts (i.e., present a portion of the assessment, provide a break in which the student can regroup and do a preferred activity, present the next portion of the assessment, provide a break, etc.). Even for students without SM, the testing process can cause anxiety, and certainly this is even more true for children who come into the interaction with a heightened baseline level of anxiety. Feeling anxious, and working to contain or manage those anxious feelings, demands a lot of selfcontrol, effort, and energy, and can result in the student becoming fatigued more quickly than they do in a non-testing environment; this is on top of the additional energy required to complete speech/ language or cognitive testing, which is taxing in and of itself. As such, allowing for breaks or spreading the testing out over multiple sessions can lessen fatigue effects and help to ensure that the clinician is getting the most accurate results possible. In addition, repeated exposures to the clinician, testing materials, and testing environment over time can help build rapport and increase the student’s comfort with the situation, thus decreasing anxiety and potentially leading to less inhibited responses and more accurate results. Parents and families are huge assets in contributing to the assessment process. In order to diagnose or rule in/out SM versus other speech and language disorders, it is vital to know how the child is able to communicate in situations where they are comfortable and not anxious. As such, requesting an audio, video, and/or writing sample from parents of the child in a comfortable environment (usually home) is critical to determine what the student is truly capable of, and noting any areas of strengths or weakness. It may be helpful to give parents suggestions of what types of interactions would be helpful (i.e., the child retelling a story of what they did this weekend or retelling the plot of a story or book to assess narrative skills; a conversation with a sibling and/or parent to assess pragmatic skills; etc.). Some children with SM are very uncomfortable being recorded, either via audio or video recording, so it is helpful to coach parents how to obtain this sample without putting undo focus or pressure on the

50  Treating Selective Mutism as a Speech-Language Pathologist

child (which may then increase anxiety and lead to a more inhibited, less accurate, sample). Gathering observations of the child in a variety of settings is another crucial aspect of accurately determining whether SM is present in addition to, or instead of, a speech and language disorder. If possible, the clinician should observe the student in multiple settings. At school this may include in the homeroom, at recess, at the cafeteria, working in a small group, and so on. Outside of school, this may include observations at home (that can be completed through a video/audio recording or through a telehealth platform) or in the community. While audio and video recordings are often the best way to accomplish this, if that is not possible, rating scales can be completed by individuals who see and/or work with students in these settings (i.e., by the coach of the student’s softball team or by the music teacher who works with the child in band practice at school). Finally, depending on the age of the child, it is important to obtain information from the child themselves about their perception of their speech, areas they perceive as their strengths and weaknesses, and contexts and people that are more or less difficult to communicate with. In some cases, it may be possible to adapt existing rating scales that may be geared toward children with articulation or fluency disorders. If this is not relevant or age-appropriate, the clinician can design informal surveys or rating scales for the student to complete. For very anxious or inhibited children, it may be difficult to complete these forms on a subject that can be hard to discuss in the anxietyprovoking testing environment; in such cases, sending the forms home and having the child bring them back at the next session or return via mail or email may be preferable. For examples of informal surveys, see “Brave Talking Questions” and “Brave Talking Goals” in the Resources section.

Assessment Procedure When determining what assessments to administer, the order of administration can play a role in the child’s ability to complete the assessments successfully. It is beneficial to begin with nonverbal tasks

4.  Assessment and Diagnosis of Selective Mutism   51

for building rapport. Next, the clinician can move on to receptive language tasks, which typically can be completed with pointing or other gestures. Ideally, these nonverbal tasks and assessments would be spread out over several sessions, in order to give the child ample time to establish comfort and rapport with the SLP. At this point, the child may be able to engage in the verbalizations necessary to complete an articulation assessment. These are typically the best assessments to begin with when first expecting verbalizations, because they usually require only single word responses or repetitions of sentences, rather than expecting the child to do the more complex task of generating their own sentences or narratives. If the child is able to successfully verbalize for articulation assessments, the clinician can then move into expressive language assessments, followed by pragmatic language assessments. See Table 4–1 for a sample testing schedule that can be used in a school setting, or other settings where the clinician has the ability to stretch the testing process out across multiple days. For clinicians in other settings, the same process can be followed in a more condensed fashion, as time allows. Of course, there will likely be instances where the child is not able to verbalize with the clinician, even after multiple rapport-building sessions have been conducted. There may also be instances where it is not possible to do a fade-in. In this case, if the clinician is not able to elicit verbalizations from the child, alternate response methods should be considered. For example, older children may be able to write responses down if they are not yet ready to speak them. Other children may be able to whisper their responses even if they cannot yet verbalize audibly. When allowing alternate response methods for standardized assessments, be sure to note that the test was administered in a nonstandardized way, report results descriptively, and interpret scores with caution. Another alternative is to include parents in the testing process. Research by Klein, Armstrong, and Shipon-Blum (2013) found that parents can be 96% to 97% accurate in administering tests after they have been specifically trained in the testing procedures. In this scenario, the SLP would train the parent (or other comfortable adult) in the administration of the test—what to read, how and when to prompt, what allowable prompts consist of, how to respond to the child if the child asks, “Did I get it right?” or “I don’t know.” The SLP

52  Treating Selective Mutism as a Speech-Language Pathologist

Table 4–1.  Sample School-Based Assessment Schedule Day of Assessment (Does Not Have to Be Consecutive)

Tasks

Day 1

Introduce self to student Observe student in classroom, other settings Give teacher and parents checklists to complete

Day 2

Make contact with student, reintroduce Observe student in other settings Tell student that tomorrow they will be coming to see your room and play some games

Day 3

Bring student to speech room Play nonverbal game (e.g., tic-tac-toe, drawing, puzzle) Give lots of positive reinforcement

Day 4

Bring student to speech room Play nonverbal game to warm up Administer receptive language test

Day 5

Bring student to speech room Play nonverbal game to warm up Administer articulation test Can begin expressive language test if student is ready

Day 6

Bring student to speech room Play nonverbal game to warm up Administer expressive language test

Day 7

Bring student to speech room Play nonverbal game to warm up Administer social language test

4.  Assessment and Diagnosis of Selective Mutism   53

Table 4–1.  continued Day of Assessment (Does Not Have to Be Consecutive)

Tasks

Day 8

Bring student to speech room Play nonverbal game to warm up Engage student in semi-structured activity to obtain language sample Look specifically at: – Yes/no questions – Forced choice questions – Open-ended questions – Spontaneous utterances – Spontaneous asking of questions

remains the person who scores and interprets the test. This may be accomplished in a variety of ways. The parent may sit in the testing room alone with the child. If possible, the SLP may use a computer, smartphone, or other camera to be able to observe the session and ensure that standardized procedures are followed. Or, if the child is able, the SLP may be able to sit in the room away from the parent and child, still allowing the child to respond directly to the parent. Still another option, if the situation allows, would be for the SLP to travel to the child’s home and administer assessments in a familiar, comfortable environment, either with or without the parent present.

Case History Obtaining a thorough case history, including family history, is critical to ensure that the correct diagnosis can be provided for the child. A suggested case history form and sample interview questions can

54  Treating Selective Mutism as a Speech-Language Pathologist

be found in the “Resources” section at the end of this book. Due to the frequency of anxiety disorders or subclinical anxious feelings or behaviors being present in the parents of children with suspected SM, parents may feel uncomfortable writing down answers to some of these questions or sharing personal family history. In these cases, it can be helpful to collect the case history via an interview rather than an intake form. The child should not be present during these discussions if at all possible. As such, it may be necessary in some instances to collect case history information prior to the first diagnostic appointment through phone conversation or telehealth conferencing with the parent(s). In general, the clinician should strive to collect all the usual case history information that would be necessary for any speech and language evaluation, including pertinent medical, developmental, academic, and social-emotional history and current functioning of the child. However, with a child suspected of having SM, it is also critical to collect specific information about when and where the child is able and unable to speak, how people in the environment respond when the child does and doesn’t speak, if the child has any particular triggers that make their anxiety worse, what the child is motivated by, and if the child demonstrates signs or symptoms of any additional disorders, including other anxiety disorders.

Differential Diagnosis Differential diagnosis is a critical step in the assessment and diagnostic process of SM. Two of the most related disorders that need to be considered and ruled out are typical shyness and social phobia. It is possible to have either of these disorders as well as SM, but it is important to determine if the symptoms involved are more characteristic of shyness or social phobia versus indicating a specific diagnosis of SM. The primary defining characteristic that differentiates SM from these other related disorders is the situational nature of the ability to talk versus not talk. Shyness is a temperamental trait that tends to be consistent across situations. Children who are shy typically experience

4.  Assessment and Diagnosis of Selective Mutism   55

a “warm-up” period where they initially demonstrate inhibition and hesitancy to talk or participate in activities, but within a short amount of time, their comfort level increases and they are able to interact, both verbally and nonverbally, with familiar people and in familiar environments. Similarly, social phobia is evident across situations and contexts, and children with social phobia may be hesitant to engage either verbally or nonverbally in any form of social situation. In the case of social phobia, although anxiety is the cause (just as in SM), performance of any kind of action, whether spoken or not, in front of an audience is difficult. By contrast, the primary characteristic of SM is that communication is difficult. When only SM is involved, children are usually able to participate nonverbally (i.e., serving as teacher’s helper, putting numbers on a calendar, waving) in various situations, but struggle with spoken language. In children with both SM and social phobia, both verbal and nonverbal interactions are difficult. These are most often the children that appear “frozen” and have trouble with actions such as pointing, shrugging, nodding, and so forth. One helpful tool for clinicians looking to determine whether additional anxiety concerns, such as social phobia, are present is the Screen for Childhood Anxiety-Related Disorders (SCARED, Birmaher et al., 1999). Although it is not within the SLP’s scope of practice to diagnose anxiety disorders, the information obtained from this screening can help determine if additional referrals (i.e., to a psychologist, psychiatrist, pediatrician, etc.) may be necessary to address other or additional components of anxiety. Additionally, many children with SM are often initially misdiagnosed as having autism spectrum disorder (ASD). To be diagnosed with ASD, children must demonstrate impairments in social functioning and communication, as well as demonstrate repetitive or stereotyped behavior (APA, 2013). Clinicians who are unfamiliar with SM as a diagnosis may see a child with limited communication skills and conclude that the child has ASD. In addition, many children with SM also demonstrate difficulties with sensory processing—another common characteristic of children with ASD. However, these two disorders are very distinct, and clinicians must take care to differentially diagnose them so that families get accurate information and children

56  Treating Selective Mutism as a Speech-Language Pathologist

can get appropriate treatment. The crucial factor to determine is in which contexts the child is able to speak, and if they have appropriate speech and social language skills in at least one environment (such as the home). Children with ASD will demonstrate deficits in communication and social skills across all environments; they will not be situationally dependent, the way SM is.

Qualification Under IDEA In the United States, children with selective mutism can qualify for special education services under the Individuals with Disabilities Education Act (IDEA, 2004). IDEA is a federal legislation which states that if students’ educational performance is “adversely affected” by one of the disabilities in 13 specific categories, they are eligible to receive special education services. The 13 classification categories are: 1. Specific learning disability 2. Other health impairment 3. Autism spectrum disorder 4. Emotional disturbance 5. Speech or language impairment 6. Visual impairment, including blindness 7. Deafness 8. Hearing impairment 9. Deaf-blindness 10. Orthopedic impairment 11. Intellectual disability 12. Traumatic brain injury 13. Multiple disabilities Guidelines for which children qualify under each of these categories vary from state to state and district to district. For children whose

4.  Assessment and Diagnosis of Selective Mutism   57

primary diagnosis is SM, they most often receive services under one of three of the following classifications: speech or language disorder, other health impairment, or emotional disturbance. The “speech or language disorder” classification can sometimes be made based on the fact that the child demonstrates deficits in the area of using social language appropriately. Additionally, because as many as 35 to 75% of children with SM also present with underlying speech/language deficits, they may qualify with a primary diagnosis of speech or language impairment due to other speech or language deficits (i.e., receptive or expressive language, articulation, etc.) and then can receive additional services addressing their SM needs. The “other health impairment” term is used by schools and districts for medical diagnoses and, in some cases, may include anxiety diagnoses. Children with a diagnosis of SM or other anxiety disorders, such as social phobia or obsessive-compulsive disorder, may fall into this category. Some districts, however, do not consider anxiety diagnoses to fall under this category and instead classify them as “emotional disturbance.” Professionals can be hesitant to use the “emotional disturbance” classification, primarily because of concerns about how the child will be perceived once this classification is assigned. Families, too, often find this classification difficult to understand or accept. However, in examining the qualifying criteria for this classification, one of the criteria is an inability to build or maintain satisfactory interpersonal relationships with peers and teachers. This includes the ability to establish and maintain friendships and be appropriately assertive as situations require. These are precisely the skills that many students with SM are struggling to use. The “emotional disturbance” classification can certainly be an avenue to provide special education services to students with SM, but professionals must be sure to carefully explain what this classification means (and doesn’t mean) and why it was assigned. Certainly, children with SM may have other comorbidities, which qualify them for special education services in one of these categories despite or regardless of their SM. A child could have a primary diagnosis of a specific learning disability and qualify for special education services, including academic support, for that disability, and may also

58  Treating Selective Mutism as a Speech-Language Pathologist

receive related services (such as social skills groups or speech and language therapy) to address SM-related needs. Additionally, specific accommodations can be put into place to help children with SM be more successful in the school setting. One obstacle that is often encountered in the special education process is that students with SM are, academically, performing at an average or even above average level. In these cases, districts may argue that there is no “adverse impact” on school performance. However, “educational performance” encompasses more than just graded academic content. According to Thomas (2016), “educational performance” includes “not only academic learning, but also social, emotional, and interpersonal development.” (p. 86). From this definition, then, it is clear that all aspects of a child’s day at school—not just those reflected by a report card—are part of their educational experience. It may be necessary to communicate to school professionals, and provide documentation of, the extent to which the child is struggling across various school contexts. For example, what happens when the child is placed in a small group of peers and has to complete a project cooperatively? Are they able to engage in collaborative conversation, share ideas and materials, assert their opinion, agree and disagree with others appropriately, and summarize and present the finished project to the teacher or a larger group? What happens when the child is at lunch? Are they able to eat in front of their peers and engage in social exchanges such as greetings, asking and answering questions in conversation, telling stories about experiences, engage in jokes and teasing, all while using a vocal volume that is loud enough to be heard in this noisy environment? What happens when the child is at recess? Are they able to engage in verbal or nonverbal play with peers? What about in “special” classes (i.e., art, music, library, physical education, etc.) with teachers who are less familiar? If the student feels ill, are they able to tell an adult? Are they able to speak to the nurse to describe what the problem is? Each of these, and many other, circumstances must be considered when making decisions about the degree of impact SM can have on a child’s educational performance and experience.

4.  Assessment and Diagnosis of Selective Mutism   59

In cases where a child is not found to be eligible for special education, an alternative option to explore is a 504 plan. Section 504 of the Rehabilitation Act (U.S. Department of Health, Education, and Welfare, 1978) is a civil rights law which states that schools that receive federal funding cannot discriminate against students with disabilities. A 504 plan also requires an evaluation, but in some cases the evaluation completed for the IEP may also serve as the 504 plan evaluation. The primary difference between the two documents is that the IEP requires that the child meets criteria for a special education classification and that they demonstrate a need for specially designed instruction, which can include making modifications to the curriculum the child is receiving at school. By contrast, a 504 plan does not alter curriculum, but can instead provide accommodations to make the school environment more accessible for the child. In some districts, students with 504 plans may also be eligible to receive related services, such as counseling, social skills groups, or speech therapy, which can help address needs related to SM and anxiety.

Accommodations In both an IEP and a 504 plan document, there are sections in which the team determines what accommodations, if any, the student needs to be able to access their school environment appropriately. There are no “one-size-fits-all” prescriptions for which accommodations are best for students with SM, due to the differences in presentation, severity, and school contexts. However, the following section includes some common accommodations that can be helpful at various stages of the treatment process. Accommodations may address topics such as training for team members, communication methods and frequencies for the team, interventions or support services to be provided, methods of reinforcement, methods of classroom-based assessment, and the timeline or process for modifying goals. Remember, both the IEP and 504 plans are “working documents,” meaning they can be reopened and revised at any member of the team’s request. Therefore,

60  Treating Selective Mutism as a Speech-Language Pathologist

the need for each accommodation must be frequently evaluated by a treating professional, whether inside or outside of the school, in order to determine that the accommodation is still an appropriate one that is adequately meeting the child’s need and not providing too much support, and therefore preventing them from making progress. The fluid nature of these documents means that accommodations can be added when needed and then removed or adjusted when the child has made progress and no longer requires that level of support.

Accommodations for Minimally Verbal Students (i.e., Answering Questions From at Least One Person, Not Yet Spontaneous) Overall n Allow [Student Name] extra time to answer questions, either

nonverbally or verbally. Avoid eye contact when awaiting [her/his] response, if necessary. n When assigning classroom jobs, assign [her/him] nonverbal jobs/ responsibilities in the classroom (e.g., cleanup, line leader). n Provide specific, positive praise when the student takes risks, engages in communicative interactions (i.e., handing materials to a peer, making eye contact, tapping teacher on shoulder to gain attention, pointing to desired object/response, etc.), or verbalizes. Note: Some children do not respond well to having attention drawn to their communicative attempts. If this is the case for your student, consider the following accommodation: Refrain from calling attention to whether [Student Name] talks or does not talk. Do not mention that you heard [her/him] speak when you do. [S/He] should not be publicly praised when [s/he] makes strides. Try to normalize the situation as much as possible. n Prepare [Student Name] for changes in routine and special large group activities (e.g., substitutes, fire drills, schedule changes, field trips).

4.  Assessment and Diagnosis of Selective Mutism   61

Tests/Assignments n [Student Name] may perform required oral assignments (e.g.,

reading assessments) via alternate assignment, such as video/ audio recording.

n The classroom teacher will provide nonverbal assessments

when possible.

n [Student Name] shall be permitted, if necessary, to take any

standardized test outside of the regular classroom, either privately or in a small group in case [she/he] needs to ask a question or seek clarification.

n

[Student Name] shall be given additional time on tests if needed.

n [Student Name] will not receive decreased grades/lose points

on assignments due to lack of speech.

Peers/Groups n Each year [Student Name] should be placed in a class with

[his/her] close friends.

n Student will have access to a “buddy” (i.e., a person they

speak to who will then tell their comments/responses to teacher) throughout the day.

n Pair [Student Name] with one close peer as much as possible

to help [her/him] feel comfortable in larger groups and in less structured settings (e.g., lunch buddy, hallway buddy, recess buddy, project buddy, running errands for teacher with a buddy). Then, gradually add other students to [Student Name]’s group of buddies.

n Assign [Student Name] to a partner whenever partnering

in activities. Do not wait for [Student Name] to initiate or choose a partner or group.

n Assign [Student Name] a seat at lunch next to [her/his]

buddy and close to trusted peers.

n In physical education class, [s/he] should participate in

activities within a small group and should not be forced to

62  Treating Selective Mutism as a Speech-Language Pathologist

participate in front of a larger audience (e.g., being “up” at kickball or up at bat in softball, etc.). Teachers n Allow [Student Name]’s parents/family members to have

access to the school environment during off hours (arrive early, stay late, summer hours, if possible) to engage in fadeins (gradual introduction of a new person with a familiar person, such as parent, still present), promote comfort and verbalization when alone with a parent, and eventually, one or more peers or a teacher.

n Allow [Student Name] to spend time with [her/his] teacher

before the school year starts to conduct a fade-in or series of fade-ins.

n The classroom teacher may provide individual time with

[Student Name] and a friend or two, when possible, to develop a rapport before school, during lunch or after school; for example, “Lunch Bunch.” This will allow [Student Name] extra time to build comfort.

n Provide a written summary of pointers and accommodations

for [Student Name] for any substitute teacher to reference. Inform office staff to advise substitutes to reference this summary before interacting with [Student Name] in the classroom.

n Teachers will form questions as forced choice questions when

possible.

Bathroom n Prompt [Student Name] to use the bathroom at set points

during the day, as [she/he] is not yet able to ask to use the bathroom (i.e., “Go ahead and use the bathroom.”). Provide praise if [Student Name] asks to use the bathroom.

n Allow [Student Name] to use a nonverbal method to request

going to the bathroom (i.e., gesture or picture card).

4.  Assessment and Diagnosis of Selective Mutism   63

Accommodations for Moderately Verbal Students (i.e., Answering Questions From More Than One Person, Occasional Spontaneity) Overall n Prepare [Student Name] for changes in routine and special

large group activities (e.g., substitutes, fire drills, schedule changes, field trips).

n Provide specific, positive praise when the student takes risks

or verbalizes. Note: Some children do not respond well to having attention drawn to their communicative attempts. If this is the case for your student, consider the following accommodation: Refrain from calling attention to whether [Student Name] talks or does not talk. Do not mention that you heard [her/him] speak when you do. [S/He] should not be publicly praised when [s/he] makes strides. Try to normalize the situation as much as possible.

Tests/Assignments n [Student Name] shall be permitted, if necessary, to take any

standardized test outside of the regular classroom, either privately or in a small group in case [she/he] needs to ask a question or seek clarification.

n [Student Name] will not receive decreased grades/lose points

on assignments due to lack of speech.

Peers/Groups n Each year [Student Name] should be placed in a class with

[his/her] close friends.

n Pair [Student Name] with one close peer as much as possible

to help [her/him] feel comfortable in larger groups and in less structured settings (e.g., lunch buddy, hallway buddy, recess buddy, project buddy, running errands for teacher with a buddy). Then, gradually add other students to [Student Name]’s group of buddies.

64  Treating Selective Mutism as a Speech-Language Pathologist

Teachers n Allow [Student Name]’s parents/family members to have

access to the school environment during off hours (arrive early, stay late, summer hours, if possible) to conduct fadeins, promote comfort and verbalization when alone with a parent, and eventually, one or more buddies or a teacher.

n Allow [Student Name] to spend time with [her/his] teacher

before the school year starts to conduct fade-ins.

n The classroom teacher may provide individual time with

[Student Name] and possibly a friend or two, when possible, to develop a rapport before school, during lunch or after school; for example, “Lunch Bunch.” This will allow [Student Name] extra time to build comfort.

n Provide a written summary of pointers and accommodations

for [Student Name] for any substitute teacher to reference. Inform office staff to advise substitutes to reference this summary before interacting with [Student Name] in the classroom.

Bathroom n Prompt [Student Name] to use the bathroom at set points

during the day, as [she/he] is not yet able to ask to use the bathroom (i.e., “Go ahead and use the bathroom.”). Provide praise if [Student Name] asks to use the bathroom.

Accommodations for Students who Are Verbal but Still Require Prompts (i.e., Answering Questions From Peers and Adults, Able to Be Spontaneous in More Than One Setting) Overall n Prepare [Student Name] for changes in routine and special

large group activities (e.g., substitutes, fire drills, schedule changes, field trips).

4.  Assessment and Diagnosis of Selective Mutism   65 n Provide specific, positive praise when the student takes risks

or verbalizes. Note: Some children do not respond well to having attention drawn to their communicative attempts. If this is the case for your student, consider the following accommodation: Refrain from calling attention to whether [Student Name] talks or does not talk. Do not mention that you heard [her/him] speak when you do. [S/He] should not be publicly praised when [s/he] makes strides. Try to normalize the situation as much as possible.

Peers/Groups n Facilitate opportunities for the student to work in small

groups with new/less familiar peers (this may include peers in the student’s class, in other grade-level classes, or in other grades). Provide structured tasks with direct instructions about what students are expected to do.

Teachers n The classroom teacher may provide individual time with

[Student Name] and possibly a friend or two, when possible, to develop a rapport before school, during lunch or after school; for example, “Lunch Bunch.” This will allow [Student Name] extra time to build comfort.

n Provide a written summary of pointers and accommodations

for [Student Name] for any substitute teacher to reference. Inform office staff to advise substitutes to reference this summary before interacting with [Student Name] in the classroom.

Bathroom n Prompt [Student Name] to use the bathroom at set points

during the day, as she/he is not yet able to ask to use the bathroom (i.e., “Go ahead and use the bathroom.”). Provide praise if [Student Name] asks to use the bathroom.

66  Treating Selective Mutism as a Speech-Language Pathologist

Accommodations for Students Who Are Verbal and Working on Maintaining Skills n Provide specific, positive praise when the student takes risks

or verbalizes. Note: Some children do not respond well to having attention drawn to their communicative attempts. If this is the case for your student, consider the following accommodation: Refrain from calling attention to whether [Student Name] talks or does not talk. Do not mention that you heard [her/him] speak when you do. [S/He] should not be publicly praised when [s/he] makes strides. Try to normalize the situation as much as possible.

n Facilitate opportunities for the student to work in small

groups with new/less familiar peers (this may include peers in the student’s class, in other grade-level classes, or in other grades). Provide structured tasks with direct instructions about what students are expected to do.

For Any Student, As Needed n The school will provide quarterly parent/faculty meetings to

update and report upon accommodations and progress.

n Resources on SM should be utilized for further suggestions

and information about [Student Name]’s condition.

n If available, [Student Name] may participate in school-based

mental health services (i.e., working with a school counselor or therapist, participating in a social skills group).

n Home/school communication will be available on a daily or

weekly basis if requested with both the classroom teacher and any the “key workers” who work closely with the student (i.e., paraprofessionals, social worker, etc.).”

n School staff who regularly interact with the student will be

provided with training regarding SM, in the form of profes-

4.  Assessment and Diagnosis of Selective Mutism   67

sional development seminar, written materials, consultation with treating professional, and so forth. [Adapted from Boggs and Morgan-Gillard (2018) and Kotrba (2015).]

Service Delivery and Frequency For children who qualify for IEPs, and in some cases for 504 plans, decisions will need to be made by the team regarding the types of services the child will receive as well as the service delivery model and frequency of services. Services can be provided in a number of ways, by a number of professionals, depending on the child’s needs and the team members’ experience and roles within the school environment. In some cases, a social worker, school counselor, and/or school psychologist may provide social skills groups or counseling sessions focused on managing anxiety and using coping skills. However, in many cases, the SLP is in the position to provide intervention targeting both communication skills as well as social skills, through the avenue of targeting social language skills. A number of factors need to be considered when determining the type of service delivery and the frequency. The primary factor to keep in mind is that, whether the services are being documented in an IEP or a 504 plan, both documents are open documents that can be reopened and revised as necessary. Therefore, decisions should be made based on where the child is and what the child needs to be successful now, with the understanding that this may change in the coming weeks, months, or year and can be adjusted at that time. The first factor to consider is the length and frequency of the sessions. Clinicians can be creative regarding how they provide services to best meet the needs of the child. For example, the clinician should consider if the child’s needs would best be met by providing one 60-minute session per week, two 30-minute sessions, or four 15-minute sessions. If the child is receiving additional intervention services from other team members, the longer, once-a-week sessions

68  Treating Selective Mutism as a Speech-Language Pathologist

may be the best model at this time. However, if the SLP is the primary (or only) clinician providing intervention services, they may need to see the child more frequently at first to establish rapport and build up momentum. Initially, two 30-minute sessions may be best for this. As the child progresses, they may benefit from more frequent, but shorter, “check-ins,” so the 15-minute blocks of time may be more appropriate. Another factor to consider is whether the sessions should be individual or small-group. Often, it is best to begin with individual, one-on-one sessions between the child and the SLP. This allows the SLP to focus on fading in themselves and establishing speech with the child in at least one environment (i.e., the speech room). Once speech has been established with the clinician, the clinician should consult the child’s talking map (see Chapter 6) as well as seek input from the child regarding what to target next. If the child has an easier time talking to peers than adults, it would be useful to switch the child’s service delivery to small-group and begin fading in peers. If the child has an easier time talking to adults, it may be better to keep the sessions as individual, thus allowing the clinician and child to fade in other adults, such as the teacher. The SLP should also consider whether services should be pullout or push-in. As discussed previously, it is typically best to begin with pull-out services as it is easier to establish speech in the calm of a speech room, rather than the noisy stimulation of the regular education classroom. Generally, the next step would be to fade peers or adults into speaking in the speech room (a now comfortable and familiar environment). Once the child has increased their conversation partners to more than just the SLP, the decision can be made regarding whether to push-in to other locations or continue to utilize pull-out services and fade in more conversation partners. When shifting to push-in sessions, it is often helpful to first push-in to the regular education classroom and establish speech there. Again, the clinician will need to scaffold this process carefully to ensure success. The typical process is to begin with the SLP and child speaking outside of the classroom; and then just inside the classroom but still in a oneon-one setting; and then just inside the classroom with other peers/ teachers in the classroom; and then further inside the classroom in the

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midst of peers/teachers; and then begin to fade in the peers or teachers that the child is already able to talk to in other environments (i.e., the speech room). After speech has been established consistently in the regular education classroom, the SLP may choose to push-in and conduct fade-ins in similar fashions in other environments around the school. This may include the cafeteria, “special” areas (i.e., music room, art studio, library, gym, etc.), playground/recess area, nurse’s office, and so forth. These determinations will depend on the child’s current level of functioning within the school environment, what environments they are able to be verbal in, and who and how many conversation partners they are able to speak to. Certainly, service delivery and frequency are not a one-size-fits-all process and will need to be adjusted and tweaked to each individual child and situation. In some cases, a combination of these services may be ideal for the student who is transitioning and just beginning to speak in more environments or with more people; in other cases, it may be necessary to progress from more intensive (i.e., pull-out, one-on-one, more frequent) to less intensive (push-in, small group, less frequent, etc.) environments.

Conclusion A comprehensive assessment is critical for ensuring that children with SM are diagnosed appropriately, that any additional needs or diagnoses are followed up on and addressed, and that they can receive the necessary services to support their performance in the school environment. Conducting a thorough evaluation provides the clinician with valuable information that can then inform the treatment process and the plan to help the child move forward. The next chapter will discuss evidence-based treatment strategies and skills that clinicians can use to provide intervention for children with SM.

5

Treatment Techniques for Selective Mutism

“The thing that helped me overcome SM was going to intensive therapy and learning to practice brave talking! I learned that the more you do hard things, the easier it gets, so I had to practice talking in a lot of different places and to a lot of different people. It really helped that I got prizes for my hard work too.”—Lily, age 13 Although selective mutism (SM) can be a difficult and debilitating disorder, it certainly does not have to be a life sentence for children who experience it. Evidence repeatedly shows that SM is highly responsive to appropriate treatment techniques, and can be treated successfully, allowing children to develop necessary communication skills across all settings and contexts. The most effective treatment for SM and the current “gold standard” in the literature is use of cognitive-behavioral therapy (CBT) techniques. Speech-language pathologists (SLPs) can (and likely already do!) utilize some aspects of these techniques in their speech therapy sessions to build a treatment plan that appropriately targets pragmatic speech skills, and reinforces the successful use of speech, with an increased number of communication partners and in more environments. Common CBT techniques include positive reinforcement, scaffolding, and stimulus fading. This chapter will provide an overview of general CBT techniques that can be implemented to shape speech therapy sessions around the needs of the child with SM, as well as SM-specific techniques, such as Parent-Child Interaction Therapy (adapted for SM) and the Ritual Sound Approach, that have been found to be particularly successful 71

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for this population of students. First, a general overview of the stages of communication that children with SM typically progress through is provided.

Stages of Communication As treatment for SM progress, children typically move through some or all of the following stages:

Noncommunicative Children in this stage of communication often appear “frozen”; they may be physically stiff and avoid both movement and eye contact. They struggle with any and all forms of communication, and are not yet using nonverbal communication, including nodding/shaking head or making eye contact. The primary goal for children in this stage is to increase comfort and familiarity with the environment in order to decrease anxiety, such that communication skills can then become the focus.

Nonverbal Communication In this stage of communication, children employ various forms of nonverbal actions and gestures to communicate messages to their partners. This may include making eye contact, facial expressions, nodding/shaking head, pointing, and giving thumbs-up/thumbsdown. This stage also includes children who are using any type of augmentative communication device, such as picture cards or language boards. It also includes the use of writing as either a bridge to oral communication or a compensatory strategy in the absence of speech.

Prompted Verbal Communication Children in this stage of communication are able to use verbalizations in structured, prompted situations. This includes students who

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are verbalizing in response to direct commands (“Go ahead and tell her what color you want”) as well as questions (“What color do you want?”). This stage includes responses to nonverbal prompts (i.e., an SLP gesturing to the person that the child needs to speak to as a way of prompting the interaction) and indirect prompts (i.e., “I wonder what question you could ask next?”).

Spontaneous Verbal Communication This level of communication is the highest and is the goal for each child to achieve in each environment. Children who are communicating with spontaneous oral verbalizations are able to initiate, respond, maintain, and conclude communicative interactions independently, without requiring direct or indirect prompts from others. Children may enter SM treatment at any of these stages, and will ideally progress to higher stages as treatment continues. However, given the context-specific nature of SM, children may be at different stages of communication in different settings or with different audiences. Different stages in different environments do not reflect “regression,” but rather the different demands of each environment and variation in the child’s comfort level in each situation. For example, a child may be completely noncommunicative in a community setting (i.e., doctor’s office), nonverbal in another (i.e., school) and spontaneously verbal in another (i.e., at home or with familiar extended family). Progression to spontaneous speech in one environment or with one audience does not mean the child will automatically transfer this progress to another environment or audience—often skills must be intentionally scaffolded in each setting to promote continued growth and progress.

Basic Cognitive-Behavioral Concepts There are a number of cognitive-behavioral therapy (CBT) concepts that can be seamlessly integrated into speech therapy sessions in order to help children with SM make progress. Systems of positive

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reinforcement can be used across settings (i.e., home, school, community, etc.) to encourage brave talking and help children take on new challenges. Scaffolding allows the SLP to provide intentional support, leading to increasing levels of independence for the child, until they are able to complete new tasks on their own. Stimulus fading utilizes the process of breaking down larger, more complex tasks into smaller, more manageable ones, which allow the child to experience repeated successes, thus building momentum for future challenges.

Positive Reinforcement Positive reinforcement is the process of providing a desirable reward in exchange for work or completing something effortful. We see examples of positive reinforcement throughout our lives every day, such as the paycheck that employees receive for completing their job, to the discount on car insurance that drivers receive for driving safely, to the praise and high fives a teacher gives to a student who has worked hard on a project or persevered on a difficult skill. Positive reinforcement is a way of recognizing that the individual did something difficult and challenging and shows that their hard work is noticed, important, and valued. From a behavioral standpoint, providing positive reinforcement significantly increases the likelihood that the reinforced behavior will be repeated. It is essential to differentiate the concept of positive reinforcement from “bribery.” Often, families and even some teachers may be averse to the idea of using positive reinforcement as they are concerned about “bribing” the child or causing them to become reliant on extrinsic motivation to engage in their intervention activities. However, positive reinforcement serves a different purpose than bribery. Bribery can be thought of as a desperate attempt to elicit a desired behavior. It is usually a promise or proposition made “in the moment” and is often not appropriate to the size of the challenge that the child is taking on, but rather quite exaggerated or extreme. An example of bribery would be when a parent and child are in a store and the child is refusing to leave without a new toy, and the parent promises a grandiose prize (i.e., “If you leave without making a fuss

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we can go to Disneyworld!”) in exchange for the child to start or stop doing something. By contrast, positive reinforcement is an intentional system that is planned out and agreed upon by the adults and child prior to engaging in the challenging situation. The reward that a child earns for engaging in a difficult task is appropriate and proportionate to the size of the challenge they are taking on. For example, if a child is taking a small step forward in their goal, they may earn a smaller reward such as staying up 15 minutes later that night. Or, they may earn check marks, stars, stickers, and so forth on a chart (see Resources section for examples of bravery charts) that allows them to work toward a larger reward, such as choosing a special dessert or earning a movie night, once a certain number of check marks has been earned. When a new behavior or task is first being practiced, the child should earn a reward more quickly to provide immediate reinforcement of the bravery they are demonstrating by attempting the new task. For example, if the child is working on speaking in a new environment, such as the cafeteria, they may earn a reward the first time they speak there or may earn a check mark each time they speak there, and may receive a reward after earning five check marks on their chart. As the child becomes more proficient at the task and it becomes easier, the level of expectation can be increased so that they now have to earn 10, 20, or 30 check marks to receive a reward. Depending on the difficulty of the task, the clinicians and families can determine small, medium, and big rewards that are appropriate for the child. Examples of possible reinforcements can be found in the Resources section of this book, but parents and children can work together to come up with ideas that are motivating and reasonable for their specific situation.

Scaffolding The idea of scaffolding is likely one that is not new to SLPs. Scaffolding originates from the Vygotskian concept of the Zone of Proximal Development (ZPD), which can be conceptualized as the middle ring of a three-tiered target (Figure 5–1). The ZPD refers to the skills and

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Figure 5–1.  Representation of the ZPD.

tasks a child is able to accomplish with help or guidance from a more skilled learner (usually an adult, but it could also be an older or more experienced peer). One level further inside of the ZPD are skills in the Zone of Independence, which the child can do without assistance. One level outside of the ZPD are tasks in the Zone of Frustration, which the child cannot do yet, even with assistance or coaching. In other words, the ZPD contains skills that the child is “proximal” to, or close to, being able to complete independently; however, the child cannot yet do so without some support (McLeod, 2019). Research indicates that targeting skills in the ZPD, by providing an appropriate amount of support, helps children develop the skill sets and confidence required to then be able to complete the tasks and skills independently (Eun, 2019). Therefore, with intervention, skills that were previously in the ZPD can move into the independence zone, which then allows the focus of the intervention to move onto new skills that are now in the ZPD.

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For example, a child may be able to speak to their parent in a community setting, such as a bookstore, independently. They may not yet be able to speak to a store employee independently, but this may be a reasonable task in their ZPD. Therefore, the parent would provide coaching, guidance, and support to help the child accomplish this skill. The parent could practice asking the child a question and having the child answer, moving closer and closer to the store employee, until the child is able to answer the question from the parent directly in front of the store employee. Once the child can do this, the parent can prompt the store employee to ask the same question and the child can answer the store employee directly. Thus, the child was able to accomplish a task that they could not have done on their own, but with some coaching and guidance, were able to be successful at. Once the child has practiced this skill a number of times and can do it independently, the skill is no longer considered in their ZPD, but rather considered an independent skill. Now, as that skill “moves up” to the level of independence, new skills may move into the ZPD, such as approaching a store employee and initiating a question. The parent and child can follow the same sequence to practice asking questions to the store employee until the child has then accomplished this new task a number of times successfully and it, too, moves up to the level of independence. “Scaffolding” is the term used to describe the support, guidance, and coaching offered by the more experienced person in the learning situation. In this example, the parent providing the opportunity for the child to practice answering the question in an intentional, measured fashion, as they moved progressively closer to the store employee, was the scaffolding. Successful scaffolding requires the teacher (this term may refer to the actual teacher or to the parent or clinician who is filling the role of “teacher” in the learning interaction) to break down larger goals into smaller steps, and identify manageable ways for the child to move closer towards the target skill without being overwhelmed. Additionally, the teacher must be able to provide an appropriate amount of support to help the child move towards independence—too much support will limit the child from building the necessary skillset to eventually be able to complete the task independently, while too little

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support may result in frustration and stagnation on the part of the child and possibly the teacher, too.

Stimulus Fading Stimulus fading is also often referred to as “fading in.” The following procedure illustrates the “fade-in” process, which is one way in which a new adult could become engaged in an existing parent-child interaction. In this scenario, the parent and child are playing together in an otherwise empty room (no other people around or in the room) and the child is verbal with the parent. The parent should be utilizing child-directed interaction (CDI) and verbal-directed interaction (VDI) skills to keep the child verbal throughout the interaction. It is helpful to meet with the parent ahead of time and review the procedure and ensure the parent’s role is clear. Alternatively, an earbud in the parent’s ear connected to a wireless microphone in which the clinician provides real-time coaching to the parent can also be used, if this option is available. Example of stimulus fading procedure: 1. Child and parent are playing in room alone. Child is verbal with parent. Door is open. 2. New adult walks past open door a few times 3. New adult stands just outside of door n Waits until child is verbal with parent 4. New adult enters room and sits/stands just inside the door n Does not directly engage with child/parent n Waits until child is verbal with parent 5. New adult moves closer to child/parent n Waits until child is verbal with parent 6. New adult moves closer to child/parent n Waits until child is verbal with parent n Begins to make occasional behavioral descriptions and/or labeled praises

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7. New adult moves close enough to child/parent to engage in play n Continues to make behavioral descriptions/labeled praise 8. Parent continues to engage child verbally. Parent asks child forced-choice or open-ended question. 9. Once child is responding to parent in front of new adult, new adult asks child forced-choice question n If child answers, new adult continues to engage verbally and parent takes a step back n If child does not answer, parent restates question, gets child verbal, new adult continues CDI skills for a few minutes and then tries again Keep in mind that there is no magic number of steps, minutes, sessions, or weeks that it takes to fade new people into an interaction and help the child be able to verbalize to them. How quickly one moves through this procedure, and how far through the procedure one gets in any given session is highly dependent on the child’s comfort on that particular day and moment. The most vital component is to ensure that the child is speaking fairly comfortably before progressing to the next step. If the child is not speaking, given some additional “warm-up” time for them to adjust to this new step, or back up to the step where the child was last successful and continue eliciting verbalizations at that step to further establish comfort, rapport, and momentum, before then trying to move forward again. Additionally, consider ways that you can break down this process into even more specific steps, for children who can’t make the jumps from step to step.

Techniques Specific to SM In addition to the more general CBT techniques discussed previously, there is evidence supporting the use of some more specific therapy techniques that are particularly beneficial and helpful for

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children with SM. These include Parent-Child Interaction Therapy: Adapted for SM (PCIT-SM), which utilizes a strong parent-teaching component to empower families to continue the progress their children are making outside of therapy. Although designed for use by families, the strategies involved in PCIT-SM can successfully be used by other adults in the child’s life, including teachers and clinicians, to help them reach their communication goals. Another technique that can be helpful for treating SM is the Ritual Sound Approach (RSA), which uses a combination of scaffolding and stimulus fading in a structured way to help children progress from nonspeaking to speaking tasks.

Parent-Child Interaction Therapy:  Adapted for SM (PCIT-SM) Parent-Child Interaction Therapy (PCIT) is an evidence-based form of therapy that focuses on improving parent-child interactions as a way of improving children’s behavior. The goal is to promote “healthy family functioning” (PCIT International, 2018). A number of practitioners (Carpenter, Puliafico, Kurtz, Pincus, & Comer, 2014; Kurtz, 2015) adapted PCIT to be used in the treatment of SM (PCIT-SM) and have found it to be effective (Cotter, Todd, & Brestan-Knight, 2018; Mele & Kurtz, 2013). These SM-specific treatment strategies include child-directed interactions (CDI) and verbal-directed interactions (VDI) and are discussed in more detail below. Child-Directed Interaction (CDI)

The purpose of CDI is not to elicit communication directly, but rather to build rapport and comfort with the communication partner and/or environment, provide verbal models of appropriate forms of communication to use, and decentralize the attention away from the child’s speech to the interaction (activity) itself. There are five strategies specifically used in CDI, which can be explained through the acronym PRIDE:

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1. Labeled Praise Reflection 2. R 3. IImitation 4. Behavioral Description Enthusiasm 5. E Labeled Praise (LP).  Labeled praise requires the adult or clinician to provide specific feedback to the student about what they are doing right or doing well in the activity, task, or interaction. Unlabeled praise, such as “Good job,” or “Nice one” is not as reinforcing because it does not provide the child with information about exactly what they did well, and which behavior you want them to repeat. In some cases, this vague praise may even elevate anxiety because of the uncertainty the child feels, not knowing what the praise refers to or what he or she should continue doing in order to keep doing a “good job.” By contrast, labeled praise should be specific, meaningful, and genuine, and provided immediately in order to have the maximum reinforcement value to the child. Examples of labeled praise include, “Great job handing me that piece of paper!” “I love seeing you smile!” “Nice job using such a loud voice to ask me that!” Reflection (RF).  Using reflections means repeating what the child

has said. This serves a number of purposes: it shows the child you were listening and value what they are saying, it confirms what the child has said and gives them an opportunity to provide correction or clarification if their message was misunderstood, and, for children who may be speaking in a whisper or quiet voice, it provides a positive model of using an appropriate volume. In settings where there are other listeners, such as small or large groups, reflecting a quiet child’s speech at a typical volume has the added benefit that other listeners hear the child’s utterance and can respond appropriately. This further validates the child’s successful communication in the interaction by allowing natural responses to occur, without putting additional pressure on the child to speak more loudly if they are not ready for that yet. Consider the following example in which a teacher is asking children one by one what they did over the summer:

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Teacher:  I’m wondering what everyone did this summer. Sarah (whispers):  Went to the pool. Teacher (regular volume to whole group):  You went to the pool, thanks so much for telling me that. Aiden:  I went to the pool too and I saw Sarah there one time! Teacher:  That’s so fun! One critical component of successfully using reflections is to ensure that the clinician’s voice does not “tip up” at the end of the utterance. “Tip ups” occur when the speaker’s prosody increases at the end of the sentence, which changes the statement into a question. When “tip ups” occur, the clinician is (usually inadvertently) changing the goal of the strategy from simply acknowledging and validating what the child says to asking for clarification, confirmation, or additional detail. This can be anxiety-inducing for the child because it may cause them to feel anxious that they didn’t do a good job communicating their message the first time, and now the adult is asking them to repeat themselves or provide further information, and being put on the spot can cause them to freeze, shut down, or lose momentum in the speaking environment. Even if the child does not interpret the “tipped up” statement as a lack of understanding of their original message, the implication is still that they are being asked a question, which then requires a response and may initiate an anxious reaction. Remember, the goal in using CDI skills is to build rapport with the child without providing pressure to speak. In that sense, then, reflections are only to be used in CDI interactions when the child speaks spontaneously. Reflections can also be used as part of successful VDI interactions, in this case validating the child’s response to questions. Imitation (IM).  Imitation is perhaps the most straightforward of all

the PRIDE skills used in CDI. Imitation simply refers to imitating the child’s actions. Doing so illustrates to the child that the adult is paying attention to and interested in what they are doing, and that the adult sees value in the child’s actions and choices. Although imitation is a nonverbal action, the adult can pair their own descriptions to these

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actions to explain their intent and make the interaction feel more natural. Examples of imitations may be using the same color the child did to color in a portion of a coloring page while stating, “I see you drew a pink fish in the ocean. I’m going to use pink to draw a fish in my ocean, too.” or observing the child make a particular type of block structure, copying this action, and stating, “That’s really cool how you put a triangle on the top. I’m going to do that for my building, too.” Utilizing imitations throughout rapport-building activities sends a powerful message that the child is important and valued regardless of whether they are talking or not and helps to build comfort in new environments or around new speaking partners. Behavioral Descriptions (BD).  Behavioral descriptions involve

providing brief, objective descriptions of what a child is currently doing. This can include the play actions they are completing, movements they are engaging in, or other observable facts occurring in the interaction. Behavioral descriptions serve the purpose of providing models of appropriate language, as well as making the interaction feel more natural (rather than the clinician and child both sitting there in silence). It is important to note that behavioral descriptions are always only about outward, observable behaviors, and do not attempt to describe what the child is thinking, feeling, or trying to communicate (often referred to as “mind-reading”). Mind-reading should be avoided at all costs, as it devalues the child’s contributions to the interaction and demonstrates that the adult is in a position of power and knows what the child thinks or wants better than the child does. Mind-reading also lowers momentum and has a negative impact on the child’s ability to communicate, and if the adult mind-reads incorrectly, the child may feel like their thoughts or feelings were “wrong” (since the adult was not able to interpret them correctly), or that there is no need to communicate because the adult will continue to assume both sides of the interaction. For example, if the child is pointing at a stack of blocks, an appropriate behavioral description would be, “You’re pointing at the pile of blocks over there.” Examples of mindreading in this situation would include, “Oh, you want more blocks.” “You’re telling me you like those blocks better.” “You think we should sit over there and play instead.”

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Enthusiasm (EN).  Perhaps the most intuitive PRIDE skill is that of

enthusiasm. An age-appropriate amount of enthusiasm is key to successful treatment as it contributes to building a positive rapport and strengthens the relationship with the student. Certainly, a different level of enthusiasm is appropriate for young (preschool-aged) children compared to older (school-aged) children, and there is certainly some variability in each clinician’s individual style. What is important is to be genuine, warm, and naturally enthusiastic about whatever activity or process the clinician and child are engaged in together. This enthusiasm helps set the tone for the interaction as something positive, pleasant, and even fun, and can contribute to lowering the child’s level of anxiety. By contrast, if a clinician is rigid, anxious, uptight, or tense, the child may sense this and in turn absorb or reflect this same anxiety and tension, thus making it more difficult to create a positive rapport. Direct Commands (DC).  Although not part of the PRIDE skill set

specifically, direct commands are often used in CDI interactions, especially when some type of action is needed from the child. Direct commands are clear, straightforward, succinct instructions about what the child needs to do. Starting these commands with the carrier phrase, “Go ahead and . . . ” can make the instructions feel more inviting and less formal or solemn. Examples would be, “Go ahead and sit down in that chair.” “Go ahead and point to the color you want.” “Go ahead and use the bathroom.” Since questions are not used during this process, many requests can be rephrased as a direct command. Rather than asking the child if they need to use the bathroom, the clinician can show them where the bathroom is and direct them to “go ahead and try” (in the case of young children who may be new to potty training). Using specific, precise, and direct language is important so that the child knows exactly what they are expected to do. By contrast, using more passive or less direct language, such as, “I would really like to see the drawing you’re working on.” or “It would be so nice if you sat down in the chair,” can elevate anxiety levels as the child may be unsure if they are expected to do the task or if it is merely a suggestion, and this uncertainty can lead to freezing, indecisiveness, or increased tension and rigidity.

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Although each of these CDI skills may sound familiar and straightforward, it can take some practice to be able to utilize them skillfully and automatically. Clinicians often benefit from dedicated time spent practicing each of these skills in order to increase their awareness of them and ability to use them naturally and successfully. Consider this example. In this session, the clinician is meeting the child for the first time and engaging in CDI skills to build a positive rapport. There is no expectation that the child speaks, but if the child does speak spontaneously, the clinician can respond appropriately. Clinician:  So good to meet you, Andre! There are a lot of cool toys and games in here. We can play with anything you want. Go ahead and sit down by something you want to play with. (DC) Child:  sits down next to blocks Clinician:  Great job sitting down next to the blocks (LP). I really like to play with blocks. Child:  sits and stares at blocks Clinician:  Good job looking right at those blocks (LP). Go ahead and take some blocks to start building something (DC). Child:  takes two blocks and stacks one on top of the other Clinician:  I see you’re stacking a red rectangle on top of that long, green piece (BD). That’s a great idea (LP). I’m going to do that, too (IM). Now I’m putting two yellow triangles on top of the rectangle. Oops! One of them fell off. I’m going to try again and see if I can get it to work. Child:  continues adding blocks to structure Clinician:  I see you’re adding more blocks to the middle part (BD). You’re doing such a great job stacking the blocks really high! (LP) Child:  It’s a castle. Clinician:  It’s a castle (RF). Thanks so much for telling me what you’re building (LP). I love your castle (LP). Now I see

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you setting up some green cylinders in front of the castle (BD). I think I will use some of those pieces for my building, too (IM). Notice a few key details in this interaction. The clinician does not use any questions with the child, since this is the initial meeting and the clinician is only using CDI skills. The clinician uses a few direct commands to get the interaction started when the child demonstrates some hesitancy to engage behaviorally. Although the clinician uses behavioral descriptions, they are careful not to mind-read and assume they know what the child is building or what they are using the blocks to represent. When the child does speak, the clinician reflects and praises nonchalantly and then continues to use CDI skills. In the moment, it can feel natural to respond to the child’s speech with follow-up questions, in order to keep the interaction going and capitalize on their ability to speak. However, when engaging in CDI, remember that verbalizations are not the goal, but rather comfort and positive rapport. Finally, throughout the interaction the clinician uses filler language, describing their own actions, opinions, and thoughts, which make the interaction more natural, decentralizes the focus away from the child, and provides strong language models of appropriate things to say in this interaction. Consider another situation with a child who demonstrates more hesitation to engage: Clinician:  I’m really excited to play with you today, Luis! There are a lot of toys in here we can use. Child:  looks at floor Clinician:  We can play with anything you want. Go ahead and sit down next to something you’d like to play with. Child:  looks at floor and doesn’t move Clinician:  I see the Zingo game over there. Let’s start there. Come on over and sit next to the Zingo. Child:  pauses for 5 seconds, looks at Zingo game Clinician:  Great job looking at the Zingo game. Go ahead and take a step towards it.

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Child:  takes one step forward. Clinician:  Awesome job moving towards the game! Go ahead and take another step. Child:  takes two more steps forward. Clinician:  You’re doing such a great job coming closer. Go ahead and take one more step forward. Child:  takes one step forward and sits down Clinician:  moves self and game a little closer to child Clinician:  Amazing job coming to sit with me! I’m really excited to play this game with you—it’s one of my favorites. The way you play this game is that you slide this piece out, and if you need one of the pieces for your board, you have to reach out and take it really fast. Sometimes we might both reach for the same one so we’ll have to be fast! Ok, I’m going to slide it first. Clinician:  slides game piece Clinician:  I got a bunny and a ball. I don’t need the bunny, but I’m going to take the ball for my board. Child:  watches clinician take the piece and put it on their board Clinician:  I love how you watched me put that piece on. Ok, now it’s your turn. Go ahead and slide the slider. Child:  stares at board Clinician:  I see you looking at your board. Go ahead and get your hand ready to slide, like me Clinician:  demonstrates holding hand up but near body Child:  lifts hand slightly Clinician:  Great job getting your hand ready! Clinician:  slides slider closer to child Clinician:  Go ahead and touch the slider with one finger, like me. Clinician:  touches slider with one finger

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Child:  reaches forward slightly and places one finger on the slider Clinician:  You’re being so brave playing this game with me! Go ahead and help me slide the slider forward. Child:  slides slider forward with clinician and then pulls hand back to lap Clinician:  Great job sliding that forward. I see a shoe and a sun. Child:  looks at board and then looks back to pieces on the slider Clinician:  I see you looking at your board. Go ahead and take any pieces you need. Child:  reaches out and takes sun piece, holds it in hand Clinician:  Amazing job being so brave to reach out and take that piece yourself! Clinician:  waits 5 seconds, looks down at own board and away from child Child:  places piece on board Clinician:  I love how you put that on your board yourself. I think you’re going to be really good at this game. Ok, now it’s my turn again . . . In this scenario, the clinician used direct commands to facilitate the child’s behavioral engagement in the activity. When the child experienced a “freeze” response, the clinician broke the task down into smaller steps (i.e., taking one step instead of walking across the room and sitting down; touching the slider with one finger instead of sliding it with the whole hand, etc.). The clinician provided frequent labeled praise, acknowledging the work that the child was doing and the effort it was taking. The clinician also employed the use of wait time, in order to allow the child to engage on his terms and give him time to respond to the request without feeling rushed or pressured. During the game interaction, the clinician did not ask the child if

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they knew how to play the game, since questions are not used in CDI. Instead, the clinician briefly explained what the expectation is and how the game would be played (typically this is a verbal game where players must call out the item they want, so explaining the rules to the child helped set the expectation that they would not be required to speak yet). Additionally, the clinician took the first turn in order to model for the child what actions would be expected and give the child additional opportunity to “warm up” to the action and observe it before being asked to engage in it himself. CDI Skills Practice

Label the following statements as labeled praise (LP), reflection (RF), imitation (IM), or behavioral description (BD): 1.

 Child:  My mom got it for me at Target. Adult:  Your mom got it for you at Target.

2.

  Adult:  Great job answering that question all by yourself!

3.

  Adult:  You’re drawing a red hat on his head.

4.

 Child:   uses play food to start making a sandwich Adult:  picks up similar pieces of food and starts making a sandwich Adult:  I’m going to make a sandwich, too.

5.

 Adult:  I love how you told me that in such a loud voice!

6.

 Child:  I went to the park yesterday. Adult:  You went to the park yesterday.

7.

  Adult:  You’re brushing the doll’s hair.

8.

 Child:   draws a castle Adult:  I’m going to draw a castle on my paper just like you.

9.

  Adult:  Coloring that purple is such a great idea!

10.

  Adult:  Oh, I see you’re making a little green cat.

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Describe what’s wrong with each of the following CDI statements/ interactions: Child:  I like Paw Patrol. Adult:  Oh, you like Paw Patrol?

Adult:  Nice job!

Adult:  You’re putting the triangles on top. You should try putting them on the bottom, it will work better.

Label the following commands as direct (DC) or indirect commands (IC):   Go ahead and sit down.   Can you please hand her a tissue?   Do you want to pick up that trash?   It would be nice if you opened your lunch box.   Go ahead and wash your hands.   Put the markers in the box.   We shouldn’t really tip our chairs back like that.   Do you think you want to try asking a question?   Go ahead and ask, “What’s your name?”   Take a pencil and write your name at the top.

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Change the following indirect commands to direct commands: 1. Can you help me by picking up those game boxes?

2. When you’re finished, can you put the lid back on the marker?

3. Do you think you want to play Spot It with her?

4. We should probably do some cleaning up at some point.

5. If you feel like it, you can raise your hand.

6. Maybe you want to try asking him a question?

7. It would be nice if you filled out your journal.

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8. Would you like to tell me to turn the page?

(Suggested answers can be found at the end of this chapter). Verbal-Directed Interaction (VDI)

Once rapport has been established, a second set of skills, known as verbal-directed interactions (VDI), is necessary to elicit speech and help the child climb the communication ladder. The purpose of VDI is to utilize intentional questions in a specific sequence in order to elicit speech in a supported and scaffolded way (Figure 5–2). This allows the child opportunities to practice approaching potentially anxiety-inducing situations rather than avoiding or demonstrating inhibition. Importantly, VDI is only ever used after a warm-up period with CDI, even with students who may start the session as being quite verbal. Additionally, CDI skills should continue to be used with and throughout VDI sequences. With practice, clinicians will learn to “dance” between the CDI and VDI skills, as each situation, client, and new speaking opportunity will require a different but delicate balance of these two skillsets. The primary rules of VDI are: 1. Do not use yes/no questions. 2. After asking a question, allow a minimum of 5 seconds for the child to respond before repeating or providing prompting. 3. When the child responds nonverbally, describe behavior rather than mind-read. 4. Do not repeat the same question more than three times in a row. 5. If the child has difficulty with a task, move down a step in the ladder of complexity to a level where the child was previously successful, and practice there.

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Figure 5–2.  VDI question sequence.

6. Use intentional scaffolding to get the child back to any challenging questions/interactions so they can successfully complete the task. 7. Continue to use CDI skills throughout interaction.

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A typical VDI question sequence begins with an open-ended question, such as “What is your favorite kind of ice cream?” Yes/ no questions are avoided because these more often elicit nonverbal responses (i.e., nodding/shaking head) and therefore are not beneficial for practicing verbal responses. After asking the question, the clinician waits a minimum of 5 seconds for the child to respond. While 5 seconds is a good rule of thumb, it is important to note that some students may demonstrate a longer latency in their response time, requiring as much as 10 to 15 seconds to provide a response in some situations. This latency may be something that can be addressed later in therapy, after the child is consistently responding to a variety of people in a variety of situations (which are the primary focuses of therapy initially). After the 5 second wait time, one of three things happens: the child may answer verbally, in which case the clinician immediately provides labeled praise, a reflection, or both. Or, the child may not answer verbally. If the child answers nonverbally, such as by pointing or shrugging, the clinician should provide a behavioral description and prompt for a verbal response. An example would be, “You’re shrugging your shoulders. Go ahead and tell me what your favorite kind of ice cream is.” Lastly, the child may not answer or respond at all. If this is the case, the clinician should repeat the question and wait another 5 seconds. If the child responds verbally on this second presentation, the clinician provides the labeled praise, reflection, or both. If the child responds nonverbally, the clinician provides a behavioral description and prompts for a verbal response. If the child does not respond again, the clinician has a few options. The clinician can provide some filler language to help take the focus off the child momentarily and allow them to regroup or formulate their answer. Then, the clinician can “shake-up” the question by rewording it or increasing the level of excitement and enthusiasm. An example would be, “There are so many different kinds of ice cream out there. I really like chocolate ice cream, that’s my favorite. I am wondering, what’s your favorite kind of ice cream?” In some cases, this may be enough to elicit a verbal response. The clinician’s other option is to say, “We’ll come back to that one and try it again later,” which acknowledges that the child is having dif-

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ficulty but underscores that they will have the opportunity to try again later. Next, the clinician should go back a step in the level of expectations and practice at the level at which the child was last successful. In this case, it may look like changing the open-ended question (“What’s your favorite kind of ice cream?”) to a forced choice question, which are usually easier for children to answer (i.e., “Is your favorite kind of ice cream chocolate, vanilla, or something else?”). Alternatively, this may look like modifying the setting or audience that the child is currently being exposed to. If the child is having difficulty answering a question from the clinician in front of a small group of peers, the clinician and child can move away from the group and practice asking and answering the question privately, and then slowly move back closer to the group. What is key about this step in the process is that when the clinician says, “We’ll come back to that one,” they actually do come back to that same situation and provide the scaffolding for the child to be successful. If not, this can easily become an instance of rescuing or accommodation, which has the opposite effect—instead of reinforcing bravery and mastery, it reinforces the escape and avoidance loop. Putting It All Together

In this session, the clinician is working on having the child answer open-ended questions in a new environment, their homeroom classroom. Previously, the child has been successful answering open-ended questions in the speech room and in the hallway. The clinician and child are in the homeroom classroom, sitting at a table, engaged in an activity (coloring). The clinician has already engaged in about 10 minutes of CDI to set the stage and provide warm-up time. Next, the clinician will transition into VDI. (For a comparison of the CDI and VDI techniques, see Table 5–1). Clinician:  Wow, you’re working really hard on your picture (BD). What are you drawing? (OE) Child:  continues drawing, does not make eye contact Clinician:  waits 5 seconds

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Table 5–1.  Comparison of CDI and VDI Techniques Child-Directed Interaction (CDI)

Verbal-Directed Interaction (VDI)

Purpose

Warm-up, break from requiring responses, rebuild rapport after a challenge, allow child to establish comfort

Building and practicing verbal skills, pushing child out of comfort zone, more traditional “therapy” mindset

Verbalizations from child?

Not expected

Expected

Questions?

None

Forced choice and open-ended

Skills required?

PRIDE skills

Question sequence

Child:  shrugs Clinician:  I see you shrugging your shoulders (BD). Go ahead and tell me (DC)—what are you drawing? (OE) Child:  continues drawing, does not make eye contact Clinician:  waits 5 seconds Clinician:  I’m drawing an ocean on my paper. I’m putting sharks and an octopus in it. Are you drawing an ocean, a farm, or something else? (FC) Child:  Something else. Clinician:  Something else (RF). Great telling me that you’re drawing “something else” (LP). What are you drawing? (OE) Child:  A zoo. Clinician:  A zoo (RF)! Amazing job telling me what you’re drawing (LP). That’s an awesome picture of a zoo (LP)! I love all the details you are adding (LP, BD). In this interaction, the child initially struggled to answer the open-ended question verbally. The clinician “took a step back” by

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changing the question to a forced choice question. When the child answered this successfully, the clinician returned to the original open-ended question to give the child the change to complete the interaction successfully. Next, the clinician would engage in a few more exchanges of CDI, to rebuild the rapport after that challenge, and then continue with another open-ended question. In another session, the clinician and child are engaged in a small group session. The child’s target goal for the day is to ask peers questions from a list of printed questions in front of them. The clinician prompts the child to ask the question, but the child is unable to respond. The clinician then engages in scaffolding by having the child practice the question with them (a familiar speaking partner) before then asking it to the target peer (a less familiar speaking partner). Clinician:  Go ahead and ask [peer] a question (DC). Child:  silence Clinician:  We’re practicing asking questions to other kids today. Let’s make sure we have a question picked out. Which question are you going to ask [peer]? Child:  points to question on paper Clinician:  I see you pointing (BD). Go ahead and read the question to me (DC). Child:  “When is your birthday?” Clinician:  Great job reading that in a loud voice (LP). Now let’s practice. Go ahead and practice asking me the question in your loud voice (DC). Child:  When is your birthday? Clinician:  Great asking and nice loud voice (LP). Go ahead and ask the same question to [peer] (DC). Child (to peer):  When is your birthday? Clinician:  Nice job asking him a question in such a loud voice! (LP)

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Often, children with SM have a difficult time making decisions, particularly when the choice requires them to share an opinion (i.e., discussing a “favorite” or “best” or “worst” something). This may come from increased anxiety regarding making the “wrong” choice or disappointing the person who is asking the question. Some children become frozen when in a position where they have to make a decision or offer an opinion. In these situations, they may offer, “I don’t know,” or “I forgot,” as a response, as a way of avoiding the pressure of making a decision or offering an opinion. It is important to recognize when this is happening. The clinician can both acknowledge the “I don’t know” response as a successful verbalization while also reframing the question or situation to help the child make the decision or share the opinion that is being asked of them. Clinician:  Do you like scary movies or you don’t like scary movies? (FC) Child:  I don’t like scary movies. Clinician:  You don’t like scary movies (RF). I don’t like them, either. What is your favorite movie? (OE) Child:  I don’t know. Clinician:  You don’t know (RF). Hmm, let’s think about it. Do you like movies about animals, magic, or something else? (FC) Child: Animals! Clinician:  Oh, you like movies about animals! (RF) What’s an animal movie you like? (OE) Child:  Secret Life of Pets. And I saw #2. Clinician:  Great telling me that you saw both of the Secret Life of Pets movies (LP). I like those movies, too. I think they are funny.

Ritual Sound Approach The Ritual Sound Approach (RSA) was created by Dr. Elisa ShiponBlum (Shipon-Blum, n.d.). RSA is a structured approach that utilizes

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careful, intentional scaffolding and the SLP’s working knowledge of the phonetic alphabet to move children from the nonverbal stage to the prompted verbal stage. Not all children require this therapeutic approach, but it can be helpful for those who require smaller incremental steps in the progression of their therapy or seem to be “stuck” in the nonverbal stage of communication. RSA can be completed without any materials, although there are a few that can make the experience more engaging for the child. A  lightweight object, such as a feather or piece of tissue paper, is helpful but not required. Paper and pencil to make a chart can also be helpful and motivating, but again, are not necessary, as a skilled clinician can move through the stages without requiring a formal “plan.” An example of an RSA chart can be found in the “Resources” chapter of this book. The clinician can make a chart as a model and assist the child in making their own and allow the child to check off each box as it is achieved. This process can be repeated in front of various audience members, as a way of “introducing” them “into the sound club.” The main methodology for RSA consists of the clinician modeling the target skill, the clinician and child completing the skill simultaneously, and then the child completing the skill independently. Later, as additional audience members are introduced to the activity, they can be active participants as well, in order to promote comfort and alleviate the feeling that the child is “in the spotlight.” Depending on the level of severity of SM and the child’s rigidity about speaking and speaking-related behaviors, it may be necessary to first establish movement through the use of oral motor activities. Not every child will need to begin at this very foundational level, and many will likely be able to begin at the level of establishing airflow (see following text). However, for those students that aren’t yet ready to participate in airflow activities, oral motor movement activities can be a good next step to move from non-oral towards verbal communication. For children who are particularly rigid or averse to oral motor activities, the clinician may need to begin with more distal movements (i.e., touch the table, stomp your foot, touch the floor with one finger, etc.) and then gradually move closer to the head, face, and mouth (i.e., pat your head, touch your nose, touch your chin, open your mouth, etc.).

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Oral motor movements may target the movement of the tongue, lips, cheeks, and/or jaw. Exercises involving the jaw and cheeks are usually considered the least invasive, followed by the lips and then the tongue. It may be necessary to work through the movement exercises in this order, or the child may be able to handle a mix of different target structures right away. Regardless, the tone of the interactions should be fun and silly, setting the expectations that these are fun games to engage in or silly faces to make, rather than structured exercises. Remember, the goal of these exercises is not physiological (i.e., to strengthen muscles), but rather psychological (to utilize scaffolding to build comfort with speech-related tasks). Some ideas for oral motor movement tasks include: n Puff out cheeks, move air pocket from one side of mouth to

the other

n Pucker/“fish face” n Alternate between smile/pucker as many times as you can in

1 minute

n Open lips to make “O” shape n Licking popsicles or lollipops (outside of mouth) n Clinician holds a tongue depressor and child uses tongue to

push tongue depressor up, down, left, right, and/or forward

n Try to touch tip of nose and bottom of chin with tongue n Use tongue to count teeth inside of mouth

The next level, and the point at which most students will begin, is to establish airflow. Exercises include various blowing and breathing activities, which promote the movement of air through the mouth, particularly out of the mouth, as a precursor to speaking. Ideas include: n Blowing kisses to stuffed animal or family member n Blowing cotton balls/pompoms across a table with a straw n Blowing on a tissue/feature to keep it up in the air for as long

as possible

n Blowing bubbles

5.  Treatment Techniques for Selective Mutism   101 n Blowing on pinwheel n Blowing in whistles/noisemakers n Whistling (if the child is able)

Once mouth movement and airflow have been established and can be completed consistently, the therapist begins to elicit voiceless sounds. It is often easiest to begin with sounds that resemble exhaling, such as the /h/ and /s/ sounds, and then shaping to other voiceless sounds. It is not necessary to practice every voiceless sound, but a variety should be established. After single voiceless sounds can be produced, the clinician can begin to combine voiceless sounds into two-sound combinations. This should begin with same-sound combinations and then progress to different-sound combinations (i.e., /h/-/h/, /s/-/s/, moving to /h//s/, /s/-/t/, etc.). Next, three-sound combinations should be targeted with the same process (same sound then different sounds). At this point, the clinician can begin introducing voiced sounds. It is typically best to do so nonchalantly, building off the child’s momentum with voiceless sounds, so as not to draw excessive attention to the fact that using the voice is now being targeted. A voiced sound can be interspersed between voiceless sounds (i.e., /h/-/o/-/s/), gradually increasing the number of sounds that are being produced. Once the child is producing three-sound combinations, the clinician can begin to shape this into the production of actual words. It is typically best to begin with nonsense words (i.e., mip) that are comprised of the individual sounds the child has just been practicing. Some children will freeze or become “stuck” if presented with real words too quickly, as this activates the anxiety regarding speaking known words. Begin by producing nonsense words in a segmented fashion (“/m/-/i/-/p/”) and then increasing speed and fluency until the sounds are being produced as a single, one-syllable word (“mip”). Continue to practice nonsense words and fade in the occasional real word, moving towards adding more real words as you progress. The next stage is using these single words as answers to questions. Be intentional about the real words that are practiced in the previous stage. Many clinicians find it helpful to establish “yes” and “no” fairly early on, as this can easily be shaped into the child

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responding to questions and allows for a huge variety of questions to be answerable with only two practiced words. It is then helpful to practice specific words that can be used as the answer to questions (i.e., if the child’s favorite color is pink, practice “pink” until the child is able to produce it independently, and then move into asking, “What is your favorite color?” and having them respond, “Pink.”). Continue asking and prompting responses to questions, fading the amount of practicing that occurs. Typically, once the child has progressed to the level of giving one-word responses to questions, the clinician can move toward prompting longer, more complex responses using the other strategies discussed in this chapter. The child may not progress through all stages of RSA in a single session. Clinical judgment is required to determine how quickly to move from one stage to the next and how far to progress with a child during a single session. If at any point the child becomes “stuck” and unable to move forward or complete the targeted stage’s task, move back to the previous stage and reestablish success and momentum before slowly scaffolding the next stage. The rows on the RSA chart are filled by completing each of these stages/activities again with new audience members present. For example, the child begins by writing the clinician’s name in the top row and then checks off each activity in each column as it is completed. Once they have moved through all the stages of RSA, they add a new name to the second row—a familiar family member or peer is best, to promote success without increasing difficulty too much—and the child moves through each stage of RSA a second time, with the new person present, thereby introducing them into the “club” and checking off each task as it is completed with that person. This same procedure can be used when fading in new people as a scaffolded, controlled approach to establish speech with a new communication partner. The RSA procedure may feel redundant at times, but it allows the child to build comfort with playing with his/her oral mechanism (movement, airflow, and voice) and taking small but steady steps forward. Completing the activities successfully many times in a row builds the child’s sense of accomplishment and mastery at speaking tasks and helps to increase self-esteem and a sense of competence with

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speaking. RSA can serve as a good introductory activity to speaking in new environments or to reestablish rapport if there has been a break in services (i.e., over summer/holiday break, due to extended absences/illnesses, etc.).

Treatment Factors Perhaps the most vital component of successful treatment for SM is an understanding of the various factors that can affect therapy goals, progress, and performance on tasks. These factors include audience, activity, environment, and language complexity. Clinicians must understand the importance of only changing one of these variables at a time. Too much change too quickly results in expectations that may be too lofty for students to meet, and when they are placed in situations where they are not yet ready to be successful, their lack of success only strengthens the avoidance loop and reinforces the idea that they are not successful communicators thus making the recovery process that much harder. As such, it is critical that clinicians understand these components and are able to adjust tasks to take into account the individual level of difficulty each factor presents to that specific child. Different children will be affected differently by each of these factors; some may be most sensitive to changes in audience while others may not be as strongly affected by audience changes but are very sensitive to changes in the environment. Clinicians should proceed cautiously at first when changing variables as they get to know which variables are more or less tolerable to each individual student.

Audience Increasing the number and types of people the child is expected to speak to and around is one of the primary goals of SM treatment. However, this must be done in an intentional, methodical way. Simply exposing the child to as many new people as possible is not an effective strategy without the proper scaffolding and support. When designing

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treatment plans and tasks, clinicians must take into account who the audience is. Are there primarily adults, peers, older children, or younger children present? How many people are present—is it one other speaking partner, a small group, or a large group? How familiar are the audience members—are they people the child has interacted with, or even been verbal with, before, or are they unfamiliar communication partners? Who else will be around observing the interaction, even if they are not a direct communication partner—is the child being expected to talk to someone while others are around and within earshot? Is attention being focused on the child or are other people watching the child, such as when they are doing a presentation? Each of these audience components must be considered and accounted for when determining who the most appropriate audience members are at each task, session, and stage of treatment.

Activity Often, clinicians become so focused on the “big” variables of audience and environment that they forget to account for the difficulty that may be presented by doing familiar versus unfamiliar activities. Children with SM often desire predictability, although this too can become a crutch and result in some children becoming very rigid about which activities they will engage in and which are off limits. The clinician, therefore, must walk a careful line of choosing familiar activities to provide a sense of predictability when other variables are being altered, but also spending time exposing children to new activities to increase their engagement and lessen rigidity when other variables are held steady. For example, a child with SM may choose to play a limited number of structured board games which they believe they are good at and can do successfully. They may be hesitant to or even refuse to participate in more open-ended activities, such as building with blocks or drawing, because they are less confident in their ability to do it right and meet expectations. A successful clinical treatment plan would include balancing the use of familiar, preferred activities when other variables are the target (i.e., introducing a new conversation partner or speaking in new environment), while also

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intentionally expanding the types of activities children are exposed to and learn to engage with, while keeping other variables held steady at familiar levels.

Environment The variable of environment can be broken down into two subcomponents: the macroenvironment and the microenvironment. The macroenvironment consists of the larger context in which the skill is being performed. This can include the type of location, such as in school, at home, or in the community, as well as the more specific aspects of those locations, such as the homeroom classroom, hallway, playground, or cafeteria at school. The microenvironment consists of smaller factors that contribute to the overall feel of the setting. This may include the layout of furniture in the room, whether or not music is playing (and the volume and type of music), the presence or absence of windows, whether the location is in a high traffic area in which many people are walking by the door, and so forth. Certainly, increasing the number and types of environments that children with SM are able to speak in successfully is an important goal of SM treatment. Determining which environments to target first requires a careful reflection on what the student is already able to do, and on what environments are most necessary and functional for them to work on first.

Language Complexity Perhaps the most familiar of these variables to the SLP is that of language complexity. Certainly, SLPs are well-versed in the concept of language complexity, and utilize the ability to modify expectations of language complexity when working with clients and students every day. It is important to keep in mind that children will progress through levels of language complexity both within and across sessions (Figure 5–3). In general, a good rule of thumb is for clinicians to start treatment a few levels before what their target is for the child that

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Figure 5–3.  Stages of language complexity from easiest to most complex.

day. For example, if the goal is for the child to use carrier phrases, the clinician should start by eliciting nonverbal or nonword sounds first as a warm-up, then single words, and then carrier phrases. This progression allows children time to warm up in an interaction and build confidence and momentum with skills they are already able to use before they are challenged with a new or more difficult task. Nonverbal Responses

The first stage of responses to work on eliciting are nonverbal responses. These include head nodding/shaking, shrugging, pointing, and other forms of nonverbal communication. Nonverbal responses may also include behavioral responses in response to following a direction or direct command (i.e., “Go ahead and hand me the green marker.”). Nonverbal responses set the stage for a successful verbal communicative interaction. Children who experience strong “freeze” reactions to new people, environments, or activities may initially struggle to utilize nonverbal responses and may need additional warm-up time, careful scaffolding of expectations, or both, in order to be successful at this level. Children with less severe “freeze” reac-

5.  Treatment Techniques for Selective Mutism   107

tions will likely be more readily able to engage in these responses. Eliciting nonverbal responses is an important part of successful CDI and VDI sequences. Nonword Sounds

Once the child is able to utilize nonverbal responses with consistency and without significant visible anxiety, the clinician may consider moving towards eliciting nonword sounds. Not every child will need to address this step in the language complexity ladder; in fact, many will skip it and be able to move directly to single word responses. However, for children who struggle to make the leap from nonverbal to verbal responses, nonword sounds can be a useful intermediary step. Research from Klein and Ruiz (2018) indicated there is a link between anxiety and physiological tension in the larynx, which has been posited as a causal or contributing factor in the development of SM. Children who were diagnosed with SM had higher levels of physiological tension in the larynx both at baseline and when being asked to engage in verbal tasks, compared to children who did not have SM. For these children, it was helpful to establish control of airflow and the use of the vocal cords for nonword sounds before moving to the more complex levels of verbalizing words. Nonword sounds allow the child to practice utilizing the voice and engaging the vocal cords without the added pressure and cognitive load of thinking of words to use or coming up with a response that fits the question or situation. The elicitation of nonword sounds can be easily incorporated into informal play activities. The clinician may also choose to use apps that are responsive to voice and sound levels to encourage louder volume or more frequent vocalizations. Single Word Responses

Eliciting single word responses is the next step in the language complexity hierarchy. Single word responses are usually elicited in the context of answering questions, although it is possible to elicit them through use of a direct command (i.e., “Go ahead and tell me which color marker you want.”). Single word responses should first

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be elicited through forced choice questions and then through openended questions. Carrier Phrase Responses

Once students can comfortably provide single word responses, the clinician can increase the complexity demands to carrier phrase responses. These most naturally occur in structured activities where the student is repeating the same carrier phrase or phrases over and over to establish comfort with the expectations. Working on carrier phrase responses helps move the student towards being able to produce novel single sentence responses independently. Single Sentence Responses

Single sentence responses may be elicited through open-ended questions or through direct commands (i.e., “Go ahead and tell me the first thing you do when you’re baking a cake.”). Older students (approximately age 6 and older) may benefit from prompts like, “Go ahead and tell me again with a full sentence,” presuming the clinician has already explained what a “full sentence” is. Once the child is consistently responding with complete sentences, the length and complexity of the sentences can be targeted to increase the complexity demand and get the child ready for the next level in the language complexity hierarchy. Multiple Sentence Responses

After students are able to produce single sentences, the clinician can move to targeting longer, multiple sentence responses. Being able to provide detailed, multiple sentence responses is a critical skill as it leads into being able to provide oral narratives and descriptions of items or events. Spontaneous Questions

Having the child spontaneously ask questions is the next level on the language complexity hierarchy. Often, the first and most func-

5.  Treatment Techniques for Selective Mutism   109

tional question that clinicians choose to target is asking for help and/ or asking for clarification. Clinicians may also spend time practicing asking to go to the bathroom, which is often a necessary skill in the school environment. After these functional questions have been addressed, therapy can progress to addressing social questions. Spontaneous Comments

The final level on the language complexity hierarchy is that of spontaneously making comments. This is often the most difficult stage for children because there are less contextual cues that indicate what their utterance should contain. When asked a question, the question itself provides the prompt for what the response should look like. When asking a question, the situation typically provides a prompt for what the question should consist of. But, when making a comment, the child is generating their own thoughts or opinions—so there is both a degree of creativity and a degree of personal information included in the utterance—in relation to the topic at hand, or perhaps initiating a new topic, which is often very difficult at first. Higher-Level Goals

Once students are able to consistently ask questions and make comments spontaneously, it is important to target higher-level language goals. By this time, students will look fairly verbal in most or all settings and may seem as though treatment has reached completion. They may no longer meet the diagnostic criteria for SM. However, ending treatment too soon results in missing vital opportunities to target important communication skills that will be necessary throughout the lifetime. These skills include disagreeing appropriately, asserting an opinion, using language to persuade another person, negotiating, engaging in humor, using sarcasm, and advocating for themselves and their needs. The SLP should consider how these goals can be targeted in naturalistic ways, in order to best facilitate carryover, and ensure that children are fully equipped to use the full range of social skills throughout all contexts. At first glance, this may seem like an extraordinary number of steps and skills to tackle in therapy. However, with a supportive

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team, clear and reasonable goals that break skills down into manageable steps, and the consistent use of appropriate therapy techniques, children can and do make progress throughout each of these areas. The next chapter will delve into more specifics of goal-writing and therapy activities.

CDI Skills Practice Answers Label the following statements as labeled praise (LP), reflection (RF), imitation (IM), or behavioral description (BD). 1. RF  Child:  My mom got it for me at Target. Adult:  Your mom got it for you at Target. 2. LP   Adult:  Great job answering that question all by yourself! 3. BD   Adult:  You’re drawing a red hat on his head. 4. IM  Child:   uses play food to start making a sandwich Adult:  picks up similar pieces of food and starts making a sandwich Adult:  I’m going to make a sandwich, too. 5. LP  Adult:  I love how you told me that in such a loud voice! 6. RF  Child:  I went to the park yesterday. Adult:  You went to the park yesterday. 7. BD   Adult:  You’re brushing the doll’s hair. 8. IM  Child:   draws a castle Adult:  I’m going to draw a castle on my paper just like you. 9. LP   Adult:  Coloring that purple is such a great idea! 10. BD   Adult:  Oh, I see you’re making a little green cat.

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Describe what’s wrong with each of the following CDI statements/ interactions. Child:  I like Paw Patrol. Adult:  Oh, you like Paw Patrol? Answer:  Adult is “tipping up” their response, turning their reflection into a question. Questions are not used during CDI. Adult:  Nice job! Answer:  Adult is not being specific enough or “labeling” the praise— may be unclear to the child what they did that was correct/successful and therefore they may not know which behavior should be repeated. Adult:  You’re putting the triangles on top. You should try putting them on the bottom, it will work better. Answer:  Adult starts with a good behavioral description, but then begins correcting the child’s play, which can cause the child to shut down. Label the following commands as direct (DC) or indirect commands (IC). DC   Go ahead and sit down. IC   Can you please hand her a tissue? IC   Do you want to pick up that trash? IC   It would be nice if you opened your lunch box. DC   Go ahead and wash your hands. DC   Put the markers in the box. IC   We shouldn’t really tip our chairs back like that. IC   Do you think you want to try asking a question? DC   Go ahead and ask, “What’s your name?” DC   Take a pencil and write your name at the top.

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Change the following indirect commands to direct commands (sample answers provided below; answers may vary) 1. Can you help me by picking up those game boxes? Answer:  Go ahead and pick up those game boxes. 2. When you’re finished, can you put the lid back on the marker? Answer:  When you’re finished, put the lid back on the marker. 3. Do you think you want to play Spot It with her? Answer:  We’re going to play Spot It with her. Go ahead and sit down. 4. We should probably do some cleaning up at some point. Answer:  It’s time to clean up. Go ahead and put those crayons away. 5. If you feel like it, you can raise your hand. Answer:  Go ahead and raise your hand. 6. Maybe you want to try asking him a question? Answer:  We’re going to ask him a question. Go ahead and ask, “What’s your favorite color?” 7. It would be nice if you filled out your journal. Answer:  It’s time to fill out your journal. Go ahead and write down your answer to question #1. 8. Would you like to tell me to turn the page? Answer:  Go ahead and tell me, “Turn the page.”

6

Meaningful Goals and Therapy Activities

Writing Meaningful Goals When creating goals for selective mutism (SM) therapy and treatment, clinicians must take into account a number of factors. Clinicians should work closely with families and, when possible, with children themselves, to determine which goals are most functional and most important at any given time. Consultation with school personnel is also critical to determine what needs to be addressed within the school setting. Clinicians can work with families to create a “talking map” (see the “Resources” chapter for a sample talking map). Talking maps are charts that detail the environments that a student is likely to encounter throughout the course of a typical month along the top of the chart, and a list of people the student is likely to encounter along the side. This creates a grid that clinicians and families can then examine together to determine in which combinations of people and environments the student is able to be verbal (i.e., the student may be verbal with parents at home, but not in the grocery store; the student may be verbal with their teacher in their homeroom classroom, but not yet with their peers, etc.) and which ones they are not yet verbal in. From this, clinicians and families can narrow down specific combinations of people and environments to target in therapy. It is recommended that goals begin with an easier, more achievable goal, and slowly work towards more advanced or difficult goals. This will, of course, vary significantly from child to child in terms of what is considered “easy” and “difficult.” Depending on the age of the 113

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child, they should be involved in the selection and shaping of goals, to whatever degree is appropriate based on their understanding of the process. There are many ways to creatively elicit input from the student about what is most important to them to work on first or what feels the easiest/most achievable. Students can view the talking map and circle or put stickers on the boxes that they think would be the easiest to talk in. Alternatively, environments and audience members can be written on cards or Post-It notes and the students can sort them into “easy,” “medium,” and “hard” piles, or line them up in order from easiest to hardest. Younger children may benefit from using visuals, such as a thumbs-up/thumbs-down or selecting a picture of a happy versus a worried face to describe their view of specific environments, tasks, or audience members. Older students can complete surveys (see Resources chapter) or rating scales where they rate the perceived difficulty of various environments, tasks, or audience members on a scale of 1 to 5 or 1 to 10. Another way to structure and plan therapy goals is by using a “bravery ladder” (see Resources chapter). Bravery ladders can start with a harder, more challenging goal at the top—perhaps one the child selects. The clinician then helps the child think of smaller, more achievable ways to break down the larger goal, and lists them on the subsequent rungs of the ladder. Younger children or children new to the “brave talking” tasks may need ladders with less steps, while older or more experienced children may be able to handle longer-term plans with more steps. An example of breaking down a goal into steps might be starting with the goal of asking the library teacher a question at the top of the ladder. Then, moving down from that, subsequent steps could be asking the speech-language pathologist (SLP) (a comfortable speaking partner) a question in front of the library teacher, asking the SLP a question in the library alone, asking the SLP a question in the hall outside of the library, and asking the SLP a question in the speech room (a comfortable environment). Then, the clinician and child begin at the bottom of the ladder, tackling the easiest goal first, and work their way up after they have successfully completed that task. Bravery ladders can be used for short term goals (i.e., what the child will accomplish in one or two speech therapy sessions) or more longer-term goals.

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SMART Goals Strong goals are essential for clinicians to actively measure progress and to drive effective data collection. Using the acronym “SMART” is a good way to write meaningful and effective goals. The acronym stands for: S: Specific M: Measurable A: Attainable R: Relevant T: Time-Based Strong goals include each of these five key components.

Specific Specificity in goals is crucial for a number of reasons. It ensures that the goal is individualized to the child’s needs, and it clearly delineates what is being addressed and measured. Specificity includes: (1) using the child’s name and (2) specifying the unique behavior or skill being addressed as clearly as possible. For example, a nonspecific behavior would be, “Student will increase their speaking at school.” By contrast, a specific goal would be, “Alex will answer forced choice questions from the speech-language pathologist in the speech therapy room.”

Measurable Goals are not useful if they cannot be measured. Measurable goals ensure that clinicians can easily collect data regarding the child’s progress in reaching the goal. These data are necessary in order to determine if the child is progressing at an appropriate rate and is on

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track to meet the goal by the specified time frame. Clear data also provide evidence that the child has met the goal and is in need of a new, more challenging goal; or, that the child has not yet achieved the goal and that further investigation as to why the goal was not met is warranted. Measurable goals must clearly delineate how the behavior or skill in question is being measured, and how frequently.

Attainable Strong goals are logical goals that are created to be reasonably attainable for the child. Goals that are not challenging enough will be mastered quickly and may not result in as much growth as the child is capable of. By contrast, goals that are too difficult can result in pushing the child to do something they are not ready for, causing frustration, embarrassment, anger, or a sense of helplessness for the child, the family, and/or the clinician. As such, it is critical that clinicians set reasonably attainable goals for students that take into consideration the child’s current abilities and short- and long-term needs. Additionally, when setting attainable goals, clinicians must carefully consider the logical development of skills including what prerequisite skills are necessary to accomplish the target skill or behavior and ensure that those prerequisite skills have or will be adequately addressed to allow the child to be successful.

Relevant Relevancy of goals is an important component for ensuring buy-in from both families and the child who is working on the goal. Children are more likely to be motivated by goals that seem relevant to their day to day lives, and families are more likely to engage in follow-up or extension activities to further promote the target skill or behavior when they can easily see the connection between the goal and the child’s needs. Determining relevant goals requires consultation with other members of the team. Clinicians may need to consult with school-based members of the team, such as the classroom teacher

6.  Meaningful Goals and Therapy Activities   117

or key worker, to determine what the child’s greatest needs are in the school environment. Similarly, the family and, when possible, the child should be consulted to determine what goals are most pressing and important to them.

Time-Based Finally, the last key component of setting appropriate and successful goals is ensuring they are time-based. The team should agree upon a specific time in which the goal is expected to be met. School-based goals in Individualized Education Plans (IEPs) may be written for what is expected throughout the course of a full school year or calendar year, or throughout the course of a semester or marking period. Outside of school, clinicians may create goals that are more shortterm, such as what can be accomplished on a bi-weekly or monthly basis. Regardless of whether the goals being set are short- or long-term goals, the length of time helps ensure accountability for the team and also provides a metric by which progress can be measured, in order to determine if the child is making adequate progress to accomplish the goal in the specified timeframe.

Goal Examples Social language goals can target a number of factors and, indeed, each of these factors should be considered and specified in the goal as much as possible so it is clear to everyone on the team what the expectation of the child is, and what success looks like. Goals may target length of utterance, such as being able to answer questions with a single word or with a complete sentence. Goals can also target the type of utterance expected of the child, such as asking a question, responding to a question, or making a comment. The environment is another feature that must be considered—is the child expected to perform this task in the classroom, cafeteria, community setting, and so forth? The audience must also be specified—is the child expected

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to complete the skill with their homeroom teacher, a single peer, a small group of peers, and so forth? Finally, the pragmatic function can be specified—the goal may address pragmatic functions such as asking for help, asking for more, denial/negation, labeling, possession, and so forth. The following are examples of some SMART goals that have been used to successfully treat children with SM. It is vital to note that goals are never a “one-size-fits-all” concept. Rather, goals must be individualized to each child’s specific needs, level of comfort with various skills, and the skills that are priorities to that child and their family. Nevertheless, a general framework by which to create goals can be helpful in conceptualizing how some of these more nebulous skills could be measured. Targeting environments: Given a picture or picture scene, [Student] will independently generate a sentence of 5+ words about the picture scene at an appropriate volume in four different environments (i.e., speech room, classroom, cafeteria, hallway) with 80% accuracy in each environment across three consecutive probes. Targeting asking questions: In a small group of familiar peers, [Student] will independently ask a question to three different peers in four out of five opportunities each across three consecutive probes. Targeting answering questions: In a structured activity, [Student] will independently answer questions from peers at an appropriate volume with 80% accuracy across four different environments (i.e., speech room, classroom, cafeteria, hallway) across three consecutive probes. Targeting audience: [Student] will independently ask a question to five different teachers in a one-on-one setting across three consecutive probes.

6.  Meaningful Goals and Therapy Activities   119

Targeting pragmatic function of asking for help: In the regular education classroom, [Student] will independently ask for help by approaching the teacher and requesting help verbally five times throughout the day across five consecutive probes.

Therapy Activities by Language Complexity Level It is important to consider the child’s short-term goal (what they are working on accomplishing in that specific session) as well as their long-term goal (such as what they are working on accomplishing as an annual goal in an IEP). Tasks should build in complexity and have higher expectations within and across sessions. If the short-term goal is for the student to use carrier phrases to say short sentences, the SLP should not expect the student to start doing this task as soon as they walk in and sit down at the table. Rather, activities need to start at a lower level of complexity and have less demands, utilizing scaffolding techniques, thus allowing the child to build comfort and momentum before pushing them to attempt a harder, or new, challenge. Regardless of short-term goals, it is always important to begin the session with a few moments of child-directed interaction (CDI), in which the child is not expected to communicate (but if they do so spontaneously, it is positively reinforced). Once the warm-up period has been conducted, the clinician can start implementing activities that are a few levels of complexity before where the short-term goal is set at for the day. For the child working at the carrier phrase level, the clinician may begin with a nonverbal task and engage in CDI, and then elicit single word responses, and then model use of the carrier phrase themselves and/or from the other peers in the session, and then elicit the carrier phrase response from the child with SM. Many activities that are already being used in the speech therapy sessions to target other goals can easily be adapted to target goals relating to SM. At times, it may be particularly helpful to introduce a new, more complex task (such as generating complete sentences instead of using carrier phrases) by using some of the same materials

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that were used in earlier stages. This provides a level of comfort and familiarity to the child and can help set the stage for success. Although the same materials are being used, a new expectation can be set; rather than eliciting carrier phrase responses, the new expectation might be to elicit full, self-generated sentences from the student. A list of activity ideas has been provided below, although this is by no means a comprehensive list.

Open-Ended CDI Activities n Building activities (blocks, Legos, Lincoln Logs, MagnaTiles,

etc.)

n Art activities (coloring pages, dot-to-dots, mazes, word

searches, hidden pictures, etc.)

n Puzzles n Board games that do not require spoken responses

(Memory/matching, Chutes and Ladders, Candyland, Hi Ho Cherrio, etc.)

Nonverbal Responses n Any receptive language task n Identify pictures by feature, function, or class n Identify picture by the sound the item makes n Identify colors of puzzle pieces, crayons, paper, objects n Sort pictures or objects into groups/categories n Give four pictures and have them point to the one that goes

with the word/sentence you said

n Following directions with manipulatives or coloring

(consider the child’s language abilities and be sure the directions are not too long or complex for them to follow successfully)

6.  Meaningful Goals and Therapy Activities   121 n Board games that do not require spoken responses (Memory/

matching, Chutes and Ladders, CandyLand, etc.)

Nonword Sounds n Play with toy cars and make sounds of cars driving or horns

honking

n Play with toy animals, stuffed animals, or puppets and make

the accompanying animal sound

n Have the child pretend to be an animal or object and make

the sound, and you guess what it is

n Create musical instruments made out of paper/recycled

materials and make the noises for the instruments

n Establish control of the voice (see list of apps in the

Resources section for suggested voice-controlled apps) n Humming n Pitch changes (high vs. low pitch) n Loudness changes (loud vs. soft voice) n Turning voice on and off on command (start/stop voicing)

Single Word Responses n Label pictures of familiar items (toys, animals, everyday

objects)

n Play “memory” games and have the child state the picture on

each card as it’s turned over

n Play Bingo or Zingo and have the child state the name of the

objects they have, or state the name of the object/picture they want

n Play hidden pictures games and have children state the name

of an object they found or are looking for

n Play Spot It! and call out the name of the matching object

122  Treating Selective Mutism as a Speech-Language Pathologist n Place a tray of objects or pictures in front of the child, have

them close their eyes, take one away, and have them open their eyes and state what is missing

Carrier Phrase Responses n Candyland—during each turn state “I got green,” “I got

orange,” “I got purple,” etc.

n Uno—during each turn, state the number you are putting

down “I have a two,” etc.

n Use hidden picture scenes and take turns finding an item and

telling the group and then coloring it—“I see a cow,” “I see a broom,” etc.

n Go Fish (use matching pictures for younger students)—

practice using the same handful of phrases—“Do you have a ____?” “Yes, I have a ____” “No, go fish”

Descriptions (Single or Multiple Sentences) n Use picture scenes of familiar, everyday events and have

children describe what’s happening. Start by expecting a phrase or single sentence and move up to expecting multiple sentences.

n Use “what’s wrong?” or “what’s missing?” pictures for added

complexity and creativity

n Use a barrier (this can be as simple as standing up a three

ring binder between you and the student so you can’t see what’s on the table in front of them) and have children describe a picture and you guess what it is, or you draw it on a whiteboard/paper while they describe the shapes/sizes/etc.

n Use a “mystery bag” and have students reach in and feel an

object and describe what it feels like, making guesses about what it may be

6.  Meaningful Goals and Therapy Activities   123

Structured Questions n Play 20 questions n Guess Who? n Hedbanz n Jeepers Peepers n Surveys—children can help develop a list of questions to ask

other peers or adults, and then go to these people, ask the question, and keep tally marks of the results (see Resources for sample surveys)

Spontaneous Questions n Ask the child to do a task but “forget” to give them all the

materials needed (i.e., ask them to cut out shapes but they don’t have scissors, ask them to sit down but there are no chairs in the room, etc.)

n Use a “mystery bag” to ask questions about what is in the bag

to get more information

Spontaneous Comments n

Do something silly or wrong and see if the child will correct you

n Have the child explain how to do a task or play a game

Scavenger Hunts An easily adaptable activity that can be used for many levels of language complexity is a scavenger hunt. The clinician can create a list (with pictures, if necessary, for nonreaders) of items for the child to find on a walk, in the classroom, in the clinic, and so forth. The required action can be modified depending on the child’s goal for

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that session. Children working on nonverbal responses might have to point when they find the target item. Children working on single word responses might say the name of it, or a repetitive practiced word like, “There!” Children working on carrier phrase responses could use phrases like, “I found the ___,” or “The ____ is over there!” Children working on sentences could practice describing where they found the object. Similarly, children working on peer-to-peer interactions can use all these same skills, but with a peer, rather than the clinician. As children are ready for more complex tasks, the “items” on the scavenger hunt can shift from being tangible things to find to actual tasks requiring various levels of verbalizations. Tasks can include things like asking someone what time it is, asking where the bathroom is, telling someone your favorite color, and so forth. Such scavenger hunts can be adapted for various situations, depending where the child is practicing (i.e., a department store, library, classroom, coffee shop, etc.). Sample scavenger hunts are provided in the Resources chapter of this book.

Video Self-Modeling A relatively recent contribution to the field of SM treatment is that of video self-modeling (VSM), also known as “augmented self-modeling.” VSM is defined as “an intervention procedure using the observation of images of oneself engaged in an adaptive behavior” (Dowrick, 1999, p. 23). Typically, VSM consists of short video clips (approximately 2 to 5 minutes in length) that show the child engaging in a target skill. The child then views these videos repeatedly for the purposes of (1) desensitizing to the interaction and thus, decreasing the level of anxiety associated with it, and (2) reinforcing the child’s ability to be successful with the target skill, through both visual and verbal reinforcement. VSM is not typically used in isolation to treat SM, but it can be a valuable tool in the clinician’s toolbox, especially if the child has hit a plateau in progress and needs an extra boost to move forward. Extant research has found VSM to be a successful treatment method for children with SM, especially when combined with other therapy techniques discussed previously in this chapter (i.e., shaping,

6.  Meaningful Goals and Therapy Activities   125

positive reinforcement, etc.). In one study, a child with SM viewed a video of herself answering questions. She watched the same video five times over a 4-week period. During these viewings, the child paused the video when she saw herself answering questions and was able to select a small reward to reinforce her speaking. In addition, stimulus fading was employed: after school, the child would play board games in the classroom with her grandmother and brother. Over time, three classmates were faded into these interactions. At the end of this period, the child was able to successfully answer questions and interact in the classroom environment (Kehle, Bray, Byer‐Alcorace, Theodore, & Kovac, 2012). Video self-modeling requires some basic editing skills, but can be done quite easily given the number of video apps and computer programs that are currently available. The process begins by videotaping the child demonstrating the target skill with a comfortable conversation partner. This most often includes the child answering questions from a family member, such as a parent or sibling. Ideally, this recording would take place in the target environment (i.e., speech room, classroom, etc.) to facilitate better generalization. Then, the target conversation partner (usually the teacher or SLP) is recorded asking the same questions that the child answered in the child’s video. The clips are then edited together so that the teacher asks the question, and the child’s response plays directly after it, simulating a backand-forth conversation in which the child is appropriately answering the teacher’s questions. Altogether, the clip only needs to last for a few minutes. Finally, the child should watch the completed video multiple times, combining other techniques such as positive reinforcement, spacing, stimulus fading, and so forth, as appropriate.

Facilitating Peer-to-Peer Interactions For some children, talking with peers may be easier and less intimidating than adults; for others, talking to peers may be more challenging. Use the Classmates and Friends Rating Form in the Resources chapter of this book to have children rate which peers are easier or harder to talk to.

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When facilitating peer-to-peer interactions, start with one familiar peer, ideally who the child has already indicated is “easier” to talk to. Initially, pairing students from the same homeroom classroom is helpful, as there is the greatest chance of and opportunity for carryover into the classroom environment. Input from the classroom teacher can be helpful, as they can provide suggestions of peers that the child sits with, is in small groups with, plays with, or seems more comfortable with. Additionally, families can provide insight into peers that the child sees outside of school (i.e., neighborhood friends, family friends, playdates, extracurricular activities, religious organizations, etc.) that can be helpful for facilitating carryover of skills to new contexts and providing additional opportunities to practice. Once a familiar peer has been selected, the clinician begins a fade-in process similar to that used with fading in new adults. Some modifications to this process are necessary, as it can be more difficult to teach peers how and when to use CDI and verbal-directed interaction (VDI) techniques appropriately. As such, there are often more clinician-directed activities initially that move from nonverbal to verbal interactions with the peer. Throughout this time, however, the clinician should continue to use their own CDI and VDI skills to maintain the child’s speech with them, and then slowly transfer this to the peer. Typically, it is easier to establish speech with peers in familiar, quieter environments, such as the SLP, student with SM, and peer beginning their interaction in the familiar environment of the speech room. Once speech with the peer in the room, and eventually to the peer, has been established, the SLP may choose to move the interaction back into the students’ classroom to begin the generalization process. Or, the clinician may choose to repeat the fading-in process with a few more peers, one at a time, to increase the number of conversation partners the child is able to speak to. It is important to use directive language when initiating the fade-in process with peers. Directive language utilizes clear, straightforward directives, such as “Go ahead and wave to Alex.” By contrast, non-directive language is more vague and often is phrased like a question, such as “Can you wave to Alex?” or “Do you want to wave to Alex?” Directive language is critical for two reasons. First, it makes it clear that the clinician is giving a direction, rather than asking

6.  Meaningful Goals and Therapy Activities   127

a question (which puts pressure on the child to think of and then provide a response). Second, it provides strong encouragement and sets the expectation of what the child is expected to do, rather than asking if they want to. Often, asking a child if they want to complete the task—which is likely a little bit difficult, anxiety-provoking, or uncomfortable, if scaffolded inappropriately—will lead to the child refusing. However, stating the expectation as a direction, rather than a choice, results in a much higher rate of follow-through and task completion on the child’s part. Directives should move in an intentional manner from nonverbal tasks to verbal tasks with the peers. Directives may begin with nonverbal communicative intents, like waving to a peer or motioning for them to come over and join the activity. They can then move to handing objects back and forth (i.e., “Go ahead and hand that green crayon to Analise.”) to begin facilitating turn-taking interactions. Peers can be prompted to ask specific questions, such as forced choice questions, which the child can then be prompted to answer. If the child is unable to answer the peer directly initially, it can be helpful to practice by answering the clinician first: Clinician to peer:  Go ahead and ask Lucy, “Do you want the blue or orange crayon?” Peer:  “Do you want the blue or orange crayon?” Child:  silent, looks down at the table Clinician to peer:  Go ahead and ask one more time. Peer:  “Do you want the blue or orange crayon?” Child:  remains silent Clinician to child:  Let’s practice answering that question. Do you want the blue or orange crayon? Child to clinician:  Blue. Clinician:  Great job answering. Go ahead and look at Simon and say, “Blue.” Child to peer:  Blue.

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In this way, the child’s responses can begin being directed towards the peer, moving towards the child answering the peer directly without the clinician as an intermediary step. Once the child is consistently answering both forced choice and open-ended questions from the peer, the child can be prompted to ask a specific question to the peer (i.e., “Go ahead and ask Simon, ‘What are you drawing?’”). Once the child can do this, prompting can become more vague, allowing the child the chance to practice generating their own questions (i.e., “Go ahead and ask Simon a question about his family.” “Go ahead and think of your own question to ask Simon.” “I wonder what Simon likes to do after school . . .”). Throughout the interaction, continue to use a lot of labeled praises and reflections to reinforce the child’s success at communicating. Often, peers quickly pick up on these patterns and can be very reinforcing, too!

What Does a Session Look Like? Once a peer or a few peers have been faded in and the child can communicate with and around them consistently, sessions may shift from being individual (one-on-one with the therapist) to being in small groups, allowing many more opportunities to practice social inter­ actions and peer-to-peer engagement. The following is an example of how a 30-minute session with a group of three students, all of whom are working on different speech and language goals, might be carried out. The session is being held in the speech room as this is where the child is working on communicating. The goal for the session for the child with SM (“Abby”) is to answer questions from peers using a carrier phrase. 9:00 am:  Students enter n Don’t use typical greetings—they usually carry a connotation

of requiring a response and elevate anxiety—use statements instead n “It’s so great to see you guys! I’m glad you’re here.”

6.  Meaningful Goals and Therapy Activities   129 n Review goals for each student (“Today you are working

on . . . ”)

n Cycle between activities for each child n

Abby begins with a nonverbal task—following directions to color a picture scene

n Clinician uses CDI skills—no verbalizations expected, but

use labeled praise and reflections for any spontaneous speech that occurs

9:05 am:  Switch to VDI mode n Abby answers forced choice questions about the picture scene

she colored (“Did you make the snowman blue or purple?” “Did you color the bird with stripes, dots, or something else?”)

n Abby answers “wh” questions about picture scene (single

word utterances expected)

9:10 am:  Hand out “hidden pictures” image n Abby and peers take turns using carrier phrase (“I see a

____”) to describe and color items in the scene

9:20 am:  Introduce a game of Go Fish. Model the carrier phrases needed n “Do you have a ____?” n “Yes, I have a ____.” n “No, go fish.” n Can have a “practice” session—“Go ahead and practice those

sentences. Go ahead and say, ‘Do you have an 8?’” —have each student practice, with Abby going last (peer modeling)

n Facilitate a game of Go Fish between peers n

Use directive statements to prompt initially—“Go ahead and ask Jocelyn for a card you need.”—and then back off and provide wait time to see if Abby can do it independently

130  Treating Selective Mutism as a Speech-Language Pathologist

Use labeled praises and reflections for Abby’s utterances n If she is unable to answer a question from a peer, have her practice with clinician and then try again with peer, or change to forced-choice and have her tell clinician and then tell peer (same goes for asking questions) n

9:30 am: Wrap up n Review what each student worked on today n Provide final labeled praises to each student n Remind students when you will see them again

Psychoeducation As stated by ASHA (2020), one of the roles of the SLP in the treatment of selective mutism is providing counseling regarding communication and emotions about communication. While this may, at first, seem like a task from the psychologist’s scope of practice, it is certainly something that SLPs are equipped to do. Likely, SLPs already have experience in this area in their work with students with fluency disorders, as there are many similarities between discussing the emotions regarding speaking and fluency and the emotions regarding speaking and SM. In the case of SM, the focus may be a little more on explaining the concept of anxiety in age-appropriate terms. Some ways to introduce the concept of anxiety are: n “Anxiety” is when we feel nervous about something. People

get anxious about lots of different things—dogs, the dark, thunderstorms, scary movies, rollercoasters, talking, and lots of other things. Everyone is anxious about something.

n When our brain gets anxious, it sends an “Emergency!”

signal to the rest of our body. If there’s a real emergency with something dangerous happening, this is a good thing, because it helps our body get ready to get away from the dangerous situation.

6.  Meaningful Goals and Therapy Activities   131 n Sometimes our brain thinks something is scary and sends

an “Emergency!” signal even if it’s not a real emergency. Sometimes it gets anxious about something that isn’t really dangerous.

n This “Emergency!” signal can cause changes in your body

and how you feel. You might feel changes in your body. When some people get anxious, they feel it as their heart pounding or beating loudly, their chest getting tight or heavy, feeling like it’s hard to breathe, feeling very cold or hot and sweaty, feeling like their head, neck, or stomach hurts, feeling like their throat gets tight and it’s hard to talk, and other ways.

n Even though these changes in our bodies don’t feel good,

they only last a short time. After we get through the situation that makes us anxious, these feelings go away and then we feel better again.

n We can help teach our brain when things are real emergen-

cies and when it’s really safe and doesn’t need to send the emergency signal. The way we teach our brain that it’s safe is by practicing the things that seem scary until they aren’t scary anymore. This teaches the brain that everything is OK and there is no “Emergency!” happening. We can teach our brain and body that it’s actually a safe and fun thing to do.

One common way to discuss the goals and purpose of treatment for SM is by explaining it in terms of developing bravery. Some ways to introduce this concept to students are: n Bravery is like a muscle. Brave muscles help keep our brain

calm, so it doesn’t send an “Emergency!” signal at the wrong time.

n We are building our bravery muscles by practicing brave

talking. We get braver and braver each time we practice.

n When something is hard, and we practice it lots of times, it

starts to get easier and easier. Soon, it becomes something we can do with no problem.

132  Treating Selective Mutism as a Speech-Language Pathologist n At first, our brain might still send the “Emergency!” signal

and make us feel anxious. It’s OK to feel anxious. It’s important to tell our brain that there is no emergency and that we can handle this situation with our strong brave muscles. When we tell this to our brain over and over, it stops sending the “Emergency!” signal about that activity because it learns that it is safe.

It can be helpful to start teaching students how to identify anxious feelings in their bodies, and assure them that these feelings are normal, and even though they don’t feel good, they won’t last forever. Creating rating scales is one way to help children learn to rate their own anxiety levels and start to see changes as they progress through therapy. Younger children may benefit from visual rating scales using 4 to 5 pictures of faces or emojis, demonstrating a range from “very scared” to “just OK” (neutral) to “very happy.” Older children may use a rating scale from 1 to 5 or even 1 to 10 if necessary. They may benefit from creating the rating scale themselves, by coming up with the words for each number (i.e., 1 = ok, 2 = a little anxious, 3 = anxious/worried, 4 = very anxious, 5 = freaking out/ panicking, etc.) and drawing a picture to represent that number (i.e., a facial expression or other symbol they associate with that feeling). Rating scales can be integrated as part of the exposure therapy process. Before engaging in a new exposure, students can be asked to rate how they are feeling about the doing the target activity. Often, students will choose a high number, indicating a very high level of anxiety or fear about the situation. Then, the clinician provides careful scaffolding and successive approximation to guide the child through the interaction. Once the child has achieved the target goal, they can return to the therapy room and again rate their level of anxiety about the task now that they have accomplished it successfully. At first, the child may still choose a high number on the rating scale. Continue to use the rating scale before and after this same activity, and see if the child is able to note when they are starting to feel less anxious about it (i.e., by the third or fourth time doing this same exposure activity, they may select a “4” instead of a “5”). When this happens, the clinician can begin to point out that what used to seem like the highest,

6.  Meaningful Goals and Therapy Activities   133

scariest, most anxiety-provoking number is now getting less scary, as the child is practicing more and her brave muscles are “growing” and “getting stronger.” Over time, as the child moves forward to harder goals and exposures, the clinician can return to the rating scale and ask the child to rate how anxious she feels about tasks that she’s already accomplished, as well as tasks that she is still working on. It can be helpful to keep hard copies of rating scales as evidence to the child, parents, and teams of how the child has progressed throughout therapy. It can be reaffirming when the child is preparing to do a new hard task, to see that she has accomplished other things that were scary and now, with practice, are not anymore.

Conclusion Children with SM are incredibly brave, resilient, and hard-working individuals, who truly want to speak and participate in interactions the way their friends and family members are able to. With the right intervention, these children can overcome their communication challenges and experience success in both verbal and nonverbal interactions. SLPs play an integral role in the assessment and treatment of children with SM. The American Speech-Language-Hearing Association very clearly delineates 12 ways in which SLPs are expected to be involved in working with children with SM and their families. SLPs bring to the table a wealth of knowledge regarding the development of social language skills, language elicitation techniques, scaffolding language complexity, and shaping responses into verbalizations. This existing experience, combined with some knowledge of basic behavioralist and cognitive-behavioral therapy techniques, means that the SLP is well-equipped to provide intervention to a child with SM. Together, partnered with the child’s family, teachers, and other team members, the SLP can work with the rest of the team to help the child unlock their “brave voice” and take steps towards accomplishing their goals.

Resources

This chapter contains reproducible resources that can be used with students and shared with family members or other treating team members, as needed. The following resources are included: n Case History n Sample Letter to New Classmates/Friends n Selective Mutism at School Handout (Teacher Tip Sheet) n Sample Talking Map n Classmates and Friends Rating Form n Teachers and Adults Rating Form n Playdate Log n Sample Ritual Sound Approach Chart n Brave Talking Practice Assignment Sheet n Feelings Rating Chart n Brave Talking Questions n Brave Talking Goals n Brave Talking Ladder (5 Steps) n Brave Talking Ladder (10 Steps) n Find-A-Friend Bingo n Brave Talking Chart (10 Spaces) n Brave Talking Chart (80 Spaces With Row Markers) n Brave Talking Chart (80 Spaces) n Brave Talking Weekly Chart (for classroom)

135

136  Treating Selective Mutism as a Speech-Language Pathologist n Pets Survey n Birthday Survey n Seasons Survey n Siblings Survey n Ice Cream Survey n Challenge Cards for School n Nature Walk Scavenger Hunt n Bookstore/Library Scavenger Hunt n Grocery Store Scavenger Hunt n Department Store Scavenger Hunt n Additional Resources

Resources   137

Case History Child’s name:  Date of birth: _______________  Gender: M  F Address:   Home Phone: ___________________________ Family Information Parent’s name: ________________________________  Age: ______ Address:   Cell phone: _________________  Work phone: _________________ Occupation:  Education:  Employer:  Parent’s name: ________________________________  Age: ______ Address:   Cell phone: _________________  Work phone: _________________ Occupation:  Education:  Employer:  Who cares for child when parent(s) is/are at work? ________________________________________

138  Treating Selective Mutism as a Speech-Language Pathologist

Siblings: Name:

Lives in same home?

Gender:

Birthdate:

    Other family members living in the home: Name: Relation:   Family History Is there a family history of any of the following diagnoses:

Diagnosis Selective mutism Generalized anxiety disorder (GAD) Social phobia Obsessive-compulsive disorder Specific phobia Avoidant personality disorder Schizoid personality disorder Separation anxiety

No

Yes

If yes, relation (i.e., father, maternal grandmother, etc.)?

Resources   139

Diagnosis

No

Yes

If yes, relation (i.e., father, maternal grandmother, etc.)?

Depression Bipolar disorder (I or II) Dysthymia Post-traumatic stress disorder Other

Pregnancy and Birth History How many successful pregnancies has the mother had? _____________ Which pregnancy was the child? ______________ How old was the mother at the time of birth? ______________ How long was the pregnancy? ______________ Did the mother have any accidents, illnesses, x-rays, medications, or complications during this pregnancy?  Place of birth (hospital, city):  Birth weight: ________  How long was labor? __________________ What kind of delivery?  Were instruments used?  Complications during birth?  Were there any breathing, sucking, feeding, or crying problems? (Explain)  

140  Treating Selective Mutism as a Speech-Language Pathologist

Was your child in the NICU? _________ How many days? __________ Explain:   Child’s Health History When did your child meet the following developmental milestones? Motor: Sit alone Feed self Toilet train Stand alone Walk alone Climb stairs with alternating feet Which hand does your child prefer?

Speech and Language: Respond to voices Coo and babble Imitate sounds Say first words What were first words? Use short sentences Examples?

Resources   141

Has your child had any of the following illnesses? Check if Yes Measles Mumps Pneumonia Meningitis Chest infections Frequent colds Ear infections Asthma Tonsillitis Bone or cartilage problems Allergies Types of allergies (list)

Please explain

Heart problems

Please explain

Kidney problems

Please explain

Hearing problems

Please explain

Has had tubes?

Age

How Severe?

142  Treating Selective Mutism as a Speech-Language Pathologist

Check if Yes

Age

How Severe?

Does child wear glasses? Why?

Name and address of the child’s physician:    Phone: ______________________  Fax: ______________________ Does your child have any other physical problems or diagnosis? If so, please describe:    Overall, is your child in (circle one): Good health  Fair health  Poor health Has he/she ever been hospitalized? ____________  Please explain:    Does your child take medications? List and explain why:    

Resources   143

Does your child use an EpiPen for any allergies? Which allergies?    Education Does/did your child attend preschool?  Where? Present School: _____________________________  Grade: ______ Does your child have a(n):  IEP _____  504 plan _____  Neither _____ What services does he/she receive at school, if any?    What are your child’s favorite parts of school?    What are your child’s least favorite parts of school?    Does he/she have any trouble learning or keeping up with classmates?   Speaking and Listening In which of the following situations is your child able to do each of the following tasks?

144  Treating Selective Mutism as a Speech-Language Pathologist

At Home: Always Use gestures (nodding, pointing, shrugging) Use greetings and farewells Ask for help Ask questions for information Answer yes/no questions Answer questions with longer utterances Make comments Make jokes/use sarcasm Share opinion Disagree appropriately Give directions about how to complete a task Tell a story about a recent event with appropriate detail

Often

Sometimes

Never

Comments

Resources   145

At School—With Peers: Always Use gestures (nodding, pointing, shrugging) Use greetings and farewells Ask for help Ask questions for information Answer yes/no questions Answer questions with longer utterances Make comments Make jokes/use sarcasm Share opinion Disagree appropriately Give directions about how to complete a task Tell a story about a recent event with appropriate detail

Often

Sometimes

Never

Comments

146  Treating Selective Mutism as a Speech-Language Pathologist

At School—With Teacher(s): Always Use gestures (nodding, pointing, shrugging) Use greetings and farewells Ask for help Ask questions for information Answer yes/no questions Answer questions with longer utterances Make comments Make jokes/use sarcasm Share opinion Disagree appropriately Give directions about how to complete a task Tell a story about a recent event with appropriate detail

Often

Sometimes

Never

Comments

Resources   147

In Community Settings (i.e., in a store, at sports, at Boy/Girl Scouts, etc.): Always Use gestures (nodding, pointing, shrugging) Use greetings and farewells Ask for help Ask questions for information Answer yes/no questions Answer questions with longer utterances Make comments Make jokes/use sarcasm Share opinion Disagree appropriately Give directions about how to complete a task Tell a story about a recent event with appropriate detail

Often

Sometimes

Never

Comments

148  Treating Selective Mutism as a Speech-Language Pathologist

Does your child understand (check all that apply): n Single words  n Short (2–4 word) sentences  n 5+ word sentences n Stories read aloud  n 1-step directions  n 2–3 step directions n Jokes/sarcasm  n Facial expressions  n Tone of voice n Gestures (pointing, nodding, shrugging)

Is your child understood by familiar listeners? n Most/all of the time  n Some of the time  n Little of the time

If not, why not? n Too quiet  n Too fast n Mispronounces some sounds (give examples):

Is your child understood by unfamiliar listeners? n Most/all of the time  n Some of the time  n Little of the time

If not, why not? n Too quiet  n Too fast n Mispronounces some sounds (give examples):

Do you think your child hears well? __________  Explain if NO:   

Resources   149

Behavior Does your child: Behavior Have difficulty paying attention? Have difficulty separating from parents/caregivers? Become easily upset? Demonstrate sensitivity to loud noises, crowds, textures, and/or bright lights? Seek out sensory stimuli such as deep pressure, rolling/wrapping self in blankets, running into things, etc.? Have difficulty sleeping? Have difficulty eating?

No

Yes

If yes, please explain:

150  Treating Selective Mutism as a Speech-Language Pathologist

How do you discipline your child?   Who disciplines your child?  What does your child enjoy doing for fun?    What are your child’s favorite TV shows/books/toys/games?    Please indicate anything else you would like to share that will help us better help your child:    

Resources   151

Sample Case History Interview Questions n When did the inability to talk begin to manifest? n In what settings is the child able/unable to talk? n Around which people is the child able/unable to talk? n What does the child’s speech and language look like at home/

with comfortable people?

n Has your child been evaluated by any other professionals? What

diagnoses were ruled in/out?

n Is there a family history of anxiety? How does that manifest/what

does that look like?

n How do most conversation partners in the community/at school

respond when the child is unable to talk?

n How do you respond when the child is unable to talk? n Have you found anything to be helpful to make your child feel

more comfortable/”brave”?

n What is your child motivated by?

152  Treating Selective Mutism as a Speech-Language Pathologist

Sample Letter to New Classmates/Friends Dear Friends, Hi! My name is [Child’s Name]. I am [age] years old and in [grade] grade at [name of school]. My favorite things to do are to play with [list activities, games, toys, etc. your child enjoys]. I love to watch [list child’s favorite TV shows/movies] and my favorite books are [list child’s favorite books/series]. I have selective mutism. Selective mutism means I get really anxious in certain situations, especially at school or out in the community, and that makes it extremely difficult for me to talk in those situations. Sometimes it’s even hard for me to wave, point, or nod or shake my head to answer questions. If you see me at school, at the park, at the grocery store, or anywhere else, and I’m not able to answer you or say “Hi” to you, don’t worry! I’m still happy to see you, even if I can’t say it right at that moment. I still want to play with you, although I might not be able to ask or invite you to do something with me. I am working really hard on my brave talking. Here are some things you can do to help make it easier for me in situations where I might have to talk: n Don’t ask me questions right away. It takes me some time to

“warm up” in certain situations. If you do have to ask a question, try to make it a “forced choice” question (i.e., “Do you want popcorn or crackers for snack?” instead of “What do you want for snack?”). These questions are usually easier for me to answer.

n Invite me to play with you! It’s hard for me to ask you to play,

but I really want to play with you and it’s really helpful if you come over and start playing with me.

n Don’t expect me to say “Hi,” and “Bye.” These are really hard

words for me to say and I am still practicing them.

Resources   153 n Be patient with me! Sometimes it might take longer for me

to answer you or ask you something, or even to follow a direction or move my body (walking, pointing, picking up a toy, etc.).

n Come over to my house for playdates. It’s usually easier for

me to talk at my house than at other places, so when you come to my house, it’s really helpful for me to practice my brave talking with you in a place that’s comfortable for me.

I really appreciate all of your help with my brave talking practice! If you have more questions, you can talk to my [mom/dad/guardian/ etc.] at [preferred phone number]. I’m so happy we are in the same class together this year and looking forward to being friends and getting to know you better! —[Child’s Name]

154  Treating Selective Mutism as a Speech-Language Pathologist

Selective Mutism at School Handout (Teacher Tip Sheet)

Selective Mutism at School What is Selective Mutism? Selective mutism is an anxiety-based communication disorder in which children can speak in some settings (such as at home) and around some people (such as parents), but struggle to speak in other environments (such as school, around peers, etc). Selective mutism is not caused by defiance or a refusal to talk; rather, it is an inability to speak due to significant anxiety.

What Does it Look Like in the Classroom?

Children with selective mutism often struggle to answer questions, do not make spontaneous comments, do not ask for help, may not participate in group/choral responses with the rest of the class, do not sing along with songs, and do not initiate verbal interactions with peers or adults. Depending on the level of anxiety, children may also avoid eye contact, avoid raising their hand, appear “frozen”, struggle to make decisions, and be hesitant to engage in movement activities in front of a group (i.e., playing Simon Says, putting numbers on the calendar).

What Can I Do? • • • •

•

•

• • •

Give warm up time: Children will warm up both throughout the school day and throughout the school year as they become more comfortable with their environment. Greetings at the beginning of the day are especially difficult for children with selective mutism, so try not to expect a response. Avoid asking questions initially: Make comments that do not require a response, such as “It’s great to see you today!” instead of “How are you?” Give specific directions: Instead of asking, “Can you please put those crayons away?” use a specific directive like, “Go ahead and put your crayons away.” This makes it clear that you are giving a direction instead of asking a question, which feels like it requires a response and causes anxiety. Limit changes to the environment: Children with selective mutism are very sensitive to changes in their environment, which includes both the physical space and the people in it. If visitors, volunteers, or substitute teachers will be present, it is much more difficult for children to speak and they may need additional warm up time. Similarly, switching seats or tables is challenging and will require additional warm up/adjustment time. Use lots of specific praise: When you see any interaction, including a smile, a wave, moving closer to a peer, or handing you a piece of paper, acknowledge this with specific praise - “Great job handing me that paper!” “That was really brave to smile at Anna!”, etc. Children with selective mutism can and do make lots of progress, but it usually occurs in small steps. Help engage and facilitate play: Anxiety makes it very difficult for these children to initiate or join in play and other interactions with peers. Suggesting activities to do at free time and recess and giving tasks to the child with selective mutism and a peer to do together (“Sarah and Anna, go ahead and clean up the art center”) are extremely helpful. Offer small groups: If the child is too anxious to complete a task in front of the whole class, offer an opportunity with a small group or to complete the activity one-on-one with you. This lessens anxiety and social demands. Accept non-verbal responses: If the child with selective mutism is just too anxious to answer or participate, offer and accept a way for them to respond non-verbally. Remain positive: Do not reprimand the child for not talking, and avoid using guilt to try to get the child to talk. Children with selective mutism are extremely sensitive to criticism and can easily be overwhelmed if they feel they are failing or disappointing someone.

For More Information: The Selective Mutism Association: http://www.selectivemutism.org Child Mind Institute: https://childmind.org/guide/selective-mutism/

Mom Dad Siblings Grandparents Teacher Coach Familiar Peers Unfamiliar Peers Familiar Adults Unfamiliar Adults











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Office

Annabelle’s Talking Map

School Classroom Cafeteria Playground Hallways

✔

✔

Home

Sample Talking Map

















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Grandparents’ Soccer House

















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Park Stores

Resources   155

Classmates and Friends Rating Form How easy or hard is it to talk to this person? Classmate’s/Friend’s Name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 156

Easy

Medium

Hard

Teachers and Adults Rating Form How easy or hard is it to talk to this person? Teacher’s/Adult’s Name

Easy

Medium

Hard

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 157

158

Date

Location

Playdate Log

Playdate Partner Activity Spon. n

n

n

Prompt n

n

n

Behaviorally Engaged? n n n n n n n n n n n n n n n

Single words Single sentences Multiple sentences/stories Answered questions Asked questions Single words Single sentences Multiple sentences/stories Answered questions Asked questions Single words Single sentences Multiple sentences/stories Answered questions Asked questions

Prompt

Verbally Engaged?

n

n

n

n

n

n

n

n

n

n

n

n

n

n

n

Spon.

159

Date

Location

Playdate Partner Activity Spon. n

n

n

Prompt n

n

n

Behaviorally Engaged?

n n n n n n n n n n n n

Multiple sentences/stories Answered questions Asked questions Single words Single sentences Multiple sentences/stories Answered questions Asked questions Single words Single sentences Multiple sentences/stories Answered questions

n

n

Single sentences

Asked questions

n

Single words

Prompt

Verbally Engaged?

n

n

n

n

n

n

n

n

n

n

n

n

n

n

n

Spon.

160

Date

Location

Playdate Partner Activity Spon. n

n

n

Prompt n

n

n

Behaviorally Engaged?

n n n n n n n n n n n n n n n

Single words Single sentences Multiple sentences/stories Answered questions Asked questions Single words Single sentences Multiple sentences/stories Answered questions Asked questions Single words Single sentences Multiple sentences/stories Answered questions Asked questions

Prompt

Verbally Engaged?

n

n

n

n

n

n

n

n

n

n

n

n

n

n

n

Spon.

✔ ✔

✔

✔

Mom

Jackson

___________



✔

✔

Ms. Ashley



(B) Breathing



(A) Movement



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✔

✔

(C) (D) (E) /w/, /h/, ww, hh, ss, wh, hs, /s/, /p/, pp, tt wp, sh, st, pt /t/

Sample Ritual Sound Approach Chart





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(F) (G) seh, wop, sit, pet, tep, wis mop, yes, no

Resources   161

162  Treating Selective Mutism as a Speech-Language Pathologist

Brave Talking Practice Assignment Sheet Child’s Name: Adult Who Will Help: Date Assigned:

Date to Complete By:

Assignment Brave Talking Partner:

Setting:

n Familiar adult:

n Home

___________________ n Unfamiliar adult: ___________________ n Familiar peer: ___________________ n Unfamiliar peer: ___________________ n Other: 

n Someone else’s home: ___________________ n Classroom: ___________________ n Somewhere else at school: ___________________ n Community: ___________________ n Other: 

Method of Communication: n In person n Phone n Writing/Email/Text n Video/online meeting n Other:  Goal:

Reward:

Resources   163

Outcome: n Could not complete—no opportunity n Could not complete—too difficult n Completed with modifications (describe in notes) n Completed as assigned n Other: __________________

Notes From Adult Helper:

Notes From Child:

164  Treating Selective Mutism as a Speech-Language Pathologist

Feelings Rating Chart Before:  How do I feel about doing this activity?

My thoughts:

After:  How do I feel about doing this activity?

My thoughts:

Resources   165

Brave Talking Questions 1. How easy or hard is it to do the following things at school: Easy Ask a question to my teacher without anyone else around Ask a question to my teacher when other kids can hear me Tell my teacher I need to go to the bathroom Tell my teacher I don’t feel well/need to go to the nurse Answer a question from another kid in my class Ask a question to another kid in my class Raise my hand and answer a question in front of the class Read out loud to my teacher in a small group Read out loud in front of the whole class Give a thumbs-up/thumbsdown to answer a question Playing with kids at recess without talking Playing with kids at recess with talking Eating my lunch or a snack at school

A Little Hard

Medium Hard

Very Hard

166  Treating Selective Mutism as a Speech-Language Pathologist

2. I think the other kids in my class know that it’s hard for me to talk Yes     Maybe     No 3. I would like _________________________ to talk to my class and tell them that even though it’s hard for me to talk, I CAN talk and I am working on brave talking Yes     Maybe     No 4. What is something you want the other kids in your class to know about you?

5. Look at the brave talking skills listed in Question 1. Which ones would you like to practice working on next?

Resources   167

Brave Talking Goals Name:Date: Which of these things do you want to work on next in speech?

Really Important to Me Talking to more kids in my class Talking to my teacher Raising my hand and answering questions Reading out loud in front of a small group Asking for help Talking in the cafeteria Talking at recess Something else

A Little Important to Me

Not Important to Me Right Now

168  Treating Selective Mutism as a Speech-Language Pathologist

Brave Talking Ladder (5 Steps)

Resources   169

Brave Talking Ladder (10 Steps)

Brave Talking Ladder Goal:

Step 10:

Step 9:

Step 8:

Step 7:

Step 6:

Step 5:

Step 4:

Step 3:

Step 2:

Step 1:

170  Treating Selective Mutism as a Speech-Language Pathologist

Find-A-Friend Bingo

Find-A-Friend Bingo Find someone who fits in each box by asking them a question. Write their name in the box. When you have five boxes completed horizontally, vertically, or diagonally, you have a bingo! See how many bingos you can get. For a bigger challenge – try to fill in all of the boxes! Likes dogs better than cats

Knows how to skateboard

Has traveled outside the country

Has gone fishing

Is left-handed

Does not like soda

Likes to play outside better than inside

Has moved to a new house/apartment

Is older than you

Has been in a play

Has a younger sibling

Can speak another language

Free Space – Make up your own question!

Has ridden a horse

Has swam in the ocean

Can play an instrument

Plays a sport

Has won a contest

Likes chocolate ice cream better than vanilla

Likes to read

Can do a cartwheel

Can whistle

Knows how to cook/bake something

Has a blue toothbrush

Has seen a shooting star

_______________________’s Brave Talking Chart

Brave Talking Chart (10 Spaces)

Resources   171

172

Brave Talking Chart (80 Spaces With Row Markers)

_______________________’s Brave Talking Chart

Brave Talking Chart (80 Spaces)

Resources   173

Teacher Notes:

Goal 2:

Goal 1:

Monday

Tuesday

Thursday

Friday

Week of: _____________________

This Week’s Reward(s)

Goal 2 Total

Goal 1 Total

Wednesday

Brave Talking Weekly Chart

Name:_____________________________________

Brave Talking Weekly Chart (for Classroom) 174  Treating Selective Mutism as a Speech-Language Pathologist

Resources   175

Pets Survey

Pets Survey Directions: Collect your data by asking people the question below and making a check mark or tally mark in the correct box. Which answer do you think will win?

What pets do you have at home? Dogs

Cats

Something Else

No Pets

176  Treating Selective Mutism as a Speech-Language Pathologist

Birthday Survey

Birthday Survey Directions: Collect your data by asking people the question below and making a check mark or tally mark in the correct box. Which answer do you think will win?

When is your birthday?

Jan.

Feb.

Mar.

Apr.

May

June

July

Aug.

Sept.

Oct.

Nov.

Dec.

Resources   177

Seasons Survey

Seasons Survey Directions: Collect your data by asking people the question below and making a check mark or tally mark in the correct box. Which answer do you think will win?

What’s your favorite season?

Bonus: Ask them “Why is that your favorite?” Spring

Summer

Fall

Winter

178  Treating Selective Mutism as a Speech-Language Pathologist

Siblings Survey

Siblings Survey Directions: Collect your data by asking people the question below

and making a check mark or tally mark in the correct box. Which answer do you think will win?

Do you have any siblings? Yes

No

If “Yes”: Do you have brothers, sisters, or both?

If “No”: Would you rather have brothers, sisters, or both?

Brothers

Sisters

Both

Resources   179

Ice Cream Survey

Ice Cream Survey Directions: Collect your data by asking people the question below

and making a check mark or tally mark in the correct box. Which answer do you think will win?

What’s your favorite kind of ice cream?

Chocolate

Vanilla

Cookies &

Strawberry

Rocky Road

Something Else

Cream

Do you like it better in a cup or a cone? Cup

Cone

Both!

180  Treating Selective Mutism as a Speech-Language Pathologist

Challenge Cards for School

Return a book to the library and ask the librarian where to find ___________________.

Go to the nurse and ask them for 10 band aids for the classroom.

Take this letter to the principal and ask them to mail it tomorrow.

Go to the cafeteria and ask one of the employees what is for lunch.

Take this note to ____________ and tell them ________________.

Find a custodian and ask them for two rolls of paper towels.

Go to the office and ask the secretary for five envelopes.

Go to _______________ and ask them if they have any jobs for you to do.

Go to ___________’s Go to _____________ classroom and ask if you and ask them to help you can borrow a pair of make a copy of this. scissors.

Resources   181

Nature Walk Scavenger Hunt

Find three different kinds of leaves

Find two things that are red

Tell someone how far you think you’ve walked

Find three different kinds of insects and guess what they are called

Find the biggest tree on the path

Listen for a bird singing and tell someone when you hear it and where you think it’s coming from

Find some kind of water

Find three different colors of flowers

Find three different animals

182  Treating Selective Mutism as a Speech-Language Pathologist

Bookstore/Library Scavenger Hunt

Ask an employee where the bathroom is

Take a book to the register and ask how much it is

Find book you’ve never read and ask someone if they’ve read it

Ask someone where the cookbooks section is

Find a book and read a page out loud

Ask an employee what time it is

Ask someone what their favorite book is

Find your favorite book and tell someone that it’s your favorite

Ask someone where the animal books are

Resources   183

Grocery Store Scavenger Hunt

Ask someone where the milk is

Find someone in the produce section and ask them what their favorite fruit is

Choose an item and ask a cashier how much it costs

Ask someone what time the store closes

Ask someone where the spaghetti is

Ask someone where the bathroom is

Find your favorite snack and tell someone it’s your favorite

Choose a food and read the ingredients out loud

Find a food you don’t like and ask someone if they like it

184  Treating Selective Mutism as a Speech-Language Pathologist

Department Store Scavenger Hunt

Ask someone where to find the clocks

Ask someone where the bathroom is

Ask someone where the toys are

Find a piece of clothing you like and ask a cashier how much it is

Ask an employee how long they have worked at the store

Ask someone where to find towels

Ask someone if there is a water fountain

Ask someone when the store closes

Ask someone where the electronics section is

Resources   185

Additional Resources Websites n Selective Mutism Association

(http://www.selectivemutism.org) Includes schedule of treatment programs and continuing education opportunities, list of treating professionals who specialize in working with SM, and a number of handouts and other resources for families and clinicians

n Child Mind Institute

(https://childmind.org/topics/disorders/selective-mutism/) Contains many resources for families, school personnel, and clinicians, including “A Teacher’s Guide to SM”

n Selective Mutism University

(https://selectivemutismuniversity.thinkific.com/) Free online training program with instructional videos regarding how to use CDI and VDI techniques, with opportunities to practice identification and coding of correct versus incorrect use of skills

Books for Children n Unspoken Words by Sophia Blum and Elisa Shipon-Blum

Illustrated book written by a young woman who recovered from having SM as a child; explores the unspoken thoughts and feelings that often accompany this disorder

n My Friend Daniel Doesn’t Talk by Sharon Longo

Picture book that helps explain the concept of SM to younger children

n Leo’s Words Disappeared by Elaheh Bos

Picture book that describes SM and anxiety management techniques; has accompanying workbook/journal

186  Treating Selective Mutism as a Speech-Language Pathologist n Lola’s Words Disappeared by Elaheh Bos

Picture book that describes SM and anxiety management techniques; has accompanying workbook/journal

n Maya, The Brave! by Elaheh Bos

Introduces anxiety management techniques to help children transitioning in to school

n Milo, The Brave! by Elaheh Bos

Introduces anxiety management techniques to help children transitioning in to school

n Maya’s Voice by Wen-wen Cheng

Story about a girl who struggles to use her voice at school, and how she is able to find her voice with the help of those around her

n Sophie’s Story: A Guide to Selective Mutism by Vera Joffe

Appropriate for children, parents, and teachers

n Learning to Play the Game by Jonathan Kohlmeier

Young adult book written by a man who recovered from SM

n Selective Mutism in Our Own Words: Experiences in

Childhood and Adulthood by Carl Sutton and Cheryl Forrester Collection of written work by various individuals who had SM, describing their experiences in childhood and adulthood

Books for Treatment Teams n The Selective Mutism Resource Manual (2nd edition) by

Maggie Johnson and Allison Wintgens Comprehensive treatment manual with more information about the clinical side of treating SM

n Selective Mutism: An Assessment and Intervention Guide for

Therapists, Educators, and Families by Aimee Kotrba Comprehensive but easy-to-understand information geared towards families and professionals working with children with SM

Resources   187 n The Selective Mutism Treatment Guide by Ruth Perednik

Includes information on understanding and treating SM, including case studies and information about treatment with teens

n Overcoming Selective Mutism: The Parents’ Field Guide by

Aimee Kotrba and Shari Saffer Comprehensive guide for parents that provides an overview of SM and tools to empower parents to help their children progress from silence to speech

n Expanding Receptive and Expressive Skills through Stories

(EXPRESS) by Evelyn Klein Structured program developed by SLPs with guidance for treatment of SM, from nonverbal through verbal stages, based on familiar children’s stories

Apps n Bla Bla Bla n Speak Up n Speak Up Too n Spinny Wheel n Talking Tom (and others in this series) n Free Candle n Chicken Scream n My Talking Pet n Funny Movie Maker n Voice Changer and Voice Changer Plus n ChatterPix n Decibel

References

American Psychiatric Association. (1975). Diagnostic and statistical manual of mental disorders (2nd ed.). Arlington, VA: American Psychiatric Association. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Arlington, VA: American Psychiatric Association. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. American Speech-Language-Hearing Association. (n.d). Social communication. https://www.asha.org/public/speech/development/ social-communication/ American Speech-Language-Hearing Association. (2020). Selective mutism. https://www.asha.org/practice-portal/clinical-topics/ selective-mutism/#collapse_4 Anstendig, K. (1998). Selective mutism: A review of the treatment literature by modality from 1980–1996. Psychotherapy: Theory, Research, Practice, Training, 35(3), 381–388. Bergman, R. L., Piacentini, J., & McCracken, J. T. (2002). Prevalence and description of selective mutism in a school-based sample. Journal of the American Academy of Child and Adolescent Psychiatry, 41(8), 938–946. Birmaher, B., Brent, D. A., Chiappetta, L., Bridge, J., Monga, S., & Baugher, M. (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study. Journal of the American Academy of Child and Adolescent Psychiatry, 38(10), 1230–1236. 189

190  Treating Selective Mutism as a Speech-Language Pathologist

Black, B., & Uhde, T. W. (1995). Psychiatric characteristics of children with selective mutism: A pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 34(7), 847–856. Boggs, A., & Morgan-Gillard, S. (2018). 504 plan suggestions. http:// www.selectivemutism.org Bradley, S., & Sloman, L. (1975). Elective mutism in immigrant families. Journal of the American Academy of Child Psychiatry, 14(3), 510–514. Brown, J. (1999). Bowen family systems theory and practice: Illustration and critique. Australian and New Zealand Journal of Family Therapy, 20(2), 94–103. Brown, J. B., & Lloyd, H. (1975). A controlled study of children not speaking at school. The Association of Workers for Maladjusted Children, 3, 49–63. Brown, S., & Vaughan, C. (2010). Play: How it shapes the brain, opens the imagination, and invigorates the soul. New York, NY: Avery. Buss, A. H., & Plomin, R. (1984). Temperament: Early developing personality traits. Hillsdale, NJ: Lawrence Erlbaum. Carbone, D., Schmidt, L. A., Cunningham, C. C., McHolm, A. E., Edison, S., Pierre, J. S., & Boyle, M. H. (2010). Behavioral and socio-emotional functioning in children with selective mutism: A  comparison with anxious and typically developing children across multiple informants. Journal of Abnormal Child Psychology, 38(8), 1057–1067. Carpenter, A. L., Puliafico, A. C., Kurtz, S. M. S., Pincus, D. B., & Comer, J. S. (2014). Extending parent-child interaction therapy for early childhood internalizing problems: New advances for an overlooked population. Clinical Child and Family Psychology Review, 17, 340–356. Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685–716. Chanksy, T. (2014). Freeing your child from anxiety. New York, NY: Harmony. Cohan, S. L., Chavira, D. A., Shipon-Blum, E., Hitchcock, C., Roesch, S. C., & Stein, M. B. (2008). Refining the classification of children

References   191

with selective mutism: A latent profile analysis. Journal of Clinical Child and Adolescent Psychology, 37(4), 770–784. Cohan, S. L., Chavira, D. A., & Stein, M. B. (2006). Practitioner review: Psychosocial interventions for children with selective mutism: A critical evaluation of the literature from 1990–2005. Journal of Child Psychology and Psychiatry, 47(11), 1085–1097. Coplan, R. J., Schneider, B. H., Matheson, A., & Graham, A. (2010). “Play skills” for shy children: Development of a social skills facilitated play early intervention program for extremely inhibited preschoolers. Infant and Child Development: An International Journal of Research and Practice, 19(3), 223–237. Cotter, A., Todd, M., & Brestan-Knight, E. (2018). Parent–child interaction therapy for children with selective mutism (PCIT-SM). In Handbook of parent-child interaction therapy (pp. 113–128). New York, NY: Springer. Craske, M., Stein, M. B., & Hermann, R. (2016). Psychotherapy for generalized anxiety disorder in adults. Waltham, MA: UpToDate. Cunningham, C. E., McHolm, A. E., & Boyle, M. H. (2006). Social phobia, anxiety, oppositional behavior, social skills, and selfconcept in children with specific selective mutism, generalized selective mutism, and community controls. European Child and Adolescent Psychiatry, 15(5), 245–255. Cunningham, C. E., McHolm, A., Boyle, M. H., & Patel, S. (2004). Behavioral and emotional adjustment, family functioning, academic performance, and social relationships in children with selective mutism. Journal of Child Psychology and Psychiatry, 45(8), 1363–1372. Dowrick, P. W. (1999). A review of self-modeling and related interventions. Applied and Preventative Psychology, 8, 23–39. https:// doi.org/10.1016/S0962-1849(99)80009-2 Dummit III, E. S., Klein, R. G., Tancer, N. K., Asche, B., Martin, J., & Fairbanks, J. A. (1997). Systematic assessment of 50 children with selective mutism. Journal of the American Academy of Child and Adolescent Psychiatry, 36(5), 653–660. Edison, S. C., Evans, M. A., McHolm, A. E., Cunningham, C. E., Nowakowski, M. E., Boyle, M., & Schmidt, L. A. (2011). An investigation

192  Treating Selective Mutism as a Speech-Language Pathologist

of control among parents of selectively mute, anxious, and nonanxious children. Child Psychiatry and Human Development, 42(3), 270–290. Elizur, Y., & Perednik, R. (2003). Prevalence and description of selective mutism in immigrant and native families: A controlled study. Journal of the American Academy of Child and Adolescent Psychiatry, 42(12), 1451–1459. Eun, B. (2019). The zone of proximal development as an overarching concept: A framework for synthesizing Vygotsky’s theories. Educational Philosophy and Theory, 51(1), 18–30. Ford, M. A., Sladeczek, I. E., Carlson, J., & Kratochwill, T. R. (1998). Selective mutism: Phenomenological characteristics. School Psychology Quarterly, 13(3), 192. Friedman, R., & Karagan, N. (1973). Characteristics and management of elective mutism in children. Psychology in the Schools, 10(2), 249–252. Giddan, J. J., Ross, G. J., Sechler, L. L., & Becker, B. R. (1997). Selective mutism in elementary school: Multidisciplinary interventions. Language, Speech, and Hearing Services in Schools, 28(2), 127–133. Goberis, D. (1999). Social communication skills—The pragmatics checklist. https://successforkidswithhearingloss.com/wp-content/ uploads/2012/01/PRAGMATICS-CHECKLIST.pdf Harvard Health Publishing. (2018). Understanding the stress response. https://www.health.harvard.edu/staying-healthy/under​ standing-the-stress-response Hassan, G. A., Taha, G. R., Mahmoud, A., & Azzam, H. (2013). Selective mutism and social anxiety disorders: Are they two faces of the same coin?. Middle East Current Psychiatry, 20(3), 156–163. Individuals with Disabilities Education Act, 20 U.S.C. § 1400 (2004). Johnson, M., & Wintgens, A. (2017). The selective mutism resource manual. Oxfordshire, UK: Routledge. Kagan, J. (1994). Galen’s prophecy. Temperament in human nature. Boulder, CO: Westview Press. Kehle, T. J., Bray, M. A., Byer‐Alcorace, G. F., Theodore, L. A., & Kovac, L. M. (2012). Augmented self‐modeling as an intervention for selective mutism. Psychology in the Schools, 49(1), 93–103.

References   193

Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., Ormel, J., . . . Wang, P. S. (2009). The global burden of mental disorders: An update from the WHO World Mental Health (WMH) surveys. Epidemiologia e Psichiatria Sociale, 18(1), 23–33. Klein, E. R., Armstrong, S. L., & Shipon-Blum, E. (2013). Assessing spoken language competence in children with selective mutism: Using parents as test presenters. Communication Disorders Quarterly, 34(3), 184–195. Klein, E. R., & Ruiz, C. E. (2018). Evaluating communication and treating children with selective mutism. [Conference presentation, May 4–5]. Selective Mutism Training Institute, Washington DC. Kolvin, I., & Fundudis, T. (1981). Elective mute children: Psychological development and background factors. Journal of Child Psychology and Psychiatry, 22(3), 219–232. Kopp, S., & Gillberg, C. (1997). Selective mutism: A population-based study: A research note. Child Psychology and Psychiatry and Allied Disciplines, 38(2), 257–262. Kotrba, A. (2015). Selective mutism: An assessment and intervention guide for therapists, educators and parents. Eau Claire, WI: PESI Publishing and Media. Kristensen, H. (2000). Selective mutism and comorbidity with developmental disorder/delay, anxiety disorder, and elimination disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 39(2), 249–256. Kristensen, H., & Oerbeck, B. (2006). Is selective mutism associated with deficits in memory span and visual memory?: An exploratory case–control study. Depression and Anxiety, 23(2), 71–76. Kristensen, H., & Torgersen, S. (2001). MCMI-II personality traits and symptom traits in parents of children with selective mutism: A case-control study. Journal of Abnormal Psychology, 110(4), 648. Kristensen, H., & Torgersen, S. (2002). A case-control study of EAS child and parental temperaments in selectively mute children with and without a co-morbid communication disorder. Nordic Journal of Psychiatry, 56(5), 347–353. Krysanski, V. L. (2003) A brief review of selective mutism literature. The Journal of Psychology, 137(1), 29–40. https://doi.org/ 10.1080/00223980309600597

194  Treating Selective Mutism as a Speech-Language Pathologist

Kumpulainen, K., Rasanen, E., Raaska, H., & Somppi, V. (1998). Selective mutism among second-graders in elementary school. European Child and Adolescent Psychiatry, 7, 24–29. Kurtz, S. M. S. (2015). PCIT adapted for selective mutism [Video file]. New York, NY: PCIT International. https://mv-ezproxy-com​ .mutex.gmu.edu/courses/c150901dc Kussmaul, A. (1877). The disturbances of language: Attempt of a pathology of language. Leipzig, Germany: Bird. Levin‐Decanini, T., Connolly, S. D., Simpson, D., Suarez, L., & Jacob, S. (2013). Comparison of behavioral profiles for anxiety‐related comorbidities including ADHD and selective mutism in children. Depression and Anxiety, 30(9), 857–864. Manassis, K., Tannock, R., Garland, E. J., Minde, K., McInnes, A., & Clark, S. (2007). The sounds of silence: Language, cognition, and anxiety in selective mutism. Journal of the American Academy of Child and Adolescent Psychiatry, 46(9), 1187–1195. Mangolini, V. I., Andrade, L. H., Lotufo-Neto, F., & Wang, Y. P. (2019). Treatment of anxiety disorders in clinical practice: A critical overview of recent systematic evidence. Clinics, 74. McInnes, A., Fung, D., Manassis, K., Fiksenbaum, L., & Tannock, R. (2004). Narrative skills in children with selective mutism. American Journal of Speech-Language Pathology, 13(4), 304–315. McLeod, S. (2017). Psychosexual stages. https://www.simplypsychol​ ogy.org/psychosexual.html McLeod, S. (2019). Zone of proximal development. https://www.simply​ psychology.org/Zone-of-Proximal-Development.html Mele, C. M., & Kurtz, S. M. S. (2013). Parent-child interactions in behavioral treatment of selective mutism: A case study. Poster presented at the meeting of the Anxiety Disorders Association of America, La Jolla, CA. Meyers, S. (1984). Elective mutism in children: A family systems approach. The American Journal of Family Therapy, 12(4), 39–45. Muris, P., & Ollendick, T. H. (2015). Children who are anxious in silence: A review on selective mutism, the new anxiety disorder in DSM-5. Clinical Child and Family Psychology Review, 18(2), 151–169.

References   195

Nathan, P. E., & Gorman, J. M. (Eds.). (2002). A guide to treatments that work (2nd ed.). New York, NY: Oxford University Press. Nowakowski, M. E., Cunningham, C. E., McHolm, A. E., Evans, M. A., Edison, S., Pierre, J. S., . . . Schmidt, L. A. (2009). Language and academic abilities in children with selective mutism. Infant and Child Development: An International Journal of Research and Practice, 18(3), 271–290. Omdal, H. (2007). Can adults who have recovered from selective mutism in childhood and adolescence tell us anything about the nature of the condition and/or recovery from it? European Journal of Special Needs Education, 22(3), 237–253. Parent-Child Interaction Therapy International. (2018). Parent-child interaction therapy. http://www.pcit.org/ Peters, K. (n.d.). Hierarchy of social/pragmatic skills as related to the development of executive function. https://nyspta.org/wp-content/ uploads/2017/08/Conv17-305-Executive-Functions-HierarchyHandout-Peters.pdf?fbclid=IwAR2bh6o4lTC1rCTxLG3PpcBNvWLoMPjAqKdhJaGCE4qME4yM7QKjqhdNH0 Powell, S., & Dalley, M. (1995). When to intervene in selective mutism: The multimodal treatment of a case of persistent selective mutism. Psychology in the Schools, 32(2), 114–123. Remschmidt, H., Poller, M., Herpertz-Dahlmann, B., Hennighausen, K., & Gutenbrunner, C. (2001). A follow-up study of 45 patients with elective mutism. European Archives of Psychiatry and Clinical Neuroscience, 251(6), 284–296. Rice, T. K. (2008). Familial resemblance and heritability. Advances in Genetics, 60, 35–49. Ruiz, C. E., & Klein, E. R. (2013, Dec). Effects of anxiety on voice production: A retrospective case report of selective mutism. PSHA Journal, 19–26. Sharp, W. G., Sherman, C., & Gross, A. M. (2007). Selective mutism and anxiety: A review of the current conceptualization of the disorder. Journal of Anxiety Disorders, 21(4), 568–579. Shipon-Blum, E. (n.d.) Transitional stage of communication: The missing link. http://www.selectivemutism.org/wp-content/up​ loads/​2016/06/Missinglink.pdf

196  Treating Selective Mutism as a Speech-Language Pathologist

Steinhausen, H. C., & Juzi, C. (1996). Elective mutism: An analysis of 100 cases. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 606–614. Steinhausen, H. C., Wachter, M., Laimböck, K., & Metzke, C. W. (2006). A long‐term outcome study of selective mutism in childhood. Journal of Child Psychology and Psychiatry, 47(7), 751–756. Szumski, G., Smogorzewska, J., & Karwowski, M. (2016). Can play develop social skills? The effects of “Play Time/Social Time” programme implementation. International Journal of Developmental Disabilities, 62(1), 41–50. Tabors, P. O. (1997). One child, two languages: A guide for preschool educators of children learning English as a second language. Baltimore, MD: Brookes Publishing. Thomas, J. L. (2016). Decoding eligibility under the IDEA: Interpretations of adversely affect educational performance. Campbell Law Review, 38, 73–89. Toppelberg, C. O., Tabors, P., Coggins, A., Lum, K., & Burger, C. (2005). Differential diagnosis of selective mutism in bilingual children. Journal of the American Academy of Child and Adolescent Psychiatry, 44(6), 592–595. Tramer, M. (1934). Elktiver Mutism bie Kindern. Zeitschrift fur Kinderpsychiatrie, 1, 30–35. Trauma Recovery. (2013). Fight, flight, freeze responses. https:// trauma-recovery.ca/impact-effects-of-trauma/fight-flight-freezeresponses/ United States Department of Health, Education, and Welfare. (1978). Section 504 of the Rehabilitation Act of 1973: Fact sheet: Handicapped persons rights under Federal law. Washington, DC: Department of Health, Education, and Welfare, Office of the Secretary, Office for Civil Rights. Viana, A. G., Beidel, D. C., & Rabian, B. (2009). Selective mutism: A review and integration of the last 15 years. Clinical Psychology Review, 29(1), 57–67. Whiteford, H. A., Ferrari, A. J., Degenhardt, L., Feigin, V., & Vos, T. (2015). The global burden of mental, neurological and substance

References   197

use disorders: An analysis from the Global Burden of Disease Study 2010. PloS One, 10(2), e0116820. Wittchen, H. U., Jacobi, F., Rehm, J., Gustavsson, A., Svensson, M., Jönsson, B., . . . Fratiglioni, L. (2011). The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology, 21(9), 655–679.

Index Note: Page numbers in bold reference non-text material.

A Academic skills, 46–47 Accommodating. See Rescuing. Accommodations (school), 59–67 All students, 66–67 Minimally verbal students, 60–62 Moderately verbal students, 63–64 Verbal students maintaining, 66 Verbal students with prompting, 64–65 Adults with SM, 37–38 Amygdala, 24, 26 Anxiety disorders, 3–4 Social anxiety disorder, 12–13 Treatment, 4 Anxiety, 3 Anxious response, 29 Psychoeducation, 130–133 Apps, 187 Assessment Alternate response methods, 51, 53 Considerations, 47–50 Procedure, 50–53, 52–53 Autonomic nervous system, 1 Avoidance loop, 29

B Bilingualism, 19–20 Books For children, 185–186

For treatment teams, 186–187 Brave talking Chart, 171–173 Classroom chart, 174 Goals, 167 Practice assignment sheet, 162–163 Questions, 165–166 Bravery ladder, 114, 168, 169 Bravery loop, 29 Building rapport, 51

C Calming process, 31 Case history, 53–54, 137–151 Child Mind Institute, 185 Child-directed interaction (CDI), 78, 80–92, 119, 196 Behavioral descriptions, 83 Comparison with VDI, 96 Direct commands, 84, 88–89 Enthusiasm, 84 Labeled praise, 81 PRIDE skills, 80–81 Reflection, 81–82 Imitation, 82–83 Skills practice, 89–92 Client perspectives, 36–38 Cognitive-behavioral therapy (CBT), 71 199

200  Treating Selective Mutism as a Speech-Language Pathologist Communication skills. See Speech and language skills. Comorbidities, 33 Conversational rules, xvii

D Decisions Difficulty making, 98 Defiance, 11, 38 Differential diagnosis, 54–56

E Etiological factors, 10–20 Behavioral, 12 Social phobia, 12–13 Family systems, 13–14 Multifactorial, 14–19, 15 Genetics, 14 Neurodevelopmental, 18–19 Temperament, 15–16 Environmental, 16–18 Psychodynamic, 11–12 Understanding of, 21 Exposure therapy, 4, 31, 38, 47, 132–133

F Fear, 1–3 Fight, flight, or freeze response, 2–3 Neurobiological response, 1

Relevant, 116–117 Specific, 115 Time-based, 117

H HPA axis, 3

I Immigration status, 19–20 Individualized Education Program (IEP), 40, 59, 67 Service delivery and frequency, 67–69 Individual vs. small group, 68 Pull-out vs. push-in, 68–69 Individuals with Disabilities Education Act (IDEA), 56–59

L Larynx, 26 Long-term impacts, 34–35

N Negative reinforcement cycle, 26–29, 28

O Oral motor activities, 99–101

G

P

Goals, 113–119 Examples, 117–119 SMART goals, 115–117 Attainable, 116 Measurable, 115–116

Parasympathetic nervous system, 2, 3, 29, 31 Parent-Child Interaction Therapy (PCIT-SM), 71, 80–98 Parents, 51

Index   201

Peers Classmates and friends rating form, 156 Find-a-friend bingo, 170 Letter to peers, 152–153 Peer-to-peer interactions, 125–128 Perspective-taking, xvi Playdate log, 158–160 Positive reinforcement, 31, 71, 74–75 Pragmatic functions, xvi Pragmatics. See Social language. Psychoeducation, 130–133

Q Questions Asking, 97 Forced choice, 95 Open-ended, 94–95

R Rating scales, 132 Feelings chart, 164 Rescuing, 29–30, 30 Riding it out, 30–32, 32 Ritual Sound Approach (RSA), 71, 98–103 Airflow, 100–101 Voiceless sounds, 101 Sound combinations, 101 Chart, 102–103 Materials, 99 Oral motor movement, 99–100 Sample chart, 161 Single words, 101–102

S Scaffolding, 71, 75–78 Scavenger hunts, 123–124, 181–184 School Challenge cards, 180

School personnel, 23 Teachers and adults rating form, 157 Teacher tip sheet, 154 Scope of practice, 43–44, 130, 133 Section 504 plan, 59 Selective Mutism University, 185 Selective mutism Definition, 7 Diagnostic criteria, 10 Prevalence, 23 Gender differences, 23 Onset, 23 Symptoms, 24–25, 25 Response to treatment, 71 History, 9–10 Shyness, 9 Social language Categories, xvi Development of skills, xv-xxiii, xix-xxiii Speech and language disorders, 35–36 Speech and language skills, 44–46 Speech therapy session, 128–130 Speech-language pathologist, 43 Stages of communication, 72–73 Noncommunicative, 72 Nonverbal communication, 72 Prompted verbal communication, 72–73 Spontaneous verbal communication, 73 Stimulus fading, 71, 78–79 Surface electromyography (sEMG), 26 Surveys Birthdays, 176 Seasons, 177 Ice cream, 179 Pets, 175 Siblings, 178

202  Treating Selective Mutism as a Speech-Language Pathologist Selective Mutism Association, 185 Sympathetic nervous system, 2, 24, 29

Audience, 103–104 Environment, 105 Language complexity, 105–110, 106 Carrier phrase responses, 108 Higher-level goals, 109–110 Multiple sentence responses, 108 Nonverbal responses, 106–107 Nonword sounds, 107 Single sentence responses, 108 Single word responses, 107–108 Spontaneous comments, 109–110 Spontaneous questions, 108–109 Stages, 106

T Talking map, 113, 155 Team contributions, 39–43 Families, 42–43 Physician/pediatrician, 39–40 Psychiatrist, 40 Psychologist, 40 School counselor, 41 School psychologist, 40–41 School staff, 42 Social worker, 41 Speech-language pathologist, 43 Teachers, 41–42 Therapy activities, 119–123 Carrier phrase responses, 122 Descriptions, 122 Nonverbal, 120–121 Nonword sounds, 121 Open-ended CDI activities, 120 Single word responses, 121–122 Spontaneous questions, 123 Spontaneous comments, 123 Structured questions, 123 Treatment factors, 103–110 Activity, 104–105

V Verbal-directed interaction (VDI), 78 Comparison with CDI, 96 Question sequence, 93–95, 93 Rules, 92–93, 129 Video self-modeling (VSM), 124–125

Z Zone of Proximal Development (ZPD), 75–78, 76