Easter Seals Outreach Program Selective Mutism: Finding My Voice Lory Greer, MS Licensed Psychological Examiner Shelly Wier, MS, CCC-SLP Speech-Language Pathologist Information about Outreach. Who we are – consultants. What we do. Easter Seals Outreach Program

What is Selective Mutism? Childhood anxiety disorder Inability to speak in school and similar social settings Age appropriate speech at home or with parents Shelly: Selective Mutism is a childhood anxiety disorder. The child is unable to speak in school and similar social settings, but has age appropriate speech at home or with parents. SM has devastating effects on social development, academic achievement and self esteem. Research indicates that when left untreated, SM can lead to worsening anxiety, depression, dropping out of school, underachievement in the work place, self medication with drugs or alcohol and suicidal thoughts.

DSM-IV-TR Diagnostic Criteria Consistent failure to speak in specific social situations Interferes with educational achievement or with social communication Duration is at least 1 month Not due to lack of knowledge of, or comfort with, the spoken language required in social situation Not better accounted for by other disorders Lory: Diagnosis -DSM IV-TR: Consistent failure to speak in specific social situations (in which there is an expectation for speaking …school) despite speaking in other situations. The disturbance interferes with educational or occupational achievement or with social communication The duration of the disturbance is at least 1 month The failure to speak is not due to lack of knowledge of, or comfort with, the spoken language required in social situation The disturbance is not better accounted for by a Communication Disorder (stuttering) and does not occur during the course of a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder.

Selective Mutism Is Not . . . Just a refusal to speak Defiance or stubbornness Just shyness Outgrown over time Shelly: SM is not just refusal to speak. It is not defiance or stubbornness. SM is not just shyness. Children with SM do not “outgrow it” or get better with time. Historically, selective mutism has been thought of as rare and untreatable. It was associated with trauma or abuse. Doctors avoided the diagnoses, because of the poor prognosis. However, recent research indicates that when SM is treated as an anxiety disorder, most children can overcome it and go on to lead normal lives with normal school and social performance. Early intervention is the key. When a child is unable to interact with peers, social skills fail to develop and the child is further paralyzed by fear of inappropriateness. Helping the child to overcome the anxiety at an early age, allows development of age appropriate social skills. In fact, treatment results are inversely proportional to age of intervention – meaning, the younger the student is when you begin intervention, the greater the results OR as they get older, you can expect less progress.

Selective Mutism vs. Shyness Lory: Typically when we think of a shy child, we picture someone who is timid and quiet. We picture a child who may initially have difficulty talking to peers or speaking up in class. But with encouragement, this child will warm up to most situations. A shy child may need peers to make the first move, but once they are invited to play, shy children will blossom. A shy child may be reluctant to volunteer to answer in class, but will find their voice when they need to use the bathroom or to ask for help. Sometimes, shyness steps over a line and becomes Social Anxiety Disorder. About 90% of children diagnosed with SM meet the criteria for Social phobia, a disorder that is characterized by persistent fear of social situations. While an adult with this disorder can often choose to avoid the situation that causes the anxiety (speaking in public, going to parties, even going outside the home) the child has no choice about attending school. When placed in this anxiety producing situation, the child becomes literally frozen with fear and cannot talk. They may also react with body language such as: Looking down or away Playing with hair or picking at scratches or moles Hiding in a corner Sucking thumb or fingers Staring with a blank look as thought they are ignoring you

Social Anxiety Disorder Discomfort in the spotlight Avoidance or refusal to initiate conversations, perform in front of others, invite friends to get together Avoiding eye contact Speaking very softly or mumbling Minimal interaction and conversation with peers Appearing isolated or on the fringes of the group Sitting alone in the library or cafeteria, or hanging back from a group in team meetings Overly concerned with negative evaluation, humiliation, or embarrassment Difficulty with public speaking, reading aloud, or being called on in class Lory: About 90% of children diagnosed with SM meet the criteria for Social phobia or Social Anxiety Disorder, which is characterized by persistent fear of social situations. The most common fears are of performing in front of others, speaking in call and inviting others to get together. For children, this disorder peaks in adolescence. While an adult with this disorder can often choose to avoid the situation that causes the anxiety (speaking in public, going to parties, even going outside the home) the child has no choice about attending school. When faced with such anxiety producing situations, the child may sweat, develop a stomach ache, feel as those their heart is racing, become dizzy, cry or throw a tantrum, or they may just freeze.

Selective Mutism When placed in this anxiety producing situation, the child becomes literally frozen with fear and cannot talk. They may also react with body language such as: Looking down or away Playing with hair or picking at scratches or moles Take on a protective body stance Hiding in a corner Sucking thumb or fingers Staring with a blank look as though they are ignoring you

Anxiety Disorders in Children 18 % 16 14 12 10 8 6 4 2 7 % School Avoidance: 2-5 % 4 % 1 % Anxiety Prevalence In Adults Social Anxiety Disorder Separation Anxiety Selective Mutism School Avoidance

Prevalence of Selective Mutism 27 24 21 18 15 12 9 6 3 Selective Mutism is thought to be a sub category of social anxiety disorder. Prevelance is less than 1 percent among elementary school children. Because it is so rare, most people have never even heard of it and don’t know how to deal with it when they do see it. Any Anxiety Disorder Social Anxiety Disorder Selective Mutism

Anxiety Timeline Reactive Infant Peripheral in Peer Play Onset of Panic Disorder Inhibited Toddler Social Fears/ Social Phobia Studies by Dr. Jerome Kegan have found that about 5% of children feel a high amount of anxiety when placed in new situations. These children have a tendency to withdraw and avoid that often begins in infancy. They are at risk for developing anxiety disorders because they do not learn to cope with/ fears. SM children are thought to be a subset of inhibited children who have severe anxiety about social situations. .3 2 5 8 13 14-18 20 30 Age (years)

Lory: Much of the SM child’s behavior can be explained by this hypothesis of severely inhibited temperament (personality style, way of dealing with others and the world around us) A child with severely inhibited temperament are thought to have a decrease in threshold of excitability in the area of the brain called the amygdala. The amygdala is an almond shaped structure that is involved in producing and responding to nonverbal signs of anger, avoidance, defensiveness and fear. The amygdala produces physical responses such as leaning away, shoulder, throat and lip muscles tense, and protective posture is assumed, bowing, crouching. The amygdala also triggers chemical responses that activate the release of adreniline which prepares the body to deal with a threatening situation. When confronted with a fearful situation, the amygdala receives signals of potential danger and sets off a series of reactions for protection.

Fight, Flight, or Freeze? [click x1] Fight – Flight – Freeze

Other Associated Characteristics Sensitivity to noise and crowds Difficulty separating from parents Difficulty sleeping alone Introspective and sensitive Creative and artistic Perceptive and inquisitive Moodiness, rigidness, procrastination, tantrums, bossiness Bedwetting, enuresis, encopresis, fear of public restrooms Shelly: Other associated behaviors and personality traits: Sensitivity to noise and crowds Difficulty separating from parents Difficulty sleeping alone Introspective and sensitive Creative and artistic Perceptive and inquisitive Moodiness, rigidness, procrastination, tantrums, bossiness, extremely talkative at home. Bedwetting, enuresis, encopresis, fear of public restrooms Not every child with SM will demonstrate these characteristics.

Do’s and Don’ts DON’T wait expectantly for the child to speak DO accept any (or no) response as OK and move on DON’T pressure, punish, or bribe DON’T overly praise or otherwise draw attention to communication attempts DO respond positively, as you would to any child’s communication Shelly: In your functional daily interactions, don’t ever make the child feel as though you are waiting on them to speak. Later, there will a gradually increased expectation within the treatment process, after anxiety is lowered. Never withhold materials or interactions as a consequence of not speaking. Pressuring, punishing, coercing, or bribing the SM child only worsens the situation and causes further anxiety and regression. When the child does speak, do not call attention to it with praise or rewards. If the child speaks first to a classmate (which is often the case) do not mention this to the child or to anyone else in front of the child. When the child speaks in the presence of an adult, resist the urge to praise, clap hands or other wise call attention to the effort. Instead, respond, if appropriate, as you would to any other child in your classroom. Because most cases of SM are caused by severe anxiety, special education and remedial classrooms are often inappropriate placement. An IEP can be helpful to help lesson anxiety but encourage mainstreaming.

How Can You Help? Accept the child as they are Visit the child at home before the school year begins Allow the child to become familiar with his classroom prior to the first day Every day, meet the child in the room before the other students arrive Lory: Some things that may be helpful: Accept the child as they are. Sending a message that their mutism is “okay” helps the child relax. Do not attempt to force speech. New teachers can visit the child at home, before school starts. Let the child take the lead during the visit. Meet the child at school, before the school year begins. Allow the child to explore the room After school begins, meet the child in the room before the other students arrive. Engage the parent in conversation and allow the child to casually observe. Ease the child into the conversation, by including them, but not requiring a verbal response.

How Can You Help? Use of hand signals Use of classroom objects or signs 3x5 cards with pre-printed messages Word rings with pre-printed messages Wipe off board for writing messages Shelly

How Can You Help? Use visual aids to allow the child a hands on method to show their work Allow adequate time for responses (verbal or nonverbal) Emphasize creativity, imagination and artistic expression in all subjects Form small groups for discussion Form a small group to include children that the child with selective mutism is most comfortable with

How Can You Help? Seat child next to children they are comfortable with Use computers to present materials visually When partners are needed, assign a partner to the selectively mute child Set gradual communication goals, with the help of a professional

How Can You Help? Identify a safe place Develop relaxation techniques Modify stressful social situations Educate all staff members Have a safe place where the child can go when they are feeling overwhelmed. Have guidelines for when and how the safe place can be used and who they need to notify before going there. Speak to the child alone instead of in front of groups, develop small lunch group, avoid singling the child out. Make sure that everyone who comes into contact with this child is aware of the child’s needs and of their method of communication.

Treatment Options Medication Cognitive/Behavioral Therapy Speech/Language Therapy Lory: A review of the case studies on selective mutism indicates that a combined approach to treatment is most effective. Medication Medications have been shown useful in helping reduce social anxiety, because anxiety is thought to be closely related to an imbalance of chemical messengers in the brain (neurotransmitters). [Press 17+enter; Return press 15+enter] Many experts who work with SM kids report success in using some medications, mainly serotonin reuptake inhibitors such as Luvox and Zoloft. Side effects are minimal if the medications is started at a low dose and gradually increased. Medications appears to have the best success rate when used in conjunction with therapeutic intervention and should always be used under supervision of a medical doctor. Cognitive/Behavioral Therapy Cognitive therapists can help children change thoughts and actions. For children with SM, this may consist of helping the child confront false or exaggerated fears such as, “if I ask to use the bathroom, the teacher may get mad at me” or “everyone will laugh at me if I talk out loud”. CB therapists can help determine where or to whom the child will speak and then expand that to new situations, gradually. Relaxation techniques can also be helpful. Relaxation Tape Here [press 18+enter] [Press 15+enter] Self Modeling - This is a method that involves video taping the teacher asking children, including the SM child, questions and their responses. The SM child is video taped not responding. Then, later, when the room is empty, a parent asks the SM child the same questions and the child’s responses are taped. The tape is then edited so that the child appears to be answering the teacher. This tape is played for the child and the child is asked to stop the tape everytime he sees himself answering the teacher. At these times he is allowed to choose a small reward. Information on this technique can be found in the article titled Augmented Self Modeling as a Treatment for Children with Selective Mutism (1998) by Kehle, Madaus, Bratta, & Bray in Journal of School Psychology, 36:3, pp. 247-260. [Both Lory and Shelly: Show videotape examples and discuss process of filming.] Desensitization/Fading : Gradually expose the child to the feared environment. Have the parent come and play a familiar board game with the child in the classroom, alone. Gradually add new people to the environment such as another child in the room, the child playing, then more children and the teacher, one at a time. [Videotape]

Neurotransmitter Why medication is sometimes helpful.

Additional Information www.selectivemutism.org www.aboutourkids.org (Search: selective mutism-profiles in silence) www.adaa.org Anxiety Disorders Association Easing School Jitters for the Selectively Mute Child and The Ideal Classroom Setting for theSelectively Mute Child both by Elisa Shipon-Blum Helping your Child with Selective Mutism by McHolm, Cunningham, Vanier. Augmented Self Modeling as a Treatment for Children with Selective Mutism (1998) by Kehle, Madaus, Bratta, & Bray in Journal of School Psychology, 36:3, pp. 247-260. Selective Mutism in Elementary School: Multidisciplinary Interventions (1997) by Giddan, Ross, Sechler, Becker, & Bonetta in Language, Speech, and Hearing Services in the School, 28:2, pp. 127-133.

Easter Seals Outreach Program Contact Us Easter Seals Outreach Program 3920 Woodland Heights Road Little Rock, AR 72212 Lory Greer Shelly Wier (501) 227-3687 (501) 221-8415 lgreer@ar.easterseals.com swier@ar.easterseals.com