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Gail J. Richard, Ph.D., CCCGail J. Richard, Ph.D., CCCGail J. Richard, Ph.D., CCCGail J. Richard, Ph.D., CCC----SLPSLPSLPSLP

Eastern Illinois UniversityEastern Illinois UniversityEastern Illinois UniversityEastern Illinois University

gjrichard@eiu.edugjrichard@eiu.edugjrichard@eiu.edugjrichard@eiu.edu

� Financial◦ Receive royalties from published materials with PRO ED (LinguiSystems), Dynamic Resources. MedBridge

� The Source for Selective Mutism

◦ Honorarium for Presentation

� Nonfinancial◦ Serve on ASHA Board of Directors as Immediate Past President

� “Aphasia Voluntaria” “Aphasia Voluntaria” “Aphasia Voluntaria” “Aphasia Voluntaria” ---- Kussmaul, Kussmaul, Kussmaul, Kussmaul, 1877187718771877

� “Elective Mutism” “Elective Mutism” “Elective Mutism” “Elective Mutism” –––– Mortiz Tramer, Mortiz Tramer, Mortiz Tramer, Mortiz Tramer, 1934193419341934

� “Selective Mutism”“Selective Mutism”“Selective Mutism”“Selective Mutism”---- DSMDSMDSMDSM----IV, 1994IV, 1994IV, 1994IV, 1994

Communication Disorder - persistent failure to speak in specific social situations, despite speaking fluently in familiar situations (Sharkey & McNicholas, 2008)

� 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.

� The disturbance interferes with educational or occupational achievement or with social communication.

� The duration of the disturbance is at least 1 month (not limited to the first month of school).

� The failure to speak is not attributable to a lack of knowledge of, or comfort with , the spoken language required in the social situation.

� 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.

� Past classification as psychotic or psychological disturbance

� Most psychiatric professionals characterize as social anxiety disorder (Black & Uhde, 1992; Kristenson, 2000; Standart & LeCouteur, 2003)

� Trend to classify as communication anxiety disorder instead of social phobia (Remschmidt et al, 2001;Yeganeh et al., 2006; Omdal & Galloway, 2008; Nowakowski et al., 2009)

� SLP becomes key professional in intervention

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ORGANIC FUNCTIONAL

Transient Persistent

Symbiotic

Reactive

Passive Aggressive

Speech Phobic

� Evidence suggests combination of genetic and environmental Evidence suggests combination of genetic and environmental Evidence suggests combination of genetic and environmental Evidence suggests combination of genetic and environmental factors contribute to onset of SMfactors contribute to onset of SMfactors contribute to onset of SMfactors contribute to onset of SM

� Some evidence of genetic linkSome evidence of genetic linkSome evidence of genetic linkSome evidence of genetic link

◦ Family history of social phobia, avoidant personality disorder (Black & Uhde, 1995;Chavira et al., 2007)

� Genetic predisposition to anxietyGenetic predisposition to anxietyGenetic predisposition to anxietyGenetic predisposition to anxiety

◦ One parent usually had extreme shyness or anxiety

� TheoryTheoryTheoryTheory---- amygdala has decreased threshold of excitability amygdala has decreased threshold of excitability amygdala has decreased threshold of excitability amygdala has decreased threshold of excitability (Fernald & Eastman, 2009)

◦ Misinterpret social signals and overreact

◦ Perceive mundane as threatening

◦ Primitive protective mechanism when feel threatened

� SpeechSpeechSpeechSpeech----Language Delay/DisorderLanguage Delay/DisorderLanguage Delay/DisorderLanguage Delay/Disorder

� Oppositional DefianceOppositional DefianceOppositional DefianceOppositional Defiance

� No evidence of abuse, neglect, trauma as causeNo evidence of abuse, neglect, trauma as causeNo evidence of abuse, neglect, trauma as causeNo evidence of abuse, neglect, trauma as cause

� Prevalence FiguresPrevalence FiguresPrevalence FiguresPrevalence Figures◦ 7 per 1,000 or 1 in 143 in U.S.; occurs in 2% of early elementary age school children (Bergman, et al.,2002)

� Gender ratioGender ratioGender ratioGender ratio: 1.9 female/ 1 male

� Prevalence 3x higher in immigrant childrenPrevalence 3x higher in immigrant childrenPrevalence 3x higher in immigrant childrenPrevalence 3x higher in immigrant children

� Onset ageOnset ageOnset ageOnset age: 3-5 years

� Referral age/DiagnosisReferral age/DiagnosisReferral age/DiagnosisReferral age/Diagnosis: 6-7 years

� Occurs across ethnic groupsOccurs across ethnic groupsOccurs across ethnic groupsOccurs across ethnic groups

� Responsive to early interventionResponsive to early interventionResponsive to early interventionResponsive to early intervention

� Normal to high IQNormal to high IQNormal to high IQNormal to high IQ

� Social Anxiety/Withdrawal/IsolationSocial Anxiety/Withdrawal/IsolationSocial Anxiety/Withdrawal/IsolationSocial Anxiety/Withdrawal/Isolation◦ Separation AnxietySeparation AnxietySeparation AnxietySeparation Anxiety

◦ Excessive ShynessExcessive ShynessExcessive ShynessExcessive Shyness

◦ Withdrawal in PublicWithdrawal in PublicWithdrawal in PublicWithdrawal in Public

◦ Lack of eye contact; avoid or avertedLack of eye contact; avoid or avertedLack of eye contact; avoid or avertedLack of eye contact; avoid or averted

◦ Minimal Facial Expression; flat affectMinimal Facial Expression; flat affectMinimal Facial Expression; flat affectMinimal Facial Expression; flat affect

� Oppositional DefianceOppositional DefianceOppositional DefianceOppositional Defiance

� Obsessive/PerfectionisticObsessive/PerfectionisticObsessive/PerfectionisticObsessive/Perfectionistic

� Speech Language DeficitsSpeech Language DeficitsSpeech Language DeficitsSpeech Language Deficits

� Poor Coordination/Motor/Body RigidityPoor Coordination/Motor/Body RigidityPoor Coordination/Motor/Body RigidityPoor Coordination/Motor/Body Rigidity

� Emotional/sensory sensitivityEmotional/sensory sensitivityEmotional/sensory sensitivityEmotional/sensory sensitivity

� Prognosis improves significantly if intervention starts as soon as identified in young child

� Minimize chances of escalating into other issues◦ Social skills (Kolvin & Goodyer, 1982)

◦ Educational progress (O’Reilly et al. , 2008)

◦ Emotional health (Steinhausen & Juzi, 1996)

� Prevent child from experiencing norm of not talking in school/public situations

� Psychological/EmotionalPsychological/EmotionalPsychological/EmotionalPsychological/Emotional◦ Social anxiety/phobia

◦ Oppositional Defiant

◦ Obsessive Compulsive

◦ Enuresis, Encopresis

◦ Trauma/Abuse

� SpeechSpeechSpeechSpeech----LanguageLanguageLanguageLanguage◦ Apraxia

◦ Articulation/Phonology

◦ Pragmatic Disorder

◦ Language Processing

◦ Syntax

◦ Bilingual/ 2nd Language

Global DevelopmentalGlobal DevelopmentalGlobal DevelopmentalGlobal Developmental•Autism Spectrum Disorder•Attention Deficit•Sensory Deficit•Learning Disability•Mental Impairment

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� Case History / Parent Interview◦ Confused; Jekyll-Hyde personality

◦ Verbal at home

◦ Manipulative/controlling versus shy/inhibited

◦ Video-tape from home setting when child in comfortable setting often enlightening

� Information ◦ Developmental milestones

◦ Family history

◦ Medical history

◦ Child’s behavioral profile

◦ General development

◦ Home environment

� Child Observation (home and school)◦ Nonverbal interaction

◦ Verbal Interaction

◦ Physical Interaction

� Teacher Interview

� Child Interview◦ Nonverbal

◦ High interest/motivating activities

◦ No risk of error

Nonverbal

Behaviors

+

-

With Whom Activity Response

+ Teacher Calendar Nodded her head to show agreement

- Teacher Calendar Wouldn’t point to day/date

- Classroom Aide Snack Didn’t indicate yes/ or no

- Peers Snack Didn’t eat or look at other children

+ Teacher Recess Put on her coat when directed

- Teacher, Aide, Peers Recess Stood at edge of playground and did not

play or interact; watched others playing

- Teacher, Aide, Peers Bathroom Would not go into the restroom or use it

with the class

Verbal

Behaviors

+

-

With Whom Activity Response

+ Teacher Music Appeared to be humming with class

- Teacher Music Did not open mouth or participate

verbally in music activities

Observation Notes

Name: Angelina Smith Date: 9-9-11_____

Place: Jefferson Elementary School – Preschool Classroom Time: _9:00-10:30 am

Additional Comments/Physical Observations:

Seemed to understand and be following teacher directions and instruction. No noticeable physical

anxiety or tension other than not responding to requests or participating.

� Receptive Comprehension – PPVT� Nonverbal /receptive evaluation

� Highly correlated with IQ

� Receptive Concept Development – Bracken� Nonverbal / receptive evaluation

� School readiness categories

� Correlates with IQ

� Articulation /Phonology

� Expressive Language

� General Language Development – CASL

� Social / Pragmatics - SSRS

� Selective Mutism Questionnaire◦ Situations for parent and teachers to rate

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� Range of reported figures, from 40% -68% (Kristensen, 2000; Manassis et al. 2007;

� Evaluate Communication Areas◦ Receptive Comprehension◦ Receptive Language Processing◦ Expressive Language� Articulation / Phonology� Verbal Organization◦ Pragmatics◦ Communicative Confidence

� Communicative Hypersensitivity/Anxiety

� Three steps to differential diagnosis◦ 1. Differentiate primary disorder category

◦ 2. Differentiate specific disorder within primary disorder category

◦ 3. Differentiate other areas affected secondarily

� Difficult within Selective Mutism due to comorbidity

� Need to identify primary versus secondary disorder

Social Phobia

Anxiety

Oppositional Defiant

Obsessive Compulsive

Trauma/Abuse

Enuresis, Encopresis

Apraxia

Articulation/Phonology

Pragmatic Disorder

Language Processing

Syntax Disorder

Bilingual/2nd Language

Autism Spectrum

Attention Deficit

Sensory Deficit

Learning Disability

Mental Impairment

Psychological/

Emotional

Speech-

LanguageGlobal

Developmental

Selective Mutism

Social Phobia

Anxiety

Oppositional Defiant

Obsessive Compulsive

Trauma/Abuse

Enuresis, Encopresis

Apraxia

Articulation/Phonology

Pragmatic Disorder

Language Processing

Syntax Disorder

Bilingual/2nd Language

Autism Spectrum

Attention Deficit

Sensory Deficit

Learning Disability

Mental Impairment

Psychological/

Emotional

Speech-

LanguageGlobal

Developmental

Selective Mutism

� Variety of hypothesized etiologies = numerous opinions on intervention approach

� Case studies difficult for careful methodological objectivity necessary for meeting empirical evidence criteria

� Present evidence-base for SM not robust

� Long term consequences of not intervening on SM significant

� Negative consequences on social skills, educational progress, and emotional health

� Multidisciplinary Team Approach

� Combination of behavioral, speech, and family therapy

� Need collaborative approach◦ School

◦ Home /family

� Requires consistent reinforcement with natural consequences

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� Behavioral Therapy –Desensitization

�Cognitive Behavioral Therapy

� Psychoanalytical

� Speech Therapy

�Medication

� Play therapy

� Parent Education

� Shift in recent years away from psychodynamic factors to treatment more cognitive-behavioral in nature

� Evidence doesn’t support significant underlying neurotic disorder

� Approach based on unresolved emotional issues

� Target presume psychiatric cause of SM, not SM symptoms

� Explore internal conflict and resolve those issues; SM will go away

� Type of counseling approach

� Cognitive aspect is to explore the child’s thoughts

� Talk about thoughts, emotion, options in a situation

� Behavior aspect is to change the child’s actions;adjustment or change in the thought process leads to different behavioral reaction in a situation

� Social Stories (Carol Gray)

� Picture Exchange Communication (Bondy & Frost)

� Floortime (Greenspan)

� Visual Supports

� Pragmatic Therapy

� Anxiety issues tied to serotonin levels –chemical neurotransmitter in brain

� Sometimes necessary to consider anxiety-reducing medication – usually SSRI –serotonin reuptake inhibitor (e.g., Prozac, Zoloft, Paxil)

� Carefully monitor positive and negative effects of medicine

� Goal is short term – not more than 2 months

� Combine with other treatment intervention

� Not routine or endorsed at present for treatment of SM by FDA; controversial

� Child and therapist engage in play activities

� Therapist observes child carefully and interprets subconscious communication and intentions in child’s actions

� Psychoanalytical approach to treatment

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� Parents often confused or in denial; different than child they experience at home

� Explore dynamics /contributing behaviors or situations in environment at home

◦ Don’t want parent reinforcing SM

◦ Don’t want unmonitored pressure applied to child

◦ Explain significance of disorder and parent role in addressing/resolving it

� Provide support, encouragement, education for parents to assist in overcoming SM

� Relatively new treatment option for SM

� Research on developmental disorders (Greenspan & Wieder, 1998) that includes problems in sensory modulation

� New research adds aspect of significant motor and sensory deficits (Kristensen,2002)

� Children over/under respond to sensory stimuli resulting in aberrant behavior

� Develop accurate sensory perceptions to suppress “fight or flight” impulsive reactions

� Voluntary Level of Intervention◦ Teacher Collaboration Team

◦ General modifications, accommodations strategies

� Modifications Under Section 504◦ Formalizes list of accommodations to implement

� Full Case Study – IEP Services under IDEA◦ Eligibility Categories

� Preschool – developmentally delayed

� Speech-Language Impaired

� Emotional Disability

� Learning Disability

� Other Health impaired

� Expose to communication situations with controlled, gradual increase in verbal expectations

� Work on decreasing emotional anxiety response to situation; increase confidence in speaking

� Professional carefully monitors situation to avoid extreme anxiety/panic

� Introduce natural consequences

� Switch environmental power and control from not speaking/interacting to communicating

� Primary goal is reduction in anxiety

� Secondary is to build confidence in assuming communicative responsibility

� Work through stages from nonverbal to verbal with consistent reinforcement

� Carefully monitor communication expectations

� Use creative, fun therapy activities that promote engagement and minimize stress

� Gradually increase communication demands

� Carry-over intervention in various sites

�Desensitize to Communicative Pressure

� Transfer Communicative Responsibility

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� Minimize academic demand

� Use immediate positive reinforcement; no negative reinforcement for non-compliance

� Allow child to choose whether to participate

� Carefully monitor level of communication demand

� Expect carryover and stabilization of communication

� Repeat activities in subsequent therapy sessions

� Achieve comfort in nonverbal interaction (outside of home setting)

� Introduce variety of activities with varying levels and types of nonverbal participation

� Repeat activities so routine becomes familiar and less threatening

� Participation should become less hesitant; progress to natural pace with no signs of anxiety, discomfort, or hesitation

� Non-academic tasks

� Highly motivating / interesting / enjoyable

� Natural or positive reinforcement for participating

� Non-participation is a choice; don’t pressure

� Don’t over-react to participation or non-participation

� Example tasks◦ Sorting by color, design, category

◦ Paint with water / coloring

◦ Puzzles

◦ Simon Says

◦ Card Games (War) ; Board Games (Candy Land, Bingo)

◦ Motor activities – nerf ball, bowling, bean bags, exercises, pantomime

� Do carryover at each phase

� Invite peer to play same activities

� Demonstrate how to word questions for teacher and parents to expect nonverbal choices

� Expect motor participation in gym, recess, library

� Give child school chores/tasks to complete in school setting to generalize nonverbal comfort

� Goal – build tolerance/comfort for using oral cavity in public setting

� Start with oral postures and progress to whisper

� Can make ghost or transfer object /puppets

� Look at transfer object, not at child’s mouth

� Use same item – use ghost whisper when your turn; normal voice for directions/interaction

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� Activities with one word simple response◦ Identifying numbers, letters, colors, shapes

◦ Building with legos – request item

◦ Object identification

◦ Wheel-of-Fortune / Hangman

◦ Yes/No Questions

◦ I Spy

◦ Hide and Seek

◦ Drawing Guessing Games

� Carryover activities – Peer, Teacher, Parent

� Increase level of communicative responsibility

� Car analogy – need motor for car to run

� Need motor/voice to ‘run’ everyday effectively◦ Let teacher know how smart you are

◦ Talk with friends

◦ Ask for help in emergency

◦ Tell parents what you want/need

� Carefully monitor gradual increase in length and type of response

� Vowel prolongations

� Environmental / animal sounds

� Activities with single word or carrier phrase

� True/False or Yes/No Questions

� Guessing Game /Identifying items from cues

� Carrier Phrase Activities

� Songs / Rhymes

� Wheel of Fortune

� Board & Card Games

� Generalize comfort in structured activities with familiar people to other environments and people

� Goal is for child to meet normal speaking expectations in all settings

� Generalize across settings and people◦ Assignments

◦ Community Integration

◦ Invite peers / teachers to join session

� Sample Activities◦ Craft, Science activities

◦ Cooking – share with others

◦ Board and Card Games – Go Fish

◦ Twenty Questions

◦ Delivering Messages

◦ Making Requests

◦ Giving Directions

� Natural consequences in home and school environments for non-speaking

� Primary goal to resolve selective mutism

� Secondary to resolve SLP issues that might be contributing to SM

� Shopping

� Concept Walk

� Categorization

� Articulation/Phonology

� Problem Solving

� Pragmatics / Social Skills

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� Although older and more ingrained, medication not necessary in most cases

� Desensitization principles still apply; skip whisper stage

� Build confidence and self-esteem; mutism part of how they define themselves

� Address anxiety and implications of not speaking honestly and openly; importance of speaking to be independent and self-sufficient

� Need cooperation of teachers and parents

� Activities◦ Social Skills Activities

◦ Problem Solving

◦ Trivia and Fact Games

◦ Explaining Absurdities

◦ Recording Speeches and Reports

◦ Community and School Integration Assignments

� Stabilization/Carry-over is throughout the program. Once accomplish step in therapy, work to stabilize in external environment.

� Never proceed to next step until child has desensitized in therapy setting.

� Provide immediate, concrete reinforcement in early phases; offset approach-avoidance conflict for client

� Monitor pressure and keep communication fun & non-threatening.

� Parental / home involvement for consistency

� Reduce anxiety or hypersensitive response to Reduce anxiety or hypersensitive response to Reduce anxiety or hypersensitive response to Reduce anxiety or hypersensitive response to talking in public situationstalking in public situationstalking in public situationstalking in public situations

� Build child’s confidence to assume increased Build child’s confidence to assume increased Build child’s confidence to assume increased Build child’s confidence to assume increased levels of communicative responsibilitylevels of communicative responsibilitylevels of communicative responsibilitylevels of communicative responsibility

Teach child they have more Teach child they have more Teach child they have more Teach child they have more control over their environment control over their environment control over their environment control over their environment

through verbal interactionthrough verbal interactionthrough verbal interactionthrough verbal interaction.

� American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, 5th

edition, (DSM-5). Washington, DC; American Psychiatric Association.

� Bergman, R., Piacentini, J. & McCracken, J. (2002). Prevalence and description of selective mutism in a school-based sample. Journal of the American Academy of Child 7 Adolescent Psychiatry, 41(8):938-946.

� Black, B. & Uhde, T. (1995). Psychiatric characteristics of children with selective mutism: A pilot study. Journal of the American Academy of Child & adolescent Psychiatry, 34:847-856.

� Chavira, D.A., Shipon-Blum, E., Hitchcock, C., Cohan, S., & Stein, M.B. (2007). Selective mutism and social anxiety disorder: All in the family? Journal of the American Academy of Child & Adolescent Psychiatry, 46 (11).

� Fernald, J. & Eastman, K. (2009). Selective mutism: An overview for SLPs. ASHA Web/Telephone Seminar.

� Giddan, J., Ross, G., Sechler, L. and Becker, B. (997). Selective mutism in elementary school: Multidisciplinary interventions. Language, Speech and Hearing Services in the Schools, 28: 127-133.

� Gresham, F. & Elliot, S. Social skills rating system. San Antonio, TX: Pearson.

� Harris, H. (1996). Selective mutism: A tutorial. Language, Speech, and Hearing Services in the Schools, 27:10-15.

� Middendorf, J. & Buringrud, J. (2009). Selective Mutism: Strategies for Intervention. ASHA 2009 Annual Convention, New Orleans, LA.

� Richard, G. (2011). The Source for Selective Mutism. East Moline, IL: LinguiSystems.

� Richard, (2016) Selective Mutism course - MedBridge

� www.asha.org/public/speech/disorders/SelectiveMutism/