Selective Mutism

Summer Seibert, M.S., CCC-SLP

Adapted from information presented by

Dr. Elisa Shipon-Blum, President & Director of
Selective Mutism Anxiety Research and Treatment
Center (Smart-Center)
 Research Indicates
Individuals who develop Selective Mutism:
1) Have strong family history of social anxiety
2) 90% have social anxiety
3) There are other reasons besides timidity
as to why a child develops SM
4) Children with SM produce shorter,
linguistically simpler, less detailed
narratives than non SM kids. Subtle
expressive language skill deficits may play
a roll in SM. (Fung, Manassis, et al 2004)
 Quick and Easy Diagnosis
Criteria
Child is MUTE in at least one setting

Child SPEAKS in at least one setting

 Influential Factors
Genetics
Neurorphysiologic
Ex. Hyper-active amygdala (responsible for
feelings)
Environment
Parents or school misunderstanding & enabling
Family stress and troubles
Child modeling
 Precipitating Factors
Social anxiety (over 90%)
Bilingual/Multilingual (silent period)
Speech-Language factors
Developmental Delay (sensory motor,
language, social, emotional)
Personality traits (controlling, stubborn,
assertive, bright, heightened
perceptions)
 Propagating Factors
Mutism REINFORCED by:
Misinterpretation of symptoms (others
respond for the child when he/she
hesitates)
Misinterpretation of testing/assessments
Misdiagnosed (autism, ODD)
Mistreated
Environmental stressors (Too much
attention to speaking)
 Interesting Facts about SM
Many children suffering in silence are
unable to communicate nonverbally as well
as verbally, and many cannot communicate
at all when anxious
Just pointing or nodding can illicit anxious
feelings
Many cannot acknowledge that people exist
Their anxiety changes from setting to
setting and from person to person. It is
related to expectation.
 Change our Perspective!
Individuals with SM have difficulty
with social engaging, nonverbal
communication NOT just MUTISM.

Selective Mutism is a Social-

Communication Anxiety Disorder
How can we evaluate if a child
does not speak or interact?
The evaluation period is necessary to
determine the reasons WHY a child is
Selectively Mute.
Evaluation period should answer 3 KEY
questions:
1. What is the CAUSE (causes) for why a child
developed SM?
2. What are the REASONS why SM continues to
exist? (propagating factors)
3. What stage or stages of social-communication
is the child in within a variety of settings?
Evaluation Gather History- pg
1
History is Important! (Medical,
developmental, social, academic, family)
What is Parental/Teacher understanding of
SM and how do they approach the child?
Parent and School misunderstanding is a huge
contributing factor to propagating SM!
Assessment forms are available on her
website.
 Interview Questions
When did parents first notice mutism?
Was child shy/timid as a baby

Where is child mute and with whom?

Has child ever commented about voice?

(speak funny, others dont understand?)

Does child speak at home?

(If not, for how long?)

Did Mutism begin suddenly?
 Evaluation
Golden Rules of Evaluating
Minimize eye contact
Talk around child
No direct questioning at first
Focus on something other than the child: PROPS!
Have NO expectations! Act as if you have no
interest in whether they speak or not.
PLAY with the child without asking open ended
questions
Respond to childs gestures as if he/she is
speaking
 Stages of Selective Mutism
Stage 0
Non-Communicative (neither verbal or
non verbal communicationnot socially
engaging another
No responding, no initiating, child stands
motionless, expressionless or blank look,
frozen looking
When is a child in Stage 0?
Senses setting is unsafe, in a new/unfamiliar
setting, feelings of high expectations,
younger children
 Stages of Selective Mutism
Stage 1
Nonverbal Communication
1A Responding (via pointing, nodding, writing, using sign
language, etc.
1B Initiating (via getting someones attention, handing a
note, raising a hand, pulling on person, etc.)
When is a child in Stage 1?
After a warm up period in most social settings, within
school, as school year progresses, as nonverbal
communication becomes easier and easier, with
family/friends
(As years progress, child may remain in STAGE 1 unless they
LEARN coping skills to communicate -> professional mime)
 Stages of Selective Mutism
Stage 2
Verbal Communication
2A Responding (any sounds i.e., grunts,
baby talk, animal sounds, moans, soft
whispering, speaking, laughing out loud)
2B Initiating (via getting someones

attention via making any sound)

When is a child in Stage 2?
At home, with immediate family and SELECT
others)
 Need to Determine:
What stage of communication is the child
in in each setting:
Home- with immediate family, extended family,
adult friends, peers, answering phone, making
phone calls
School- within classroom, playground,
throughout school, school personnel
Out of home- at others home, friends, family,
in public places, restaurants, stores, parties

(Pay attention to warm up time)

SLPs Role in the School Setting
With Students with
Selective Mutism
SLPs should be involved in assessment.
SI should NOT be the childs only eligibility.
Student can qualify for direct services if it is
determined that the child also has a speech
and language disorder.
If no speech/language disorder is present,
ED may be the childs only eligibility but
Speech can be added as a Supplemental
Aid and Service
Can see child on consult and work with the
teacher/counselor
 Treatment Approach
Social Communication Anxiety
Therapy (SCAT)
Lower anxiety
Build self esteem
Increase confidence and communication
in social settings

Dont treat to speak! Address the factors

of shut down and the reinforcers. Un-
learn learned behaviors and build
coping skills.
 Goal of School
Accommodations &
Interventions
Increase comfort and ability to
engage, socialize and communicate
in social settings to move from
nonverbal to verbal.
Help Child Acknowledge/Assess

Feelings charts
Heights of building blocks for younger kids
Using hands/fingers to gage feelings

- Where child can RATE feelings of being

scared, uncomfortable and/or where it is
difficult to communicate
- Give them example situations with the
emotion scale and have them compare to
an easy situation.
 Emotion Chart
Give the child time to assess their
feelings.
How do you feel about making these
sounds with me?
Proceed if the child is responding
positively.
Pull back if the child is very resistant.
Trust their feelings! They dont fake it!
 Countless Methods:
Use Choice and Control Trophy Games
Using Sounds Ritual Games
Yes/No Game Phone Game
Interview Game E-mail
Mr./Mrs. Handover Verbal Intermediary
Mr./Mrs. Takeover Desensitization
Waving Game Fading
Clockwatcher
Hi/Bye Game
Eye-Spy
 Use of Control and Choice
Direct questions
Yes/No questions
Use visual choices
Ask questions that the child knows the
answer to.
Allow for hesitations
Give child choices to give them control.
But dont take no for an answer.
Find a way for them to communicate
without pressuring them to speak.
(pointing, eye blinks, eye gaze)
Giving these children control helps lower
anxiety. These kids are always being told
 Use of Sounds- pg 2
(Transferring into Verbal
communication via the back
door)
Good method for child who already makes
sounds (grunts, groans, laughs, etc.)
Begin making tapping noises, finger snap
noises.
2 snaps/taps = YES & 1 snap/tap = NO
Progress to mouth popping sounds
2 pops = YES & 1 pop = NO
Have the child write out the alphabet first.
** Give LOTS of wait time for response at
 Use of Sounds Cont.
When child can make Pop sound, let them
know they make a P sound.
Can begin crossing off letters of the
alphabet/animal sounds
Write simple words on paper with P sound
Use P sound and SHAPE into other sounds (i.e.,
b, then bbbbb = bye
Eventually: hhhh = hi
As you work through sounds, sssssssssss = YES,
nnnnn = NO
Put beginning and ending sounds together
yyyyy + ssssssss = YES & nnnnn + ooooo =
NO
Dont make a big deal out of it when they
make sounds. Let them know youre not
pressuring them.
 Hi/Bye Game- pg 3
The child collects stickers, stars, etc
each time they :
WAVE
Hand a card that says hi or bye
Use sounds or a verbal intermediary,
Copying hi/bye
Saying hi/bye independently
Children who respond to hi/bye get
one sticker; Children who initiate
hi/bye get two stickers.
 Yes/No Game- pg 4
Do you like donuts?
Do you like ice cream?
Do you like dogs?
Do you like chocolate covered spiders?
Do you like rats?

Keep up with who the child plays the game

with and the date.
 Interview Game- pg 5
Stage 1 A: Other person asks questions, child
answers with point, nod, written response
Stage 1 B: Child goes up to person and hands
her a card/journal with question. Person
responds.
Transition to verbal: Person asks questions,
child answers through intermediary or child
uses intermediary to ask questions. Can also
use tape recorder
Stage 2A: Person asks questions. Child
answers via whispers, words, reading answers
off card
Stage 2B: Child goes up to person to ask
question via whispering, sounds, reading off
cards.
 Interview Game Sample
Questions
Whats Your Favorite Game
Color? Ice cream flavor? Pet? Holiday?
TV show? Book?
Color Game: What color is.
Grass? The ocean? An Apple?
A book about my teacher pg 6
 Verbal Intermediary pg 7
Use a person or object (whisper buddy/
puppet) who the child can speak to:
Whisper close up
Whisper at fist length away
Whisper at half arm length away
Whisper at full arm length away
Whisper across table
Look in direction of person

* The other person should NOT make a big deal

out of the child talking!!
 Mr./Mrs. Handover / Mr./Mrs.
Takeover

Handing things onto the conveyer belt at the

grocery store
Handing the credit card/money to the cashier
Taking the change back from the cashier
If this is too hard, parents can hold her hand
Also, can allow the child to place the item in
front of the store clerk rather than handing
something to them.

*Non-Verbal communication is the KEY to social

engagement and is the precursor to
communication.
 Waving Game

Change the connotation of waving.

Dont tell the child to Wave! or Say
hi!
Instead:
Hand twist
Flopping
Wash the window
Hand rock
Give an Man's when they wave.
 Clock-watcher
Tell me when its lunch time.
Student can tap desk or hand
teacher a note.
 Eye-Spy
Many kids shut down when they see
someone they know in public. (Emotion
goes to amygdala and evokes fear).
This game helps bypass the amygdala and
shoot the response to the cortex by
cognitively thinking about it.
Make a list of people we might see.
Make a list of observations we will make:
What color shoes are they wearing? Etc.
After the outing, check off the people we
saw and see if our predictions were correct.
 Plan Ahead
Anticipate what will be asked / talked
about in certain situations.
Prepare the child for what will be
asked and how they can respond.
Keep a list of questions.
After the event, check off what
questions were asked.
This will lower anxiety.
 E-mail
Have child e-mail with the teacher
from home or therapy room to get
used to communicating with her.
They can attach pictures to make it
more interesting to the child.
Younger children can sit in the
parents or therapists lap and
dictate the e-mail.
 Photo Album
Provide child with a 24-page tape-record
picture album.
Select pictures of events in the childs
life that she might like to tell someone
about.
In a comfortable environment, she can
record captions for each of the pictures
She can share the book with people she
is uncomfortable speaking around.
 Desensitization
Spend one-on-one time with the child
within the school. Practice
Communicating.
One-on-one time with teacher.
Classmates: Playdates (one new child at
a time, then increase to a few at a time)
Bring friends to school before/after hours.
Practice on playground/eating/bathroom
Small groups: introduce one child at a
time.
 Fading
School:
Parent interacts with the child in the small
group
When child is verbalizing, add another child
When child continues to verbalize, parent
gets up and teacher moves in.
Next, parent leaves the group and the
teacher stays.
 Fading
Home
Playdates: Parent interacts with child
and new friend.
When child begins talking, mom slowly
goes away.
 The Phone
(start young)
Answering Phone Calls:
Answer knowing its mom or dad.
Add grandparents, close friend, etc (plan phone
calls)
Mystery caller between 3 or 4 people.
Making phone calls in the same progression.
To ease the stress:
Play phones, walkie talkies with friends, use of cell
phone in own home.
Set sayings reading off cards. (Great for answering
machines)
Older kids can leave script by phone
 The Phone
Call and order pizza
Write script and rehears
Emotion chart
Rehearse with phone in hand
Emotion chart
Open cell phone and rehearse
Emotion chart
Put phone to ear and rehearse
Emotion chart
Make the phone call
Emotion chart
 Phone Game
Can play with home phone & cell
phone or with walkie talkies
Friend tries to guess where the child
with SM is hiding
Is there a sink in the room?
Is there a tv in the room?
Friend Goes home and calls the child
with SM and plays the game again.
 Trophy Games pg 8 - 11
Helps child develop inner control by emphasis on
incremental progression of communication.
The child must have at least one person present
who she can speak to.
Prior to beginning, the child should have a reward
system in place for positive reinforcement
After so many stickers/tokens/play money, the child
receive a reward/privilege/item
Example Games:
Restaurant
Handover/Takeover
Hi/Bye
Finish the Sentence
Interview Game
 Ritual Games pg 12-13
Can be used for children in ALL stages of
communication.
Helps child feel in control over their
communication progress.
Difference between trophy games and
ritual games: Trophy games help the child
DEVELOP inner control while Ritual games
USE the childs need for inner control to
help the child progress communicatively.
Similar to Trophy Games: the child should
have a reward system in place (positive
reinforcement) to help the process along.
 Ritual Game
Ritual Games are contrived and individual-based
rituals the child goes through as they progress
communicatively.
Have the child help you develop the ritual: ex. 5
favorite sounds, all the alphabet, yes/no
questions, etc.
Do this out of the classroom first, then move to
the back of the room, then to the desk, etc.
The child will not speak in front of people who
they havent done the ritual with.
Every child has a different ritual.
May need a trigger question to be able to start
talking in different settings.
 Signs of Lowered Anxiety
Relaxed body language
Excellent eye contact
Smiling more
Child laughing (with or without
sounds)
Initiating without effort
Responding rapidly and freely
 Things to Keep in Mind
Dont make a big deal out of the child
making sounds/talking
Dont stare at the child when you ask a
question.
Dont let them think you give a darn so
they dont feel anxious
Act like your attention is divided: play on
the computer, clean your desk, etc.
Never work on eye-contact! It will come as
comfort comes. Eye-contact is very invasive.
You can work on looking toward someone.
 Things to Keep in Mind
Allow for time to respond. Children with SM
hesitate when anxious. Do not jump in with the
response if the child is not communicating.
Praise and support the childs efforts: You did so
well!
Help child to express feelings: comfort journal,
bedtime snuggle time, etc.
Prepare child for changes/transitions: substitute,
going to parties, outings
Arrive to places early, bring a friend.
Increase independence at home (chores /
responsibilities) to build self esteem
Strengthen strengths to build self-esteem,
 I also have more information
about:
SM and Medication
Why, When, & How
Accommodations to set up at school
IEP goals
Case Studies
 For More Information:
www.selectivemutismcenter.org
www.selectivemutism.org
sminfo@selectivemutism.org
SMartCenter@selectivemutism.org
215-887-5748