Wednesday, March 9, 2016

Selective Mutism (SM) is an anxiety disorder that typically appears before the age of 5.  Many children are not diagnosed until they begin school, as they typically talk to immediate family members living in their household.  These children present as extremely shy, and find themselves unable to talk in social settings.  It is not a refusal to talk, but an emotional inability to talk.  Some of these children struggle with maintaining eye contact or even giving non-verbal responses to other people, such as nodding their head in response to a question.  Progress can be fast or very slow, and must be measured by very small gains.  Children with SM are sometimes misdiagnosed with oppositional defiance, but it is not an oppositional disorder.  Their inability to communicate in social settings stems from anxiety.  Often children with SM are also diagnosed with social anxiety.  Language skills typically develop normally.  Academic skills are more difficult to determine due to the fear of speaking, and as such, I have included some recommended accommodations that that might be both helpful for the child’s academic advancement and academic assessment.
            When I read Individualized Education Plans (IEP) and 504 plans, I have often noticed that the child’s behavior is frequently characterized in terms of a refusal to engage in certain behaviors.   These children do not refuse to engage in behavior, they are fearful of engaging in certain behaviors.  Anything that draws attention to them or makes them feel like they are standing out or targeted, will activate the SM.  Even being taken out of the class to work with an individual that focuses specifically on them and that they may not have developed a relationship with, will make the child shut down, a common aspect of SM.  Some children are even very uncomfortable being pulled out of class for testing and may do much better being allowed to take all tests in class.  If the teacher determines the child is not coping well with the testing in class, the teacher can recommend that the child be pulled out at that time. 
            Some IEP and 504 plans suggest that the child avoids other children and does not make friends.  I find that to be contrary to what many children and their parents have shared with me. These children often have friends in the neighborhood or through family that they play with, even if they are not verbal.  Again, it is not that these children refuse to talk or engage in group activities, they are afraid to talk or engage in certain group activities.  If gently guided to a group activity, some of these children will sit with the group, and when comfortable, will interact nonverbally.  Children that  have trouble gathering information they need for class activities may benefit from being provided with  a class ‘buddy” or having  instructions written down for them. Providing the child with their own white board to use for written communication can also be very helpful. This way the child has the opportunity to respond to written directives and can write a question if they require more information to complete an activity.  At some point, when the child is ready, they can be recorded by a parent while reading so the teacher can assess their reading.  This can gradually be phased in to the child being present while the teacher listens to the tape.
            Some of these children are even very uncomfortable showing their work, which is another manifestation of their anxiety.  It is not an oppositional behavior. The child is very uncomfortable when they feel people are looking at them, and this includes knowing that someone is looking at their work.
            Given what I have read in many IEP and 504 records over the years and some possible confusion about the nature of SM and the best accommodation options for these children, the following accommodation recommendations are provided as a guideline for your consideration:

1.      Use the least restrictive environment possible.  It is important for the child to feel part of the group.
2.      Allow nonverbal communication such as pointing, head nodding, shaking head yes or no, thumbs up or down to indicate yes or no. Using one finger for yes and two fingers for no can also be very helpful.
3.      Use both verbal and written alternatives for presentation of class material.
4.      Use video and/or audio taping at home. This works better when set up and monitored with a therapist.
5.      Place the child in small work groups even if they do not appear to be participating.
6.      Use testing accommodations such as taping reading fluency lessons at home with video or audio tape as you work on a gradual introduction to verbalization in the classroom.  The following steps might help in this process:
a.      Allow the child to tape their lessons at home when they have reached a solid comfort level with the teacher.  They may refuse at first, so give it time.
b.      Allow and encourage the child to tape a verbalization with a parent present in the school setting, maybe when their classroom in empty.
c.       Encourage the child to tape part of a lesson on tape followed by whispering the lesson to her teacher or mother within the class setting without other students present.
d.      Have the child whisper the entire school lesson in the classroom with only the teacher present and maybe a parent in the hallway or back of the classroom.
e.      Then have the child whisper part of a lesson to another student they are comfortable with in addition to the teacher.
f.        Attempt to have the child verbalize an entire, but brief, lesson to the teacher.

Each individual step that may appear to be very small is, in actuality, a huge leap for the child as they may feel the words are stuck in their head even though they want to speak.  Even the smallest of successes from a child with SM, such as looking at the teacher or sitting with the group, should be calmly and fully praised.  Do not praise the child for these efforts in front of others, but do so quietly and privately. 
7.       Provide related services such as speech and language therapy, occupational therapy, and the services of an applied behavior analyst.
8.      Do not single the child out and make them the center of attention.
9.      Provide a structured setting within the classroom routine.  These children do better with predictability.
10.  Provide a safe place in the classroom such as a desk with a partition so the child can reduce all the stimulation from the classroom.
11.  Do not expect the child to talk.
12.  Do not comment to the child if you do hear them talk.
13.   Provide a “buddy” for the child that sits next to them and helps the child manage classroom communication and expectations. Rotate the buddy weekly so the child has interaction with several children in the classroom.
14.  Ask the child questions requiring only yes and no responses.
15.  Do not pressure the child for eye contact and allow it to occur naturally.
16.  Give the family advance notice of any changes in routine such as planned substitute teachers, guest speakers, and field trips.  Allow a parent to be present during these situations.
17.  Weekly communication between the teacher and the parents is very helpful.
18.  Do not draw attention to the child but either talk with her privately or positively comment on good behaviors in general.  Stickers for success also work quite well.
19.  Be aware that these children are sensitive to loud noise or being overwhelmed by a lot of activity or chaos.
20.  Explain to these children how you feel so they do not have to guess, which tends to make them more anxious and uncomfortable.
21.  Be concrete as children with SM often have difficulty understanding abstract language.
22.  Quarterly meetings with all related service providers and the teacher are very helpful to both the teacher and the parents.
23.  Minimize direct questioning in front of others.
24.   Provide these children with word prediction software to encourage them to communicate with written responses that can be heard by the teacher.
25.  Provide one-on-one time with the teacher to play a simple and familiar board game or computer game.  These familiar activities that are not performance based may allow children with SM to become more comfortable and transfer that comfortability to verbally engaging with the teacher. This may have to occur several times to reach a higher level of comfort with the interaction between teacher and child.
Please keep in mind that progress may seem very minimal to the adults involved with the child with SM.  However, each minor success builds a foundation for the next success and progress is progress.  Plateaus are also not uncommon, and you can use that time to reinforce what has already been accomplished.  Although not yet mentioned, some children respond better to treatment when they work with a psychiatrist and take medication.  Parents worry about medication, but it is helpful and usually temporary.  The medication often allows the child to progress more quickly through the therapy process.  Whatever you decide, be patient and advocate for your child.  Some schools are very cooperative and unfortunately, some schools are not.
      If you are interested in reading a picture book about therapy with your child to get them ready for therapy, consider reading our new book, “I Have A Voice”.  You can also find great resources through the Selective Mutism Foundation.

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