SELECTIVE MUTISM

  

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. http://www.amazon.com/gp/product/1616337281?ie=UTF8&camp=1789&creativeASIN=1616337281&linkCode=xm2&tag=theshrlin-20

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When Your Voice is NOT Heard:  TOXIC PARENTS

There are, unfortunately, so many different types of dysfunctional family systems that I cannot fit them all into one blog.  Today I am going to focus on the adult who has parents that are dysfunctional and toxic.  We expect our parents to be the people that love us the most in the world.  To have our back and love us unconditionally.  Unfortunately, it does not always happen and many people stay in a state of denial for many years.  Some people spend their adult lives trying to earn the approval of parents that are just not capable of approval or unconditional love. Instead, they experience years of guilt, pain, frustration, emotional abuse and manipulation, financial burden, broken relationships, and chronic disappointment. At some point, many people realize that their parents are highly dysfunctional and toxic, but they don’t know what to do about it, how to heal some of the damage.

            A relationship with toxic parents is like an emotional and spiritual cancer.  This type of relationship is typically based on behaviors and manipulations that are emotionally damaging, leaving you feeling guilty, insecure, controlled and manipulated, threatened, and beaten down.  It just does not feel safe.  In a healthy relationship, the caring, love, and respect is mutual and nurtured throughout the years.  Compassion is freely given, without manipulation or strings attached, such that both sides feel loved and supported. Unlike other relationships, when the toxic person in the relationship is a parent or parents, it can leave you feeling burdened and trapped.  In most cultures, we are taught to respect our parents.  In most religions, we are also taught to respect and honor our parents.  If a friend or spouse is abusive we are encouraged to leave.  When contact is cut off with a parent, there is much less support and understanding, especially from people who are blessed with healthy parents. At this point, you may feel your guilt is on steroids and dominating your life.  

            This is the person who gave you life and raised you.  They supplied all your basic survival needs such as food, clothing, and shelter.  They were supposed to give you unconditional support.  Unfortunately, for some, this is the person who constantly criticized you, put you down, and manipulated you with guilt.  They lied to you and about you, embarrassed you, sabotaged all your relationships, controlled you and never seemed to let you go.  Rather, they trapped you and convinced you that you were at fault, inadequate, unappreciative, and undeserving of love and respect.  You may feel that if your own parents could not love you that you must be unlovable. 

            Reasoning with a toxic parent does not work!  Sacrificing your life for a toxic parent does not help as it is expected.  Being the perfect child does not help because the toxic parent is always disappointed and wants something more.  These parents make sure you never develop a close relationship with siblings or other family members or friends.  They keep you isolated so they can have more control over you.  Toxic parents are an EMOTIONAL CANCER!

            What do we do with cancer?  We eradicate it and get it out of our body.  This is what we have to do with toxic parents and any toxic person in our life.  These people suck the life force out of us and if we keep them in our life, we have no joy and no quality of life.  Remember, your parents chose to have you and it was their job to raise you and provide for you.  That does not mean you owe them every part of you and your life.  To disconnect from parents you will have to deal with guilt, grieve over the loss of the parents you wanted and deserved, accept the disapproval of some family members, maybe even siblings, and most importantly, setting strong boundaries.

            How do you start?  First comes the acceptance that you have a toxic parent who is a destructive force in your life.  Not only can you not change your parents, it is not your job to change your parent.  The only person we can ever change is ourselves.  Accept that your parents are damaged and dangerous to you.  Next, be very aware of guilt and how your parents use guilt to manipulate and control you.  They have most likely been doing this to control you your entire life and they know exactly what buttons to push. 

 When someone tries to manipulate you through guilt, it is in their best interest, not yours.  Acknowledge the guilt as manipulation which will help you not buy into it.  Very importantly, if you cannot completely disconnect from your parents, limit your contact with them as much as possible.  You are not responsible for their happiness or the consequences of their choices.  You do not owe them your life.  They are adults, as are you.  You have to live for you, not your toxic parents.  Stop giving up your relationships and your life goals to please parents that cannot be pleased.  Give yourself permission to live your life for you, with healthy and balanced relationships, mutual love and respect, and balance and stability.  If you can’t do this on your own, do not hesitate to seek professional help as this is a very difficult and challenging process.

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2016 NEW YEAR RESOLUTIONS

Happy New Year!  Many of us look at the New Year as a time to change our lives.  We often see it as a new beginning and as a way to re-invent ourselves and our lives. While we are trying to motivate ourselves through the new resolution, we also have to be ready for the change as most change is challenging.  If the behavior we wanted to change was easy, we would not need the resolution.  Psychological studies have shown that approximately 50% of adults tend to make New Year resolutions, especially regarding weight loss, exercise, smoking cessation, and better money management and debt reduction. Other common resolutions include but are not limited to getting more organized, volunteering and helping others, learning something new, drinking less, enjoying more family time, and generally enjoying life more.

Please keep in mind that if a resolution is unrealistic, you may be buying into false hope and setting yourself up for feelings of failure. Your resolution has to be realistic and match your internal view of yourself and what you are capable of given your life situation.  For example, debt reduction is a wonderful goal, but it has to match your income and fixed expenses.  It would be unrealistic to reduce your debt by an amount that is not commensurate with your income. Also, if you make a resolution but tell yourself that you don’t really believe you can do it, the resolution can lead to negative self-talk, making you feel like you failed. 

To change a behavior, you first have to change your thoughts and expectations and you have to be realistic with the goals you set.  To help reach this goal, try focusing on one resolution at a time.  Set realistic goals in steps or chunks.  For example, with debt reduction, first stop putting any more charges on your credit cards.  Pay some over the minimum on each card but target one card to pay down to zero, however long that takes.  Once that card is paid, target another card, and so on.  Make your resolutions daily and not yearly.  Every morning, remind yourself what your goals are for that day and reinforce your resolution with your recent success. Ask yourself how you are going to meet your goals today.  When you achieve smaller goals along the way, it is less overwhelming and much more reinforcing.  It is also very helpful to enlist the help of someone else, like a support buddy.  This can be a friend or a family member.  Depending on the resolution and goal, it can even be a co-worker or a support group (like weight watchers for weight loss).  Practice your new thoughts based on supporting evidence.  For example, for weight loss, remind yourself that you have stopped gaining weight and have started to lose weight.  For debt reduction, remind yourself of the decreasing balances on your credit cards.  Verbally reinforce for yourself how good your success feels and how much you want to continue to feel that success.  Be aware of your thoughts and feelings, especially those thoughts that might sabotage your success. 

Don’t forget to have fun and reward yourself along the way.  It is important to recognize and acknowledge those intermediate successes so the journey does feel impossible.  Most importantly, have a plan for relapse prevention and goal maintenance.

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HOLIDAYS 2015 

The holidays are once again fast approaching and maybe this will be the year that we do things differently. So many of my patients and friends confide in me that they really do not enjoy the holidays. They rush through Thanksgiving and dive head first into shopping for gifts, sending out cards, going to parties and giving parties, and find themselves feeling flat and tired. Let yourself enjoy each holiday in its own right.  

Halloween is a lot of fun, especially when you have children who are excited about their costumes and all the candy they will receive. Thanksgiving truly is a day to give thanks for what we have, family, friends, a safe place to live, and food to eat. 

Try and really look at the difference between wants and needs. If all your needs are met and you are able to have some of your wants, than you are much better off than many people around the world. As for the post‐Thanksgiving holidays, make your budget, your list, and methodically make your way through and really enjoy the processing of selecting gifts and wrapping them and anticipating the pleasure of the person you are giving the gift to. If you have to spend time with family members that you really do not enjoy, try and look at what you do like about that person and remember that every person has a story and you may not know their entire story. Wish them well in your thoughts and maybe you will even see them smile. If you are missing people that have passed away or are not able to be with you this year, focus on the positive memories. For those people that cannot be with you this year, call them. Maybe even arrange a group call on skype or face time. Share memories and remember what you are thankful for. Even if your life is not where you want it to be, there is always something to be thankful for and something to share. HAPPY THANKSGIVING AND HAPPY HOLIDAYS!
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SOCIAL MEDIA ADDICTION

Everybody has an opinion about social media.  Some people do not see or understand the attraction to social media and other people cannot understand why more people are not more involved.  Like anything else in life, we all don’t like the same things.  For those of us who do like social media, some are involved on a very minimal level and others are involved throughout their day.  The question is; when is it too much?  When social media is used as an escape it is too much. 

If someone turns down a social invitation or time with family because they want to update Facebook or follow someone on Twitter, it is too much.  Social media should add to the quality of our lives, not become the focus of our lives.   There is nothing wrong with enjoying pictures on Instagram or Facebook, or following someone on Twitter.  However, to put anything meaningful on these sites, you have to go out and live life.  If your children seem overly consumed, maybe limit them to an hour a day.  And while you are at it, limit yourself to an hour a day.  I have met people who proudly tell me that they spend up to five hours a day updating all their social media.  What else could have been accomplished in that five hours?  Maybe spending time with family or friends, working out and exercising, learning a new hobby or skill, reading a book.  Social media is an adjunct to life, not the center of life.  

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COPING WITH THE BREAKUP OF A ROMANTIC RELATIONSHIP

I wish there was one easy answer to this issue.  Unfortunately, the answer depends on so many different variables such as duration of the relationship, intensity of the relationship, age at time of breakup, and reason for the breakup.  Breakups are stressful and painful no matter how they happen, even for the person doing the breaking up.  The loss of a relationship is a form of grieving, just like when we experience a death.  We grieve many types of losses, not just by death or loss of relationship.  We may grieve the loss of a job, moving away and losing our home and community, loss of a friend, even loss of physical integrity.  When dealing with the loss of a relationship, as painful as it is, we have to remind ourselves that the pain is temporary.  We have to also remind ourselves that were the relationship strong and balanced, it would not have ended.  Therefore, I like to describe it as a dress rehearsal for the real relationship.  It was a time to learn about relationships and what you like and what you don’t like.  Many people express a fear that they will end up alone.  Better to be happy alone than miserable in a relationship that just does not work or even worse, may be abusive.  So how to go forward?  

The most important requirement to coping with a breakup is to get out from under the covers, take a shower, look great, and go out with your friends and/or family.  Stay active and involved.  If you were never that involved or active, now is a good time to start.  You can hurt and be miserable or you can hurt and be active and distracted.  That latter is better as it allows you to see that life can go on in a positive way.  Who knows, maybe when doing something you love, you might meet someone wonderful who really gets you and wants to be with you forever.

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ACCEPTING HELP GRACEFULLY

 There are many of us who are quite happy to give help and enjoy the role of caretaker.  It makes us feel good to help someone else.  However, there is a subset of us who are not comfortable accepting help from others.  We are concerned that we are a burden, we feel guilty that someone may have spent money on us or gone out of their way to do us a favor.  The bottom line, however, is that a balanced relationship allows us to be on both sides of help and sometimes we just need to be gracious and say “Thank you”.  This means not constantly or frequently telling the other person how sorry you are for inconveniencing them and accepting their help at face value.  Helping you allows the other person to also experience the joy of helping and actually creates a better balance in the relationship if you have been able to help them in the past.  All this being said, even when offering or accepting help, we need to have healthy boundaries.  Don’t accept help that you know will absolutely hurt the other person and don’t offer help that you know you either can not afford to offer or will hurt you and your family in some way.  There are times we want to help, but what we can offer may not be realistic for our current life situation. 

However, the strength of emotional support can never be underestimated.  Even small measures of help can have a tremendous impact on the other person.  For example, a phone call or visit, sending over dinner or inviting someone over for dinner.  This allows the other person to know you care.  If you are on the receiving end of this type of help, understand the other person is giving what they can based on where their life is and know they are thinking about you and you are not alone.  Remember, when someone wants to help you, they care.  Let them care.


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