Tuesday, July 30, 2013

Selective Mutism, Tips for Successful Communication! - A Guest Post

Hello blog visitors!  Today we have a fantastic guest post on the social communication anxiety disorder of Selective Mutism.  It is written by a kind- hearted and very intelligent, Speech- Language Pathologist named, Becky Lulai. Mrs. Lulai is a Speech- Language Pathologist in the Minneapolis-St Paul area with over 15 years of experience working with a variety of communication disorders.  She owns and operates Able Speech Language Services, a private practice specializing in education, consultation and treatment of selective mutism.   She provides in-home, on-location, or web-based services for families or other professionals interested in selective mutism.   Becky is also a Clinical Specialist for the Department of SLHS at the University of MN-Minneapolis and she can be reached at  ablespeech@gmail.com or 612-251-6021.  

We hope that you find this post as informative, interesting, and helpful in as many ways as we did! Thank you for stopping by the blog today and a HUGE THANKS to Becky for all of her hard work on this WONDERFUL guest post!
Manda & Shanda, SLP's
Twin Sisters Speech & Language Therapy

Selective Mutism, Tips for Successful Communication!
By Becky Lulai,  M.A.  CCC-SLP

Many SLPs experience a little anxiety of their own when coming across the diagnosis of Selective Mutism (SM).  Very little time is spent discussing this issue in graduate school, but more of us are finding these kids on our caseload.  Although this is a complicated social communication anxiety disorder, there are many simple things that we as “communication experts” can do to help these children overcome their communication difficulties.  Below are 10 guidelines when considering a diagnosis of SM. 
1.       Lay off a little!
Decrease the pressure to speak.  As counter-intuitive as it seems, the focus of our treatment for a child with SM should not be to get him to talk.  This child will most likely talk when he feels comfortable in his environment and is socially engaged with another person.  Never, ever create a power struggle over speaking.   Quite frankly, you will never will.  Even if you try to wait a child out, eventually you will both need to go home for the day.  A child’s anxiety does not decrease in this type of situation, and it will not get any easier for him to talk.   
2.       Let’s get non-verbal!
Communication, of any kind, is our focus in SM.   It is our role to provide methods of communication that are comfortable for the child. If we are able to meet the child at her level of comfort and provide opportunities for her to engage and communicate in a manner she can handle, she will feel successful.  As in all things, success begets success.  A simple way to start doing  this is to provide “tickets” (Index cards for “yes”, “no” and “I don’t know”. )
3.       IDK is AOK ! 
Often kids with SM have perfectionist personalities and do not like to guess or take the chance of being wrong.  This makes the traditional trial and error learning style of American schools quite intimidating.  In my experience, once kids know that it is OK not to know every answer, there are many more options for exchanges.  Along with the yes, no and IDK tickets, I will often provide a child with a “free pass” to use when he knows the answer but just doesn't want to say.  All of these messages are valid social responses and should be accepted without consequence or further questioning. 
4.       It’s no big thing!   
If this child has been mute for a while, there have likely been a lot of adults giving him lots of attention and trying to make him talk.  The biggest way to decrease the pressure is to take the “it’s no big deal” approach.  Casually acknowledge that the child is not talking, but try not to express concern.  Do not be surprised or react if he does speak.  Our SLP instinct would be to provide lots of verbal praise when a child speaks.  However, this would likely draw attention to the child.  Usually, the last thing a child with SM wants is to be singled out for something, good or bad. 
5.       SM (Plus?)  
It is necessary to rule out other speech/language issues.   Recent research is showing that 30-40% of children with SM also have other speech/language issues.  A complete assessment of a child with SM needs to include a representative sample of the child’s speech and language skills when she is comfortable speaking.  This means we have to get creative.  Utilize video or audio recordings of the child at home or when speaking to her friends.  Assess the child in her home.  Teach a parent to present the stimuli for a standardized test and then score it from a video recording.  These are all valid assessment tools as long as some preparation has taken place.
6.       It’s more than just not talking.  
Selective mutism is the manifestation of severe anxiety.  Mutism is a neuro-biological response to a lower threshold of excitability of the limbic system.  SM starts as a coping mechanism to a situation that causes extreme anxiety.  At its core, mutism is not a choice, but an inappropriate coping behavior.  Unfortunately, if the child’s anxiety decreases when he withdraws into mutism,  this coping mechanism will reinforce itself.  It is important to treat SM appropriately and early to decrease the chances of the behavior becoming engrained.   
7.       Take baby steps.
There is no cure for SM or anxiety disorders.  A person can learn to utilize healthier coping skills to respond to anxieties.  This is a slow and systematic process.  Often, a very subtle difference in the setting will determine if a child will be able to speak or not.  As SLPs we can use alternative communication strategies to provide successive approximations of the desired behavior.  Just as we do not begin treatment at the conversational level with a child working on /s/, we need to start slowly with the child with SM.  When learning any new skill, a child may have periods of slight regression.  Meet the child where she is and nudge her forward. 
8.       Don’t go it alone.   
Ideally, all children would have a team of trained professionals guiding their daily treatment.  However, that is not always the case.  Consultation with a mental health professional can be very insightful and should be utilized whenever possible.  However, a child encounters many people throughout the day.  Twenty minutes twice a week with an SLP is not going to make a difference outside of the therapy room.  Children need consistent responses and consistent opportunities for successful communication.  When all adults in the child’s life are using the same strategies, the likelihood of generalization of social comfort is greater.  Educate yourself, along with staff, family members, teachers, even lunch and playground staff to encourage social engagement without pressuring a child to speak.  Also, don’t forget about the subs!  One well-meaning adult who pressures the child to talk can take away weeks of progress.
9.       Get comfy, fix later. 
If your testing does reveal a co-existing speech, language, fluency or voice disorder, the child needs direct speech therapy.  However, that fluent, error-free speech may have to wait.  If a child is not comfortable communicating with you in the treatment room, drawing attention to her speech errors is not going to decrease her anxiety.  Once the child is socially engaged in activities with you in a variety of settings, then go ahead and practice those /r/s as you would with any other child. 
10.   Kids just wanna have fun.
All kids  want to play,  to be silly and  have fun.  The more opportunities a child has to have fun and be relaxed, the less anxiety a child will feel.  Find ways for your kids with SM to be involved in group games.  (eg., time keeper, clock watcher, score keeper)  Sometimes, just getting these kids sitting at the same table with their peers is a huge success. 

Working with a child with selective mutism can be challenging, frustrating and extremely rewarding!  With the proper approach applied from the start, a child can make rapid progress.  As SLPs we need to arm ourselves with the information and training necessary to change the lives of a child.  

For more information about Selective Mutism , check out the Links pages on my website.  www.ablespeechlanguage.com

Becky Lulai,  M.A.  CCC-SLP



Seana Morgan M.A. CCC-SLP said...

Oh my goodness, this was wonderful. I keep hearing of the diagnosis, but have had no idea what to do if I actually got a student with SM. These are excellent strategies and I'm bookmarking this so I have it if I ever need it.

Twin Sisters Speech and Language Therapy said...

Thank you Seana. We're so glad to hear that the post was helpful to you. We appreciate the feedback.


I am a 39 y/o twin. I have never heard of this and yet everything I have read describes me. I have always felt like I was suffering alone. As a child my parents said I would only speak to my twin, who does not suffer from this. I have overcome alot and feel successful in my battle but still have times when I have to mentally force myself to speak, make a decision and cope with being wrong. Thank you for helping so many and I will visit this blog again.

Rhonda Gaines said...

Thank you for this!

CD said...

Thanks so much for this post. This describes a twin in my grade to a tee. I'm feeling reassured after reading this that I've been on the right track with how to approach most things in and outside the classroom. I'm sending this link to her new teacher (and twins teacher) for next year. Thanks again


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