Selective Mutism

Children Who Can Talk…
But Don’t
DVD “Silent Children”
Children” SMIRA
Working With Selective Mutism
Maggie Johnson
Selective Mutism Advisory Service
Kent Community Health NHS Trust
(page numbers refer to the accompanying Word handout)
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Selectively Mute Children...
Common Symptoms of Anxiety
• WANT to speak but are unable to
• Become afraid of the act of speaking
and people hearing their voices
• Become increasingly wary of any
form of communication which could
lead to an expectation to speak
• In time learn to avoid distress by
avoiding communication
•
•
•
•
•
Body tension
Blank facial expression
Lack of coping strategies
Avoidance
Can’t analyse/explain source of
anxiety
• General helplessness
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Diagnosis
Types of Mutism (page 2)
• Essential Features of SM
• ‘Pure’ selective mutism (speech phobia two months in one location)
• Selective mutism (SM), plus speech or
language impairment or learning English
as an additional language (EAL)
• ‘Complex SM’: children with selective
mutism and other diagnoses or major
concerns
• Traumatic mutism (very rare, see page 2)
– A phobia of speaking to / being heard by
certain people
– A consistent pattern of talking/not talking
– Has lasted at least 2 months in a new setting
– Maintained by other people’s behaviour
• Who can make a diagnosis?
• Is a formal diagnosis necessary?
• Is referral to SLT necessary?
Maggie Johnson 2015
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1
Onset and Incidence
• Most frequently reported age of onset 3-5 yrs
• Sometimes later onset which is usually linked
to bullying/humiliation
• Sometimes gradual development from ‘low
profile’ to ‘high profile’ selective mutism
• More girls than boys affected
• Affects approximately 1 in 150 children
• Incidence higher in migrant/bilingual families and
geographically/ethnically separated communities
• Higher incidence of speech and/or language
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difficulties
Fear of the Dark
Factors Contributing to the
Development of SM
• Personality type – sensitive, wary, cautious,
need to get it right, hate uncertainty,
perfectionist
• Life events/triggers lead to escalated anxiety
– loss, separation, change, disapproval, public
scrutiny etc.
• Maintaining factors - negative associations
with communication and positive associations
with avoidance, strengthen and perpetuate the
child’s fear
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Maintaining Factors p.3
• Home
• School
• Identify which factors are operating
• Understand how they strengthen and
maintain fear of speaking
• Agree the changes that need to be made
9
Selective Mutism - Summary
What can we do?
Now seen as a manifestation of
social anxiety or phobia,
occurring in temperamentally
predisposed children who are
unable to take normal life-events
in their stride, particularly when
the reactions of others reinforce
silence rather than speech.
As with any phobia we are aiming to….
• Understand the fear
• Reduce the child’s overall anxiety
• Help the child to face the fear
…..one tiny step at a time
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Maggie Johnson 2015
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2
Ideas for when and how to manage
additional SLCN
Principles of Intervention
• phonology/articulation/language impairment/delay
- anxiety reduction takes priority but can do input work at
SLT clinic/pre-school with child doing output work at
home with parent
– group work should only be contemplated after SM
strategies are in place and child understands that
speaking is optional
• ASD
– same treatment for SM with usual ASD adaptations
• EAL
– treat anxious or frozen child as though they have SM,
even in “silent period”
– investigate bullying/teasing/speech awareness
– ensure parents do not model avoidance
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• Early intervention in relevant setting(s)
(see page 1 and next slide for Prevention)
• Ensure a united, consistent approach
• Talk openly and positively about the
child’s fear of speaking.
• Support participation rather than
avoidance
• Reduce anxiety by taking a small steps
approach changing one thing at a time
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The Stages of Confident Speaking
(page 4)
Totally frozen or absent
Relaxed, free conversation
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Linking RapportRapport-Building to the
Stages of Confident Speaking
Strategies to build confidence and
independence (1)
• Stage 1 – Take pressure off child; tell child you (or
Grandad/Auntie Sue etc) don’t mind if they don’t
talk, just want them to have a good time
• Stage 2 – Support participation & shared play
• Stage 3 – Find activities that don’t require speech
and respond positively to non-vocal communication
• Stage 4 – Encourage sound play and/or laughter
• Stage 5 – Gradually ‘slide in’ once child is talking
comfortably to parent / friend etc.
• Stage 6-7 – Gradually join in talking activities,
initially talking through parent / friend etc.
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• Using louder instruments in music
• Help to move further away from wall or teacher
in physical education or hall sessions
• Extra encouragement or practice on climbing
apparatus in hall or playground
• Jumping/flopping onto mattress, beanbag etc
• Bigger stronger actions or roles in mime,
movement or dance
• Joining in noisier group activities – singing,
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chanting, clapping, vocalising as animals
Maggie Johnson 2015
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Strategies to build confidence and
independence (2)
Strategies to build confidence and
independence (3)
• Increasing artistic expression through clay,
painting, movement or dance
• Jobs or responsibilities in the classroom;
supporting younger pupils
• Running errands, at first with another child
• Using puppets in play or drama
• Answering/reading in unison
• Outdoor challenges, zip wires etc
• Extra visits to new school or class prior to
admission. Take photos/make a book to show
relatives. Introduce new staff in advance.
Ideas for desensitisation
– Communication cards or a dry-wipe board
(but consider child’s ability to initiate)
– Aids to Communication (e.g. talking cards,
talking tin or photo album) see slides 21-24
and 57-58
– Voicemail – child records the home message
or leaves a message with friends and family
– Read to teacher/TA via telephone
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Talk Time Postcards
www.specialdirect.com
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Talking Tins
Price £4.00
(£4.70 inc.VAT)
3 for £10.99 + VAT
Price £5.50
(£6.46 inc.VAT)
The postcards contain a voice recording chip - simple
record and play operation. Slot any pictures in the plastic
pockets and record your own 10 second message.
Talking Products Ltd
www.talkingproducts.co.uk
Tel: 02380 730731
Available in packs of 3, 10, 30 or 100.
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Cards & Key Ring
Price £4.25
(£4.89 inc.VAT)
Talking Photo Album
Price £21.25
(£24.96 inc.VAT)
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Maggie Johnson 2015
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4
A1. Create the Right Environment
Treatment Progression
A. Educate home and school (including peers) about
SM in order to create a consistent, positive,
inclusive environment, with no pressure to speak
B. Explain to the child why they are having difficulty
and how they will overcome it
C. Set up small steps programme to establish
speech with designated keyworker (using parent
where possible)
D. Generalise speech to other people/places
E. Actively manage (and subsequently monitor)
transition into a new class/school (pages 23-25).
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A2. Create the Right Environment
• Raise a shared awareness
– education, teamwork and consistency are
essential for family, staff and peers
• Understand the child’s anxiety
– modify interaction/expectations (adjust
Maintaining Factors on page 3 and see
handouts on pages 7-10)
• Reinforce risk-taking rather than
avoidance
– do things with rather than for the child or make
them easier
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A3. Create the Right Environment
• Acknowledge child’s difficulties but cut them
down to size
• Remove all pressure to speak and
ensure that all associations with
communication are positive
– play down difficulties without ignoring them
– hide own anxiety and be positive about future
• Foster a special relationship with at least one
adult at school
– provide opportunity not expectation
– cajoling, gentle persuasion, bribes and
reprimands all amount to pressure
– suggest alternative (natural) forms of
communication until child is ready to speak
– never remove all need to communicate
– rapport building for confidence and trust
• Use friends and family to mediate and
facilitate communication
– sit children with their friends, invite parents into class
– communicate through friends or parents
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B. Talk to the child openly and positively
• Don’t ask children why they don’t talk, tell them “Talking to
new people can feel scary to begin with – so scary your
words get stuck and don’t come out. But it’s OK, you don’t
need to talk to play these games.”
• Reassure them “You’ll be able to talk to me when you’re
ready, but til then you can just talk to Mum/friend if you like.”
• If appropriate – “it’s hard learning a new language / talking
clearly / not knowing anyone / being worried about making a
mistake.”
• “Talking might be difficult at the moment but you can join in &
have fun without talking. It’s OK to laugh, it’s OK to sing!”
• “You’re not the only one who finds it hard to talk sometimes.”
• “It won’t always be like this – talking will get easier.”
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Maggie Johnson 2015
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5
B. Talk to the child (keyworker)
Jessica
Kingsley
Publishers
• You are not alone
• I know you can’t help it
• When you get worried about talking your
throat goes tight and your voice gets stuck
• There’s a reason why you feel this way,
and ways we can help
• This is how we do it - tiny steps
• We only move on when you are ready
• If you ever feel uncomfortable, we stop
• It won’t always be like this
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Hannah tells
her family,
friends,
relatives and
teachers how
they can help
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(15 year old’s letter)
Speechmark
Publications
See a different Megan (aged 10) from Dover on
the BBC documentary ‘My Child Won’t Speak’,
which is available on You Tube (Parts 2-4).
“every child with selective mutism should have
a friend like Daniel”
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A letter is read out to her class in Part 4
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Communication Load (p.11)
Programme Planning
• Understand Anxiety Hierarchies
– Stages of confident speaking
– Communication load
•
•
• Understand the techniques to elicit and
generalise speech
• Who?
• When?
• Where?
• How often?
•
•
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Maggie Johnson 2015
•
LOW
rote language
economical
e.g. yes/no
no risk of getting
it wrong
elicited/structured
speech
Talking in unison
•
•
•
•
HIGH
alternatives/
reasons
opinions/ideas
unsure if answer is
acceptable
initiated/unplanned
speech
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Sliding–in Technique (5 yrs+)
C. Eliciting Speech (page 12)
• Use sliding-in technique, if a conversational
partner is available to help
– enter room while child is talking and join in once
child can tolerate your presence
• Use shaping approach if not
• Desensitisation (use of audio/video tape)
• Combination of above
Small steps following systematic
progression
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• Structured approach to introduce a new
person into the child’s comfort zone
• Short specific talking tasks in gradual small
steps (quiet voice is ok and will get louder)
• Change one thing at a time (location of new
person, door, eye contact, activity,
communication load)
• Talk through the programme, no surprises!
• Record progress (age appropriately)
• Start each new session with a warm-up
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D. Generalising Speech
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D. Generalising into the Classroom
Do not expect child to use speech in whole
class activities until:
• Half the class and teacher have heard their
voice during sliding-in activities and/or voice
recordings
• Child can talk or read to TA / teacher in
classroom while other children are occupied
• Child has practised lesson activities outside the
classroom
• Child can talk to their talking group in the
classroom as a lesson activity
Maggie Johnson 2015
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Reassurance: remind child it goes at their pace,
e.g. teacher will just be coming into resource
room - no expectation to talk in class yet
Work on the following in any order but only
change one thing at a time:
• Slide in new people, slide out original people,
eventually include strangers
• Increase number of people present
• Change location
• Increase communication load from structured
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to spontaneous speech
D. Generalising in the Community
(see Parents Advice Sheet for detail)
To build child’s tolerance to speaking in
public:
• Break the whispering habit
• Educate people you see often and ask them
not to directly question the child (do this
discreetly)
• Let child know that people understand so
there’s no pressure
• Redirect questions from strangers
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Programme Planning
Small steps programme
Need to agree:
• Understand Anxiety Hierarchies
• Understand the techniques to elicit and
generalise speech
• Where: Initially home? Private room at school?
• When: Intensive burst in holidays? After school?
Lunchtime?
• How often? At least 3 x week initially,10-15 mins
• Who? Best placed school based staff member
plus parent in initial stages
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Slow progress or
‘regression’?
•
•
•
•
•
•
initial keyworker/overall progression (page 6)
sliding-in technique or shaping? (pages 12 and 16)
timing/frequency of sessions (page 16)
rewards/recording system
priorities for generalisation (page 14)
realistic targets following systematic progression at
child’s pace
• what to do if target failed (page 21/22)
See summary checklist on page 13
Regression…. or is it?
Rebecca aged 4;9
•
•
•
•
Many factors can impede progress
All can be resolved / avoided
Never too late to repair setbacks
Requires open discussion and
positive attitude
• True regression is extremely rare
“Rebecca achieved Stage 5 with her
teacher and was thrilled. She wanted to
do it again the next day. However she
did not speak at all the next day and
has since regressed. How do we deal
with this?”
Look at what actually happened and
discuss a way forward.
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Regression…. or is it?
Maddy aged 7;0
Day One
Reading to Mum in home corner in
classroom at end of day. Teacher came
in unexpectedly and to Mum’s surprise
and Rebecca’s delight, R carried on
reading.
Day Two
Teacher sat in classroom while
Rebecca and Mum went into home
corner. Rebecca was unable to read.
Rebecca went home in tears.
“Maddy’s doing really well at school but
regressing at home. She’s always spoken to
her Maths tutor who comes every Saturday but
didn’t speak to her this week. She spoke a few
words to me in front of her but that’s all. I just
don’t understand it”
Look at what actually happened and discuss a
way forward.
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Maggie Johnson 2015
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Regression…. or is it?
Jodie aged 9;0
Most Saturdays
Mum welcomes the home tutor and has
a cup of coffee and chat with her before
Maddy starts her lesson. Mum leaves
them to it.
This Saturday
Mum needed to go out so Dad let the
home tutor in. Maddy was silent during
the lesson. When Mum got home
Maddy spoke to her in front of the tutor.
“Jodie was talking to me and her TA fine
but then we handed over to the next
Year group. Now she talks to them but
not us – why has she gone backwards?”
(class teacher)
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Regression…. or is it?
Kelly aged 14
Success depends on
• Thoroughly assessing and reducing
reinforcement of mutism
• Full involvement of child
• Relationship with keyworker
• Understanding the progression and
keeping anxiety to a minimum
• Being prepared for and ready to cope
with setbacks
• Knowing when to let go
“Kelly just blanked me, I couldn’t get a
word out of her. Do you think she’s
annoyed with me because I had to
cancel her session?”
(TA)
(TA stopped Kelly to talk to her in the
corridor and explain she couldn’t see
her that afternoon)
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When to let go?
• keyworker’s role is to move things on and reduce
child’s dependency on one adult (page 13)
• intervention can only be regarded as successful
once child has transferred speech to a new
setting and is coping with new adults and children
in that setting
• must actively manage (and subsequently
monitor) transition into a new class/school
• prior to transfer introduce new adult(s) to child
and/or introduce child to new setting
(see ‘Transition Planning’ pages 23-25)
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Maggie Johnson 2015
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Further support
• ‘Silent Children’ DVD available from SMIRA
• SMIRA (Selective Mutism Information and
Research Association) – a parent/professional
support group based in Leicester with free
membership
[email protected]
Help Line 0116 212 7411 (4-7pm not Thurs)
• SMIRA website www.smira.org.uk and SMIRA
Facebook Group with free downloads, info
packs and chat groups (older children have
their own ‘SM Space Café’)
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Addressing Anxiety
Resources
• The Selective Mutism Resource Manual
Speechmark Publications 01908 326 944
ISBN 9780 86388 280 7 Order Code: 002-4759
• Can I Tell You About Selective Mutism? by Maggie
Johnson & Alison Wintgens, Jessica Kingsley
Publishers, June 2012. ISBN 9781849052894
www.jkp.com £7.99
• My Friend Daniel Doesn’t Talk by Sharon Longo
Speechmark Publications [email protected] £9.99
ISBN 9780 86388 562 4 Order Code: 002-5288AF
• Social Skills Poster: Facing Fears
Taskmaster Ltd www.taskmasteronline.com
0116 270 4286 for catalogue
• Dawn Heubner (2006) What to Do When You
Worry Too Much: A Kid’s Guide to Overcoming
Anxiety, Magination Press (Order through Amazon)
• Stallard P (2002) Think Good – Feel Good: A
cognitive behaviour therapy workbook for children
and young people, John Wiley & Sons, Chichester
• Stallard P (2005) (A Clinicians’ Guide to) Think
Good – Feel Good: Using CBT with children and
young people, John Wiley & Sons
• Anxiety UK Children and Young People with
Anxiety: A Guide for Parents and Carers/ Young
Person’s Guide (£3) www.anxietyuk.org.uk
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Aids to communication (1)
• Talking photo-album 24 inserts, 6x4 ins
£24.99 and Talking Postcards, 3 for £10.99
Special Direct 0800 318 686
• Talking Toucan or Repeating Parrot £14.95
Nauticalia 0870 905 5090 or
www.nauticalia.com
• Talking Teddy around £20. Make a bear to
your own specification and include a recorded
message www.buildabear.co.uk
• Nintendogs’ game (£25-£30) for Nintendo DS
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console - talk to dog to make it perform
Maggie Johnson 2015
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Aids to communication (2)
• Talking Products Ltd Tel: 02380 730731
http://www.talkingproducts.co.uk
Talking Tins, Mini Me Voice Recorder,
Talking Photo Albums, Talking Keyrings,
Talking Labels, Talking Greeting Cards etc.
• Lucky The Incredible Wonder Pup
(Amazon/Argos). Lucky is a Voice
Recognition Puppy who understands
15 phrases and obeys commands such
as "sit", "come here", and "go to sleep".
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