Implementing a small steps programme
The majority of selectively mute children have developed a chronic anxiety reaction in situations where they are required to talk to people for the first time, especially when they can be overheard (a phobia of speaking). As a result, they have a very limited talking circle and are only able to talk to certain people in certain situations.
Following assessment, all work to overcome this type of difficulty starts with ensuring that people in the child’s school/home environments understand:
a) what to do to encourage communication and the confidence to try new things, and
b) what is unhelpful and maintains the mutism.
This might be achieved by arranging a meeting in school with parents/key staff using the Silent Children DVD(*1) as a springboard for discussion and information-sharing, both in general terms and in relation to the individual child. One crucial step will be to begin talking to the child with open acknowledgment and explanation of their difficulties.
For younger children, a change in other people’s reactions and expectations, together with encouragement and support to enjoy non-verbal communication, can be sufficient to facilitate a progression towards verbal communication. When no change is noted however, selectively mute (SM) children are likely to benefit from a more formal behavioural programme designed to reduce their anxiety and extend their talking circle.
Such programmes use three behavioural techniques to elicit and generalise speech:
a) ‘stimulus fading’
It is the audience/conversational participants or setting which changes rather than the child’s speech effort. The child talks to a trusted conversational partner (usually a parent) in a minimal anxiety situation and then one factor is changed – an anxiety trigger is introduced. If the child is relaxed to start with and the change is only slight, the child can tolerate the anxiety trigger and keep talking. For example they can tolerate another person gradually coming closer and joining in the activity.
When this is carefully planned and broken into very small steps we call it ‘the sliding-in-technique’. At first the child talks freely to a member of their family with the keyworker outside the room; this is repeated with the door slightly ajar, then with the door open and finally with the keyworker inside the room. If the child is able to maintain some voice at this stage, the keyworker can move forward and join in the activity. Direct eye-contact is generally avoided until the child is talking more confidently. The process is further facilitated by setting specific targets and starting with very short, undemanding turn-taking activities, such as counting to 10, which are gradually extended to longer sentences. Specific target-setting is only appropriate for older children who understand the principles involved and are motivated to overcome their difficulties, having reached a point where the selective mutism has become well entrenched and beyond their control.
b) ‘shaping’
It is the speech target that changes. The child starts with non-verbal communication with a keyworker in a minimal anxiety situation and then takes tiny steps towards verbal communication by gradually increasing articulatory effort, voicing, eye-contact, syllable-, word- and sentence-length etc.
c) ‘desensitisation’
The child gets used to the thought of doing something they previously believed they couldn’t manage by carrying out related, but less-threatening activities. For example they allow a teacher or classmates to hear their voice on tape. Or they talk to a classmate over the phone before trying it face to face.
Stimulus fading or shaping?
In practice we use a combination of techniques depending on the age of the child, how anxious they are and whether the parent(s) can be involved. Desensitisation activities can play a valuable part in both stimulus fading and shaping programmes but should never be allowed to become a substitute for speech.
a) Up to 6-7 years
Shaping works very well with the very young or less anxious SM child and leads on from rapport building with a familiar and trusted staff member (keyworker) in the child’s school setting. The children benefit from both individual and group sessions where they feel absolutely no pressure to talk, but are gradually encouraged to move from non-verbal communication and action-rhymes, to sound-making, singing, humming, speech sounds and words. At the same time, parent(s) spend time in the classroom/playgroup and at home using the stimulus fading principle to help the SM child speak near to, and eventually with, other children and adults. Other professionals (speech and language therapists or psychologists) have a valuable role with overall coordination, supervision and support. As they can represent an extra pressure, they should avoid direct involvement with the child unless there are other concerns about the child’s language development, learning, behaviour, or family dynamics.
a) parent supports generalisation to other people and places and slides out as child’s confidence grows (omit this step if parent not available)
b) rapport-building with keyworker
c) shaping games with keyworker to elicit speech
d) keyworker/parent supports generalisation to other people and places including transition to new school/class
b) 5-6 years and above
After working through the above strategies, more anxious children may need a specific programme to elicit speech with a keyworker. They need to feel in control of their anxiety, so are made fully aware of each target and record their success at each step. Stickers etc. are a confidence boost and provide a natural break which reduces the anxiety level between targets. For most children, stimulus fading with the parent provokes far less anxiety and yields quicker progress. Some teenagers find it difficult to work in front of their parents and prefer shaping however. And sometimes there is no talking partner available so stimulus fading is not an option.
How often and how long will it take to elicit speech?
A shaping programme to elicit speech should only be attempted if the child can be seen individually for a short time three or more times a week for at least a term without a break.
Any less than this and it’s like starting again each time for the child.
Stimulus fading also needs a commitment of three sessions a week with close collaboration between home and school or clinic, but speech is usually elicited with a familiar keyworker after 2-4 sessions. Once the child is talking comfortably to the keyworker, sessions need to continue on a twice-weekly basis to slide-in other significant adults and children and transfer back to the classroom. Once talking in the classroom, targets can be managed within the school day and extra sessions need only be arranged to manage transitions from one year group to another.
Transitions between schools and classes must be carefully managed as part of the programme. It is relatively easy to elicit speech with key adults and friends, but generalisation to other children and adults in all situations can take several years, depending on the age and anxiety levels of the child. What we can be sure of is that the earlier we start and the more we do, the quicker the difficulty will be overcome.
Specialist involvement?
Sometimes it may be appropriate for an outside professional to establish speech with the child in the first instance – for example a speech and language therapist may already have established rapport with a child during assessment, or be able to capitalise on a holiday period to get a programme underway in preparation for a new term. Or the child may have put up so many barriers at school that they need to gain confidence and belief that progress is possible on neutral ground. Equally, therapists and psychologists will benefit from the experience of working with at least one SM child in order to advise and support more effectively in future. But whichever approach is chosen, it is essential to find or hand over to a keyworker in the child’s school as soon as possible. Only staff on site have the day to day contact necessary to sensitively and effectively manage the generalisation phase.
If a school-based keyworker has been identified:
a) elicit speech with keyworker at home or at school using sliding-in technique with parent or shaping programme
b) fade out the parent either at home or school so that child can talk to keyworker without parent present (omit if parent not involved)
c) keyworker facilitates generalisation to other people and places at school including transition to new class/school
d) when half the class have heard child’s voice, conduct activities during class time
parent supports generalisation in wider community
If the keyworker has to be a parent (not ideal but sometimes unavoidable):
a) parent visits school regularly to slide-in selected children and adults in a room where they will not be disturbed, and slides-out for part of the session as child’s confidence grows with new people
b) new adult (e.g. teacher) introduces new activity while parent is out of the room
c) if possible, new adult starts next session and parent arrives later to take over
d) parent transfers activities to the empty classroom
e) parent continues generalisation to other people and places including transition to new class/school, always sliding out for part of session.
f) when half the class have heard child’s voice, conduct activities during class time
g) parent supports generalisation in wider community
If the initial keyworker is not school-based:
a) elicit speech with keyworker A at home, school or clinic using sliding-in technique
b) slide out the parent either at home, school or clinic so that child can talk to keyworker A without parent present (or do this after next step)
c) keyworker A hands over to a school-based keyworker B
d) slide out keyworker A
e) keyworker B facilitates generalisation to other people and places at school including transition to new class/school
f) parent(s) support generalisation in wider community
Full details of target-setting are set out in ‘The Selective Mutism Resource Manual’ (SMRM)*2.
Common practices that prevent or hinder progress
Firstly it must be stressed that although there are many factors that can impede progress, they can all be resolved or avoided! It is never too late to repair the situation after a setback, with open discussion between all involved to identify and modify the relevant factors.
1. The programme was started too early.
Inadequate assessment may lead to an inappropriate diagnosis and/or intervention plan.
a) The child may have additional problems such as autistic spectrum disorder, attachment disorder or receptive language difficulties which need to be addressed alongside the mutism.
b) Their reluctance to speak may be due to cultural or personal inhibitions which need to be addressed in the first instance.
c) Factors at home or at school which may be reinforcing the child’s mutism or raising their anxiety may not have been fully explored and addressed.
It may be helpful to revisit the child’s speaking habits and to use the Parental and School Interview forms in the SMRM(*2) as a tool to obtain more information about other concerns and possible maintaining factors.
2. Lack of teamwork, information or support.
Insufficient time has been invested in information sharing, joint planning and monitoring, leading to loss of momentum or the programme being abandoned.
An on-going team-approach involving both home and school is paramount and will be flagged up again in point 5, for any unaddressed anxiety or inconsistent handling will undermine the effectiveness of direct work with the child. Even when parents are not able to contribute to the programme directly, every effort should be made to forge a home-school link as parents can provide information, ideas and back-up that are crucial to the overall success of an intervention plan.
It must also be recognised that working with SM children is emotionally draining and keyworkers need ongoing support and regular opportunities for reviewing progress and sounding out ideas with the school SENCo, class teacher or visiting specialist. Outside agencies should note that leaving a programme in school without building in this support is rarely successful. Inexperienced keyworkers will need help to plan targets with encouragement and reassurance to maintain momentum. Never put the onus on a keyworker to make contact only if they have a problem, as this implies failure if the need arises. Review meetings should be set in advance and then cancelled if not required, with additional telephone contact arranged within a week or two of leaving a programme. Aim to review progress once a month for the first term and twice a term thereafter. By the second year, once a term is usually sufficient but contact can be maintained between meetings via telephone or email.
3. There has been inadequate discussion with all involved about the nature of intervention and the time it is likely to take.
Some schools may not have been aware of the time commitment required to successfully address selective mutism, nor appreciate that a relatively small time investment now, will eliminate the need for prolonged intervention and anxiety in later years. Other schools may be committed to the long haul but have allocated a keyworker to the child for only one or two over-lengthy sessions per week.
Frequent 10-15 minute individual sessions will be required to establish speech initially
(minimum three times a week), with a gradual reduction in frequency in the generalisation phase (sessions can now be increased to 20-30 minutes). Generalisation to other people and situations, and the transitions into new classes and schools must be managed as part of the intervention plan.
4. The child is not an active partner in the intervention process.
i) There has been little or no discussion with the child about the nature and resolution of their difficulties. Never ask children WHY they do not talk – how can they possibly know why this is happening to them?! All they know is that talking fills them with dread and they will do anything to avoid that feeling.
Instead, TELL them why. Before embarking on a programme, children need reassuring that you understand why they cannot talk in certain situations and know they are not doing it deliberately – it is anxiety that is stopping their voices from coming out of their mouths. Go on to tell them that this anxiety developed when they were much younger – they got scared when first separated from parents/teased for speaking/found it hard to use a new language/felt different or awkward in a new/noisy/crowded environment etc.
Explain that this happens to lots of children and it’s nothing to worry about – as they get older and braver the anxiety will disappear.
ii) There has been insufficient reassurance that progress will be made by moving one small step at a time at the child’s pace. The child therefore has no sense of where each activity is heading, leading to heightened wariness and anxiety. Do not fall into the trap of thinking you can fool SM children into talking or that it is somehow kinder to avoid explanations! They can only control their anxiety by knowing exactly what is happening and what is about to happen.
Breakdown at this stage often leads to a sense of being ‘tricked’ into talking and a dread of further consequences. Many children fear that if they talk to one person, they will immediately be expected to speak to everyone else as well – the secret will be out! They need to hear from everyone involved – parent, keyworker and teacher are the usual minimum – that time is NOT the essence, and that they can get used to talking to just one new person at a time. Only through trusting that what the keyworker says will happen, actually does happen, will children be able to relax sufficiently to take new risks. For example, if told they will be working alone they need to see a ‘Do Not Disturb’ sign on the door, rather than worrying that someone will come in at any moment. They should be given opportunities to help plan their programme.
5.There has been a lack of overall co-ordination with consequent inconsistency for the child.
For example, if the child has been assured that everyone at school understands their difficulty and that they need only talk to their keyworker for the time-being, valuable trust can be lost if other staff try to elicit speech. Or if one person is offering money, chocolate bars or Happy Meals for achieved targets, it should not be surprising that someone else’s stars appear less exciting.
It is worth emphasising that rewards are a valuable incentive – they are fun to win and provide tangible evidence of progress – but they are NOT bribes. The value of a reward lies not in its material worth, but in fostering the child’s belief that success IS possible with an opportunity to enjoy that success.
6. There is a poor relationship between the child and designated keyworker.
Young children need very regular contact with a keyworker in a familiar place to gradually feel comfortable and confident in their company. Sessions therefore need to be either at home or school in the early years with an appropriate adult who is part of the child’s day to day routine.
Perhaps there has been insufficient time to develop rapport before attempting the sliding-in technique or the keyworker has little understanding of the condition and conveys impatience or insensitivity. Sometimes the keyworker has not been particularly sympathetic to the child in the past and the child has a clear memory of this. A genuine apology and fresh start can work wonders!
7. The child has no clear indication about how often sessions with a keyworker will take place or how long they will last.
There is no warning that sessions are about to take place and no explanation if sessions are missed. Or there is a rather ad hoc approach to the sessions with no agreed time-limit (10-15 minutes recommended). SM children need to know exactly what is happening, otherwise they worry which is counter-productive to ‘having a go’ and taking risks. Many selectively mute children have a heightened sense of ‘abandonment’, and it is vital they believe that, all things being equal, their keyworker is not going to let them down.
8. The child is not clear about the content of the sessions/the keyworker is not clear about the child’s limitations.
The keyworker is attempting to build rapport through general chat rather than specific target-setting activities. This is appropriate for shy children but not SM children for whom social conversation carries the highest ‘communication load’ and generates acute embarrassment when they cannot respond. Provide an outline of the session (e.g. 10 minutes on targets, questionnaire about bullying, check to see how coursework is going) and give students the option of choosing the order (they may prefer you to choose). Younger children may simply be working on targets.
9. The programme has come to a standstill.
The child is enjoying the keyworker’s attention but little or no progress is being made. Perhaps the keyworker lacks confidence and is holding the child back by their own fear of failure. They are repeating tasks excessively rather than moving on each time. Or perhaps the keyworker is getting a boost from the unique relationship they have built with the child, and is sub-consciously delaying the generalisation phase while genuinely believing that the child cannot cope with more pressure.
Sometimes children are given too much control and are allowed to set not only the pace of the programme, but also the content. They then avoid taking risks and choose to repeat ‘easy’ anxiety-free activities. It is important for children to be given options, but only within an overall structure or progression which has been set by the keyworker.
In order to move the programme forward, the keyworker may need to reiterate their role (point 4) and remind the child that they are there to help the anxiety (‘nasty feeling’) go away so that the child can have friends and fun, get help with their work and so on. The phrase ‘I can’t do that because then I wouldn’t be helping you’ is a useful one to have ready! Keep the child’s favourite activities for rewards rather than time-fillers, and terminate sessions early if the child is not ready to try something new (see point 12).
10. The rule of changing only one variable at a time when setting a new target has not been adhered to.
The child is being expected to cope with too many changes at once. Variables include the identity of those present, the number of people present, the location, and the task.
If new activities are carried out within earshot of other people, perhaps through an open window or door, this alone represents a significant change for the child. Similarly, if group-size is increased, it is unreasonable to expect the child to cope with a change of activity at the same time. Either the number of people present should be increased or the complexity of the activity, but not both together.
So, if succeeding in a withdrawal room with the keyworker, the next step should be to either repeat the same activity in the classroom with no-one else present, or to repeat the activity in the withdrawal room with an extra child or adult of the child’s choosing. Or if the child talks to a teacher at home, they could try the same thing at school in an empty classroom with a parent present. Repeating the activity without the parent is a separate step.
11. Only one variable has been changed but it has been too big a step for the child.
How can the step be made smaller? Many factors can influence anxiety levels, so it is important to understand which factors are operating for a particular individual. For example, does it make a difference if the listener looks at the child or is turned away, if the child is required to silently mouth or use voice, or if a visible or hidden articulatory movement is involved (as in ‘p’ vs. ‘s’)?
More detail is given in the SMRM2, but essentially the keyworker should try to reduce or modify one or more of the following factors:
- the choice of person present
- the number of people present, either as part of the task or hovering in the background
- the extent of physical involvement (articulatory effort, eye-contact and gesture)
- the length of the task (keep it short and specific rather than open-ended: ‘read 5 words’ or ‘read for one minute’ cause far less anxiety than ‘read to me’)
- the ‘communication load’ of the task itself
The communication load is low when using rehearsed or familiar speech, minimal responses and factual language, and high when a child is required to initiate, express opinions, use complex language or hold open-ended conversations.
With regard to the choice of person present, care must be taken to ‘slide-in’ the child’s teacher at the appropriate time. If the child has little rapport with their teacher, sees them as an authority figure, is afraid to fail or wants to succeed almost too much, their anxiety level may be too high to allow the sliding-in technique to be successful. They will gain more confidence if the keyworker slides in a child or less ‘threatening’ adult first. Sometimes the child has such strong associations of failure with their current teacher, having tried to speak and failed on many occasions, that it is better to develop their communication with a classroom support worker in the first instance, and work towards generalising speech to the teacher in the next year group.
12. The child is being rewarded for silence rather than communication.
The child has failed to meet a target but was still rewarded – either with their usual token ‘for trying’ or by spending the remainder of their special time with the keyworker repeating anxiety-free activities. This reinforces silence and lack of risk-taking, and leads the child to view the keyworker as someone nice to spend time with, rather than someone who is there to help them move forward (see point 9 for related discussion).
Children should never be allowed to feel they have failed – only that their anxiety was too great to allow them to succeed. The keyworker’s job is to make the steps toward a challenging target smaller, giving reassurance that this will make it easier for the child to manage. This can either be done immediately with a shorter or simpler task (see point 11), or by terminating the session early with a very casual “Never mind, we’ll try again next time”. The experienced keyworker will use both these options to the child’s advantage, but less experienced workers are advised to opt for early termination. This provides breathing space and planning time, and means the child will feel disappointed that the session is over, rather than relieved that the pressure is off. If they have a good relationship with their keyworker (point 6) they will look forward to the next session, remaining motivated to attempt activities or discuss other ways forward. Fixed times for the sessions (point 7) ensure that the end is always in sight and that both child and keyworker usually finish ‘on a high’.
13. The child has been moved through the programme using a whispered voice.
Generalisation will be significantly delayed if this is the case, for whispering indicates audience-awareness and extreme tension around the vocal cords. It will be necessary to back-track with the sliding-in technique, moving more slowly (see point 11) so that a quiet but audible voice is maintained throughout, reminding the child to ‘use big voice’ or ‘switch voice-box on’. For example the keyworker may need to enter the room backwards to prevent reversion to whispering, or join in talking games while still outside the room. As long as the child is relaxed, volume then usually increases naturally as short manageable tasks are achieved and confidence grows. Activities involving silly noises and humming may also be helpful, as are blindfold or barrier games where the keyworker cannot lip-read and says ‘Pardon?’ if unable to hear.
N.B. It is perfectly acceptable for children to whisper at other times outside the special time allocated to working on targets. Any communication in natural settings is to be accepted until the programme helps them to feel better about using a stronger voice.
14. The programme has been discontinued too early with not enough attention paid to transitions.
It cannot be assumed that once a child is talking to one or two people they will now improve spontaneously and transfer easily to a new class or school. Change can sometimes be an advantage as mentioned in point 11, but for most children the generalisation phase needs to be closely monitored and facilitated. Prepare children for transition by introducing them to a new school or teacher in the term before the move, and take advantage of school fetes, informal visits and existing friendships to establish positive links and associations. Examples that help children settle include exploring and talking in a new school when it is empty, looking forward to sitting with a friend in a new class, having the continuity of a support-worker across two year groups, and being visited by a new teacher before the transfer for rapport-building and sliding-in.
Maggie Johnson
Speech & Language Therapist Advisor
Alison Wintgens
Consultant Speech & Language Therapist
(*1) Silent Children: approaches to Selective Mutism, 24 minute DVD made with grant from DfES, available from SMIRA, email: smiraleicester@hotmail.com.
(*2) The Selective Mutism Resource Manual, Maggie Johnson and Alison Wintgens.
Speechmark Publishing, 2001, ISBN 0 86388 280 3.
