Information for Professionals

TRANSITION PLAN

Preparing to change School, Class or Teacher or start at school or nursery

Time invested in agreeing and implementing a Transition Plan will ensure that the child adapts quickly to a new environment, builds on progress made and develops in confidence and independence.

A change of class and/or teacher can be a stressful time, particularly if a child is doing well and parents are afraid of losing momentum. However, if the transition is managed well, children can leave old memories and associations behind and gain confidence and independence in the new setting.

The following recommendations also apply to starting school or nursery for the first time.

1, It is vital that all staff in the new setting understand the nature and implications of selective mutism and that there will be no pressure on the child to speak until they are ready. Reassurance should be given to the child to this effect, both by parents and staff (see Phase 1 intervention for relevant information). Identify a learning mentor / keyworker / support teacher in the new setting who will provide an escape route if necessary and meet with the student regularly to ensure they are happy, not being teased/bullied etc.

2. Preparation should start several weeks in advance with positive comments about the move and familiarisation with the building, classroom and staff.
eg:

• social visits with parents for summer fair, concerts, charity events, play schemes etc
• look round school/class when building is empty (during holiday or after school)
• take photos and make a booklet about My New Class/School
• meet the head and classroom teacher/key staff in as informal a situation as possible.
• include younger siblings if available and appropriate.
• routine visit with current class plus one extra visit with familiar adult or friend
• new teacher/teaching assistant (TA) to visit child in current class or at home. (Home visits likely to be extremely beneficial – SMRM page 131).
• slide-in new teacher/TA before end of term (Phase 2 intervention)

3. If it is not possible to meet new staff in advance, try to ensure continuity by
eg:

• keeping the child with a best friend
• arranging for previous teacher/TA to spend some time with the child on their first day
• ‘borrowing’ previous keyworker to hand over to new keyworker at beginning of term (Phase 1 or 2 intervention)
• keeping current keyworker (but beware of child becoming too dependent on one adult over a long period of time)

4. It will be helpful if new teachers/teaching assistants (TAs) can make some time for a few minutes of rapport-building with the child on a one-to-one basis during their first week in order to achieve as many of the following as seem appropriate:
eg:

• reassure the child that they will not ask them questions or pick them for demonstrations unless the child volunteers
• enlist the child’s help and then praise for a job well done
• reassure the child they will be checking they are OK, have a friend to sit with, understand the work, have been to the toilet etc.
• give the younger child confidence to respond by playing games that initially only require pointing, nodding, shaking the head etc.
• reassure older children they can contribute/ask questions by writing things down until they feel relaxed enough to talk.
• explain that they will need to use a loud voice sometimes but this does not mean they are angry (SM children are very afraid of getting things wrong and will withdraw rather than risk being told off).

5. Foster friendships with other children as actively as possible, particularly outside school by inviting peers home to play/have tea. Try to find out in advance if there are children nearby that attend the same school/playgroup and make contact with their parents. Teachers can help by suggesting which children would make good friends and introducing parents after school if parents find it difficult to make the first move.

6. Parents should stay with children in pre-school settings until the child is comfortable for them to leave. Do not EXPECT the child to be anxious, as this anxiety will be conveyed to the child. Parents need to stay relaxed and calm themselves and praise the child for being brave and staying on their own for longer each day. Do not delay the initial separation too long however, as it is only by facing their fear and successfully coping on their own that children will learn not to be afraid.

7. If children are finding it hard to join in at pre-school/reception class, parents can come early and join in the last few activities/story with the child so they leave with a positive experience. Alternatively, a parent can stay for the first half an hour, joining in the activities and helping the child to integrate/make friends/build rapport with a designated adult (SMRM page 132). This may occasionally be necessary in Year 1/Year 2.

8. Pupils preparing for transition to secondary school or college need to focus on developing their independence outside school and confidence in talking to strangers as much as possible during their final year, e.g. making phone calls, running errands, dog-walking, ordering pizza, banking birthday money, earning money car-washing and baby-sitting, going swimming, joining clubs, developing interests etc. etc. (SMRM page 170). The summer holidays are a good time for shared activities and trips with friends who will also be attending the new school/college, and for meeting new people who know nothing of the child’s difficulties. Confidence grows through achievement and as the child becomes their own person, the seeds can be sown that a fresh start in a new educational establishment is exactly what they need. If they can talk to strangers, they will be able to talk in a new environment.

• See Danielle aged 15 in BBC Documentary ‘My Child Won’t Speak’

SMRM = Selective Mutism Resource Manual, Johnson & Wintgens, 2001, Speechmark Publishing Ltd.

Copyright Maggie Johnson 2011.

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.

The Older Child or Teen with Selective Mutism

Ricki Blau

Selective Mutism in the Older Child

Selective Mutism (SM) is usually noticed when a child begins pre-school or kindergarten, if not before. So when a student in the upper elementary or secondary grades has SM, it’s safe to assume that he or she has been living with Selective Mutism for many years. Within the lifetime of today’s teens, researchers and treating professionals have learned much about this anxiety condition. Young children who receive prompt and appropriate treatment now make great strides. But information about SM is still not as widely available as it should be—educators, doctors, and psychologists often fail to recognize SM or understand how to help affected children. Consequently, many children do not receive early diagnosis or appropriate support.

Older students with SM may have received no treatment or may have suffered years of inappropriate treatment and negative reinforcement. Instead of being helped to control their anxiety and become more comfortable at school, they may have been pressured to do the things they feared, such as speaking. Over the years they have developed ingrained behavior patterns and maladaptive coping mechanisms by which they avoid situations that make them anxious. Not speaking has become a habit that is difficult to break. They begin to see themselves as “the kid who doesn’t speak” as do many people around them. The fear of receiving attention if they should start to speak makes it harder to imagine changing. They may also have developed phobias about speaking or having their voice heard. Older children with SM often lag behind their age peers in social competence because they’ve had less experience with peers and adults. Treatment plans for the older child must take these complications into account. 1

Students with SM are, in general, extremely sensitive individuals. Older children and teens are acutely aware of their differences and the responses they elicit from their teachers and other adults. People have been trying to get them to talk for years! They understand that they repeatedly fail to meet standard expectations in the school setting. Consequently, they are wary and keenly aware of the most subtle pressure to communicate. Wanting to avoid attention, they typically have learned to hide the appearance of anxiety; while younger children may freeze and show a blank expression, older students more commonly appear relaxed and “ok,” even when they’re not.

In summary, older children have developed more complicated profiles, influenced by their experiences and environmental stressors. Their individual profiles tend to show more variation than with younger children, and treatment needs to be tailored to the individual.

Helping the Student Make Progress

For all of the above reasons, you can expect progress to be more difficult and slow once a child has reached the age of eight or nine. Different strategies and interventions are needed for older children or teens. Consider, for instance, a fading strategy, in which a child first talks with a parent in a private room at school, and over time other individuals are gradually drawn into the conversational group. This often succeeds with a very young child. Older children, on the other hand, have developed a self-image as a noncommunicator and would recognize the situation as a set up aimed at getting them to talk.

The fading strategy doesn’t work for them. As experienced treating professionals have found, the older child or teen needs to be actively involved and in control of their therapy, which aims to help them recognize their anxiety and take small, controlled steps in real life situations. In younger children, medication to reduce the anxiety often produces quick and dramatic results. With older students who have many habits to unlearn, medication is often an important adjunct to behavioral therapy but many treating professionals have found that it not as effective on its own.

For older children, the thought of changing longstanding habits and exposing themselves to anxiety-provoking situations is frightening, and they can become quite resistant to therapy. Dr. Elisa Shipon-Blum, the Medical Director of the Selective Mutism Group/Childhood Anxiety Network, has observed that if a child is not verbal in school by the age of eight or nine, he or she is unlikely to talk at school until at least high school, and possibly later. For students in this age range, she has suggested that the emphasis be on helping the student realize his or her academic potential and remain socially connected. This will usually require flexibility about assessment and participation.

The student’s self-consciousness usually extends to situations beyond speaking and commonly affects non-verbal as well as verbal communication. In general, the student with SM finds it much easier to respond to another individual than to initiate communication. A student who is able to respond to a teacher’s question, (verbally, in writing, or with a gesture) may be unable to initiate with that same teacher to ask a question or contribute to a class discussion. He or she may be unable to take a note to the attendance office, check out a library book, or make a purchase at the snack bar. SM has an impact both academically and socially, and students can feel left out because of their inability to interact with ease.

If teachers can help decrease anxiety at school and increase the student’s self-confidence, there will be a greater chance of progressing communicatively, both non-verbally and verbally. Perhaps the student will interact with new work partners, carry notes to the office without a friend, or respond more easily, in writing, to discussion questions. It is important to recognize even small improvements and not become discouraged! Measure success by how well the student functions at school in general, and not by his or her communicative relationship with the teacher. Even the most empathetic and skilled teacher is an authority figure, and students with SM are commonly more inhibited with teacher than with other people. At the beginning of a new school year, new teachers should start allow for plenty of “warm-up” time. Start slowly with the goals of getting to know the student, gaining their trust, and helping the student become as comfortable as possible at school. Emphasizing or pushing for communication in any form, non-verbal, written, or oral, is likely to cause the student to withdraw. Communication will develop as the student becomes less anxious.

Helping the student make and maintain social ties is vital. It is, unfortunately, too easy for a socially anxious individual to become isolated and depressed. Depression is more likely as a child enters adolescence and can lead to more severe anxiety, social isolation, lower performance in school, suicidal thoughts, and self-medication with alcohol or drugs.

It’s More than Not Talking

Studies have shown that over 90% of children with SM have Social Anxiety Disorder, also known as Social Phobia. 2 3 4 5

In fact, some experts have suggested that SM may be a manifestation or variant of social anxiety. These students are excessively selfconscious. They are afraid of being embarrassed, judged or criticized, and of receiving scrutiny or attention. 6

Social anxiety does not make a child anti-social or even asocial. A socially anxious child can be very social and enjoy the company of family and friends when in a familiar and comfortable setting. Many students are more comfortable with their peers (this is more common), but others are more comfortable with a trusted adult.

Some students, who may have partially overcome their SM, do speak at school. Most likely, these students still experience anxiety, even though it is less obvious. 7 8

They may not be able to speak in all situations or with all people. A student who is able to respond to a teacher’s question or even contribute to a discussion may be completely unable to ask a question or express a concern.

Anxiety can affect academic performance in many ways, even in a student who begins to talk at school. Not talking is only the tip of the iceberg! Other manifestations of anxiety include:

• Perfectionism; worry that work is inadequate in quality and/or quantity
• Procrastination and avoidance
• Problems with test-taking and timed testing; may rush for fear of not finishing in
  time; may panic; may be too anxious to check answers or may check answers repeatedly and not finish
• Problems with open-ended or unclear assignments; worry that they don’t know what the teacher wants or that they will do the wrong thing
• Unable to ask for help or clarification; unable to express worries or complaints
• Afraid to express an opinion, even to express likes or dislikes
• “Blanking,” or panic-like reactions
• Easily frustrated
• Illegible, tiny, or faint writing to obscure answers they’re unsure of
• Difficulties with group work; may be unassertive or passive; conversely, may be a “control-freak” if worried that the group’s work is inadequate
• School refusal or faked illness to avoid social situations at school or because of worries about schoolwork

The first step in helping a student with these difficulties is to recognize that they are manifestations of anxiety. The student is not choosing to behave this way and is neither unmotivated nor oppositional. Then,

• work to build the student’s self-esteem and self-confidence,
• increase the student’s comfort and reduce anxiety at school,
• back off on all pressure to speak, and
• make accommodations, such as those suggested in the following section, that allow the student to progress academically.

Mild expressive language difficulties may be more common in students with SM, and they can be a source of added self-consciousness and anxiety.9 10 Subtle effects on oral and written expression can include: word retrieval glitches, terse writing with few descriptive details, and the use of non-specific language (e.g. “that thing” instead of a precise noun). A screening by a Speech and Language Pathologist or Neuropsychologist may be appropriate if there are concerns about language difficulties.

Accommodations and Classroom Strategies

Listed below are suggestions for strategies and accommodations that may be helpful for the older student with Selective Mutism. 11  Accommodations and modifications may be specified in an IEP or 504 Plan (in the US). Some accommodations are appropriate for almost any student with SM:

• Training for teacher(s) covering the nature of SM and classroom strategies; training before the start of the school year followed by on-going support
• Brief training so that all adults who might have contact with the student understand SM and how to interact with the student.
• No grading down for not speaking or for any failure to communicate that is due to the anxiety condition.
• No pressure to speak. No teasing, threatening, limiting the student’s participation, or punishment for any failure to participate that is related to the anxiety condition.
• Alternative forms of assessment and participation to substitute for speaking, such as: written work, non-verbal communication, audio- or video-taping, collaboration with friends, practice at home under parent’s supervision, the use of a computer, or the use of another person as a verbal intermediary. Individual work may be allowed for a student who is unable to participate in a group.
• Warm, flexible teachers who understand SM as an anxiety condition
• Avoid singling out the student or calling attention to any differences.
• Avoid calling attention to any new steps the student makes, such as talking in a new situation; other students should be told, without the student present, to not comment if the student with SM talks
• Do not attempt therapeutic interventions except under the guidance of an authorized treating professional or as specified in the IEP or 504 Plan, and keep written records of interventions.
• In general, except as specified in the IEP, treat the student as much as possible like any other student.

Other accommodations and strategies to consider, depending on the individual student, include:

• Clear, specific assignments and expectations; detailed grading standards or rubrics that reduce the student’s worries about what is expected
• Clear and specific prompts and questions for written work and discussion topics, rather than open-ended topics
• Place trusted friends in the same class(es). In secondary school, this probably will require hand scheduling.
• Frequent opportunities for small group activities, preferably with at least one trusted peer.
• Frequent opportunities for hands-on activities, since many students are more engaged and less distracted by worries when physically active.
• Frequent opportunities for gross-motor activity (not only organized physical activities, but also informal opportunities to get up and move around) to help the student with self-regulation.
• Teachers initiate a regular check-in with student to compensate for student’s difficulty in initiating verbal or non-verbal communication; ask if the student has any questions or anything they want to communicate.
• Seating in less conspicuous locations: back half of the room, towards the sides, and away from the teacher’s desk
• Seating next to a trusted friend and near students identified as good work partners
• Vary modes of participation for the entire class to include non-verbal communication, e.g.: students write on individual small white boards, students signal “thumbs up” or “thumbs down,” students indicate a numerical response by raising the corresponding number of fingers, students write a question or comment (possibly anonymously) to hand in
• Advance preparation for class discussions; present questions to the student the day before or earlier in the day. If the student is unable to respond, move on rather than waiting for the student to answer.
• Extended time for testing and assignments, or non-timed testing.
• Advance notice for large projects; help break projects into smaller chunks to avoid overwhelming the student.
• Alternative forms of participation in school performances. Some students with SM enjoy acting and find it easier to speak in the role of a character, and some sing or do cheerleading in a group.
• Many are too self-conscious to appear onstage even in a non-speaking role but contribute as a writer, publicity artist, set designer, or lighting technician.
• A private location to dress for PE
• Support social connections: identify potential friends and work partners; initiate activities with those students and monitor as necessary; teacher assigns partners rather than let class choose
• Encourage the student to tell others how he or she would like to be contacted, for instance if they are working together on a project that requires some contact outside of school
• Set aside an area within the classroom where a pair or small group of students can work more privately, so as to encourage more easy communication. The area might be equipped with small whiteboards, office supplies, etc.
• Social support at lunchtime, on field trips, and at other unstructured times
• Support for participation in extracurricular activities
• A steady adult, such as a trusted teacher or counselor, responsible for maintaining a continuous relationship with the student from year to year
• Disability awareness and sensitivity training for other students; monitoring for bullying; be prepared to answer questions from other students, help them understand SM, and address their
• Regular and frequent communication with the parents and outside treating professionals; communication mechanisms, such as email or voicemail, so that the parents can alert the school to immediate problems
• Support for the student’s goals in behavioral therapy under the guidance of an outside (or in-school) treating professional, including: communication with treating professional (possibly through the parents), record keeping and reporting, and carrying out the specified communication activities. Examples of activities: send student on an errand to the office with or without a buddy, student “interviews” teacher with written questions, student mouths words while class recites poem.

With appropriate support the older student with SM can achieve academically and develop social relationships. Helping students gain comfort and confidence at school fosters an environment in which they experience less anxiety and can increase the level and variety of communication at school.

1  The discussion in this and the following two sections are based on a series of lectures given by Elisa Shipon-Blum, D.O. at the conference Speaking Out for Our Children. Quality Resort Hotel, San Diego, California. 17-18 January 2004.

2  Bruce Black and Thomas W. Uhde, “Psychiatric Characteristics of Children with Selective Mutism: A Pilot Study.” J. Am. Acad. Child and Adolescent Psychiatry 34:7, July 1995: 847-856.

3  Denise Chavira et al., “Selective Mutism and Social Anxiety Disorder: All in the Family?” J. Am. Acad. Child and Adolescent Psychiatry 46:11, November 2007: 1464-1472.

4  E. Steven Dummit III et al., “Systematic Assessment of 50 Children with Selective Mutism.” J. Am. Acad. Child and Adolescent Psychiatry 36:5, May 1997: 653-660.

5  “Practice Parameters for the Assessment and Treatment for Children and Adolescents With Anxiety Disorders.” J. Am. Acad. Child and Adolescent Psychiatry 46:2, February 2007: 267-283.

6  Ibid.

7  R. Lindsey Bergman, John Piacentini, and James T. McCracken, “Prevalence and Description of Selective Mutism in a School-Based Sample.” J. Am. Acad. Child and Adolescent Psychiatry 41:8, August 2002: 938-946.

8  Bruce Black and Thomas W. Uhde, op.cit.

9  Hanne Kristensen and Beate Oerbeck, “Is Selective Mutism Associated With Deficits in Memory Span and Visual Memory?: An Exploratory Case-Control Study.” Depression and Anxiety 23:2, 2006: 71-76.

10  Katharina Manassis et al., “The Sounds of Silence: Language, Cognition, and Anxiety in Selective Mutism.” J. Am. Acad. Child and Adolescent Psychiatry 46:9, September 2007: 1187-1195.

11  School accommodations for younger students are discussed in Elisa Shipon-Blum, The Ideal Classroom Setting for the Selectively Mute Child (Jenkintown, PA, The SMART Center, 2003) and in Angela E. McHolm, Charles Cunningham, and Melanie K. Vanier, Helping Your Child with Selective Mutism (Oakland, CA, New Harbinger, 2005).