Understanding Selective Mutism with Emily Laracy

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Transcript of “Understanding Selective Mutism” – Bright Conversations Podcast

Okay, hi everyone and welcome to today's episode of Bright Conversations, the new virtual talk show by Bright Ideas Media. I am your host Sarah. I am one of the co-founders of Bright Ideas Media as well as SLP Toolkit. And I'm really excited about today's topic and I know everybody will be because it's something that we all want to know more about and that is selective mutism, what it is, how it develops and how SLPs can support individuals through assessment and evidence-based treatment. And fortunately we have a guest here to talk about this because I have no expert on this topic but our guest today, Emily Laracy, is so welcome, Emily.

Thank you. Thanks so much. So happy to have you here. Before we kind of dive into it, tell us a little bit about yourself, your background and how you ended up specializing in selective mutism. Sure.

So currently I'm a school-based SLP. I primarily work with elementary students so kindergarten through fifth grade, although throughout the years I've worked with everybody from preschool up through like our 18 to 21 year old population. I selected mutism was actually my introduction into the field of speech pathology. So when I was in high school, I was teaching part-time at a preschool and one of the students there had an SM diagnosis and his speech therapist would come in and work with him at the preschool and just kind of watching her work with him and seeing the strategies she was using and watching how he went from having absolutely no words at school whatsoever to being able to use words and then sentences and kind of seeing his progress and development was just so intriguing to me. And I hadn't heard a speech therapy prior to that.

So I kind of was interested in that. But what I was finding at the time was when I talked to people in kind of the speech world about like, "Hey, have you heard of selective mutism? Do you ever work with this? What do I do to learn more about this?" Speech therapists at the time were telling me, "Oh, no, that's really not our thing. That's really a psychology thing.

If you want to do that, you need to go the psych route." So I got my undergrad and a master's degree in psychology. And then at that point, the program that I was in for my psych masters was very data analysis focused and not very clinical focused. And at that point, I was really feeling the pull to do more clinical work and kind of working with kids specifically. So I did a second master's program in speech language pathology and then also sought out some opportunities to get trained in working with selective mutism with some intensive treatment programs based primarily in New York. So went through several days of intensive training, worked through several weeks of these treatment programs for kids since then I've kind of become a one-on-one counselor, a lead teacher.

I co-organized some of the programs. So I've kind of moved through different positions there, but was able to get a lot of experience with this population and just found it so intriguing and so interesting and just really the intersection of my interest in kind of the psychology world and the speech pathology world. So I was literally going to say because like you said, I maybe had one appear on my case and I remember just being frozen, like I have no idea what to do with this school psychologist didn't really either. And so you have the best of both worlds. It's incredible.

Yeah, yeah. So it's been really exciting and it's really nice kind of having some background in both worlds and having colleagues in both worlds to kind of pull from both of those backgrounds. And I've just been focused a lot these last five years or so on just kind of thinking about how can SLPs get more involved in working on this? We have so much to offer this population and we bring so much to the table. And I think as we were talking about earlier, it's not really something we talk about in grad school.

It's a fairly low incidence disorder, so it may not be something that we encounter often or have kind of a framework for. But what I'm finding is over the past couple of years, especially post-COVID, we're seeing more and more cases of this pop up and more and more SLPs are saying, you know, what can I do about this? How can I help these kids? How can I help these individuals? You know, what do I need to know about this?

And so there's just, there's definitely an interest in this kind of information . So it excites me to be able to talk about this and bring this to more people. Fantastic. And I mean, obviously we all want to get into the yes, how can we help? But before we get to that part, let's talk a little bit about what is it?

Like what is the causes, some of the factors that we need to be aware of? Sure. So kind of the short definition is it is an anxiety disorder and the key defining factor of selective mutism is the situational nature of it. So what defines kids with SM is that they're able to speak in at least one setting or with at least one person comfortably and typically, but then they're not able to speak to some degree in at least one other setting. So typically this looks like kids who are able to communicate at home and with their close family members, but then in other settings, particularly school, but also community or extracurricular settings, they really, really struggle.

And so we can kind of delineate that from like an expressive language disorder where we tend to see the same level of difficulty across settings. It doesn't necessarily matter if they're at school or at home. They still have the same difficulties expressing themselves. Whereas with these kids, there's really significant noticeable differences depending on the setting or the who the people are that they're trying to communicate with. Fascinating.

And so how does this typically get diagnosed or especially like I imagine that if the family isn't seeing it because of the comfort level of that child, it's probably kind of surprising to them when they hear any concerns. But is that what typically tends to happen? Is it to teach her somebody? Okay. Yeah.

So typically we see this first kind of manifesting during like preschool years or when kids start kind of a formal schooling process when they are in a new setting and kind of away from the parents for the first time. And it is usually teachers that bring it up to parents. Often parents are quite surprised because parents will often say, you know, this child is my loudest child at home. They are a chatterbox at home. They are animated.

They are loud and boisterous and extroverted and all of these things. And so when the teachers come to them, you know, at parent teacher conferences or a couple months into school and say, I haven't heard so and so's voice. They are not asking to use the bathroom. They can't communicate with me when something is wrong or if they are upset about something. I don't see them playing with other kids.

Often it's a big surprise to parents. And so that tends to kind of be the introduction into that. And then typically parents will pursue diagnoses from like psychologists, licensed clinical social workers, things like that. But more and more SLPs are being asked to be part of that assessment and diagnostic process. Yeah.

That's what I was just going to ask you. It shows up in school. And so is it something that the team would handle, an IEP team? And SLP would be a part of it. Yes.

Yes. Okay. So what does that assessment look like then? So it can look a lot of different ways, kind of depending on the student. And you know, one thing about SM is, you know, one of my colleagues likes to say it's consistently inconsistent.

So, you know, some kids can have really severe presentations where at school they may not talk to anyone at all in any setting under any circumstances period. There's just absolutely no speech. I've had some really severe presentations where kids weren't even able to like nod or shake their head or give a thumbs up. Even those nonverbal communication was really difficult for them. And then in other situations, you may have kids who after some time may be able to kind of warm up and adjust and may be able to talk to an adult in like a one on one setting when there's not a lot of pressure on them.

So it can look a lot of different ways. But essentially when you're working with a child who's likely pretty unfamiliar to you as an SLP and likely not going to be able to talk much if at all to you, obviously we kind of start with like receptive language types of assessments because typically those don't require verbal responses. You can do a lot of pointing or sorting pictures or things like that. So starting with that to kind of get just some rapport built with the child. I also often tell SLPs that I know in school settings we're really busy and our schedules, you know, there's lots of schedule constraints and many SLPs are jumping between several buildings or several different settings.

But as much as possible kind of the some of the key things I try to keep in mind are one, introducing yourself to the child prior to ever kind of pulling them for any testing just to kind of make yourself a more familiar person. And that can just look like stopping by the classroom being like, "Hey, my name 's Mrs. Percy, you know, I'm the speech teacher here, I just wanted to stop and see what you guys are doing." I also wanted to let you know that tomorrow we're going to head down to my classroom and play a couple of games and then we'll come back so that it's more expected for them. It's not kind of this new brand new situation, brand new person that was unexpected and hard to prepare for. So prepping kids ahead of time, being transparent with them about what you need them to do.

So if you're just doing receptive language testing, you can say, "I'm going to show you some pictures in my book. I just need you to point to them and then we'll be done for today." Because I think for all of us, when we know what's expected of us, that can help decrease some of our anxiety and help us kind of perform better or more calmly or confidently. So starting with those receptive assessments, I'll then often try articulation assessments. The reason being most of our Arctic assessments are either single word kind of labeling pictures types of things or repeating a sentence that the therapist is providing. So the kids aren't really having to generate their own novel spontaneous utter ances, which can be a much harder and more anxiety provoking task.

So some kids may be able to do that. Others may not. You can certainly try some expressive language testing and if you're working with an older kid, sometimes will modify it a little bit and have them write out their answers and they might be able to do that. Other kids might be able to whisper their answers. So even if they can't use their full kind of vocalization, if they can whisper it and you can hear and understand them, you could administer the whole test that way.

But in many cases, those kinds of things don't work. And if that's the case, I really prioritize getting video language samples from the family at home. So you can really look at a lot of those things informally. So what does their articulation sound like? Is there any stuttering present?

What's their vocabulary and sentence structure? Some of those types of skills. And then really the bulk of this assessment tends to be social language focused or pragmatic language focused because I try to kind of shape this as, is the child using age appropriate social language skills at school? Because if they're not using those skills at school, that really justifies my involvement as a school based SLP to say, you know, they, they're not performing age appropriate ways. They're not able to access their education.

And so what can I do to kind of support that and build those skills for them? So you know, lots of observations in different types of settings, whether that 's small group or large group, more structured tasks in the classroom versus unstructured times like lunch or recess or gym class, and having both teachers and parents fill out different types of rating skills. So you can really start to compare and say, are these things looking very different in different settings here? Right. So in with the eligibility, it's so if I've got the language samples and I'm from everything I've been able to gather, I can, I can tell that this, it's typical language and I, so I don't, it's not going to be, well, would it be SLI still?

What's the eligibility? OHI for the anxiety? I've seen it be very district and even state dependent. The two most often classifications that I see used are either the SLI and you justify it as a pragmatic language disorder deficit. And or if the child does have kind of a formal diagnosis of either a generalized anxiety disorder or selective mutism or social anxiety, many schools will use the OHI class if you have a certification.

In a few cases, I've seen like the emotional disturbance label used. That's not used quite as often just because it tends to be kind of a heavier classification and carry a lot of connotations. But when you look really closely at the criteria for that one, some of the qualifying criteria are unable to be appropriately assertive, unable to maintain friendships, you know, in inappropriate feelings and thoughts and kind of normal circumstances. So if you've got a child who's got such a significant level of anxiety, just sitting in math class that they're not able to raise their hand and ask a question, that is, you know, technically an inappropriate level of that feeling. Just maybe not in kind of that externalizing way that we often think about for that.

So I have seen the emotional disturbance label used, but I would say more often it's the SLI or the OHI. Yeah. And that's why I think about like in the schools, you know, always, we always have the kind of the protocols and every state and district is different. But just kind of like how to qualify students and needing those standardized assessments. And, but we don't need them.

So if I'm unable to get the child to perform on the standardized tests, and so I don't maybe have, you know, that love like I can't have a criterion for their expressive and receptive language skills based solely on the pragmatic is make the argument. Okay. Yeah. There's some kind of creative ways if you're in a situation where you've got a district or an administrator that's really pushing for those standardized assessments. There's some research by Evelyn Klein and her colleagues out of La Salle University that found that they could train parents to give standardized tests and have those parents be up to 97% accurate in their administration.

So, you know, if you're training a parent on how to give the self or the tolls or the castle, the parent, if they have the ability to come into school could be sitting in the room, reading the test questions, you know, prompting the child through it. And the child may be able to talk to their parents since that's a familiar person. And then you as the SLP would do the scoring and the interpretation and kind of figuring out those types of things. But that is an option that's supported by some evidence. Another option that I found to work really well, especially as we've all gotten really good at like zoom and Google meets and things are I've administered tests through zoom while the child was at home.

So they were kind of at home in a comfortable environment with a parent home. And then I was, you know, at school or in my office or something and administering the test that way. And I've had a lot of success with kids who couldn't talk at school, but then were able to talk pretty uninhibited when they were at home that way. So there are some kind of creative ways to get around it if you really are in a situation where you need that. But yeah, I tend to rely pretty heavily on rating scales, observational evidence, language samples, teacher and parent reports, those types of things.

Fantastic. Do we need a diagnosis of anxiety or no? We have to have some kind of medical outside diagnosis. I personally don't say that you have to. I tend to encourage parents to pursue that just because that can open up some doors for them in terms of family therapy, outside services, you know, because I'm in a school based setting, there's a lot I can do in school.

But if the child's struggling with extracurriculars or at church or with extended family members there's not much I can do to support that. So, you know, if parents are looking for kind of outside support for some of those things, that diagnosis can be really helpful. In my district specifically, SLPs don't necessarily make diagnoses per se. We more just look at educational classification. So really for my part, if I can document evidence that the child, you know, has a deficit in pragmatic language skills compared to their peers and that it has an adverse educational impact, that's kind of my justification for providing services, whether or not kind of the official medical diagnosis is there or not.

So often in my reports, I'll write things like the student demonstrates characteristics of selective mutism, including, you know, difficulty initiating conversation, difficulty asking questions, difficulty asking for help, things like that. Okay, fantastic. Oh my gosh, this is so interesting. Okay, so let's get into the key considerations in for treatment. What does treatment look like?

What would be typical goals and services that we would provide? Like how often the frequency is a direct indirect? So typically, I am a big proponent of starting with pulling kids one-on-one individually in pull-out services. The reason being is it's likely going to be easier to establish speech with you one-on-one in a kind of quiet and calmer environment versus trying to do that in a group or pushing in or things like that. So starting out with those one-on-one pull-out sessions, there's some processes that we can use to kind of work on getting speech with one person.

So we use a process called fading in. So often what we do is if the child hasn't been able to talk to me at any point throughout this kind of assessment process, my next step would probably be to invite the parent in. If they're able to do that, there's also kind of creative ways to do it over Zoom or FaceTime too, if they have, you know, work constraints or childcare constraints or things like that. So inviting the parent in and then essentially you set up a situation where the parent and the child are doing an activity, just the two of them, and you kind of coach the parent ahead of time on, okay, it's your job to keep the child talking as much as possible. So asking forced-choice questions, which are like multiple-choice questions, like do you want the red one or the blue one, asking open-ended kind of WH questions, things like that.

We try to stay away from yes/no questions because a lot of kids will just kind of default to nodding or shaking their head and then they're not really getting that verbal ization practice. So coaching the parent on that, teaching them some kind of strategies like praising the child when they're using verbalizations, things like great job telling you that in your loud voice. I love how you're playing so nicely with me. You know, great job answering all these questions. I love how you looked at Mrs.

Larrissey when she came in the room, so really specific praise for those things. So we start with the parent and child playing and have the parent get the child verbal in that situation, which is probably like my office or a quieter space. And then if I'm trying to fade myself in as the new person, I might walk past the doorway a few times and wait and see if the child keeps talking. And if they do, I might just come right in the doorway and kind of sit by the door and do something unrelated, work on my computer, write paperwork, just so the child 's getting used to kind of me being there, even if I'm not directly involved in talking to them. Wait for them to be talking to the parent and then kind of move a little bit closer.

Wait for them to talk, maybe sit on the floor or at the table with them and kind of observe what they're doing, make sure they're still talking and responding. And then I'll start to make some comments like, wow, you know, I see you really working hard with those Legos or, oh, you're putting a red one on top. And if the child's able to stay verbal with me kind of interacting, I'll go in and start asking some questions like, are you building a castle or something else? Or, oh, are you going to put the polar bear in the front or the back of the zoo ? And if the child's able to answer me, we'll kind of ask a couple more to make sure that's consistent.

And then the parent will follow kind of the same procedure to fade themselves out. So they might, you know, back away from the table a little bit. They might go sit by the door. They might be like, hey, guys, I'm going to run to the bathroom. I'll be back in five minutes, leave for a couple minutes and come back and then eventually kind of fade themselves out all the way.

So for many of our kids, a procedure like that is really helpful in kind of passing the speech baton and kind of transferring speech from a familiar person to a new person. And the key to that fade in process working is just being really gradual and intentional about your steps. Some kids can kind of do that whole process in 15 or 20 minutes and be good to go. Other kids, you might need to do it several times in just really small incremental steps, depending on kind of the practice they've had talking to other people before, how successful that's been. But often that strategy can be really helpful.

And then in turn, once the child's consistently talking to me, I become the new familiar person. So now maybe the next week I work on fading their teacher in. So now I start with the child in my classroom. I coach the teacher ahead of time to kind of fade herself in and then work on fading myself out. So now the child's verbal with the teacher and then the teacher can do that with peers and we can kind of slowly increase the number of people and the places that the child's able to communicate.

Oh my gosh, this is so amazing. Like literally this is all new to me. I'm like just like thinking this is, first of all, to see that kind of progress , I imagine like you said, even if it does take a few different sessions, like it's always so rewarding when you actually start to make progress where so many of our goals, I feel like we work on forever and ever and ever. So okay, so that's the first one is the fading. And so now we've got more people that this child is able to communicate with.

And so then what's next? I imagine that's not where we're stopping. No, that's not where we're stopping. There's kind of lots of directions we can go depending on what's the biggest area of need and what's motivating for the child at that point. So kind of our overarching goal when treating SM is increasing the number of people, places and activities that the child can talk in.

And one thing we know is that at least early on in SM treatment, not a lot of things just generalize automatically. You often need a lot of very specific practice with lots of different people and in lots of different situations. And so because the name of the game is that situational dependency, just because the child's talking freely with me during my speech session in our speech room doesn't mean that they can talk to me in the hallway as we walk back to class. It doesn't mean that they could talk to me if they see me outside on the playground or in the cafeteria or things like that. So kind of thinking intentionally about how can we be changing one variable of what we're doing at a time to increase the difficulty just a little bit.

Not so much that we kind of send the child into this panic or this shutdown of like this is too hard. Too much pressure, I can't do this. But just very incrementally changing those variables. So if we get to the point where now the child's talking to me and are one on one sessions, you know, pretty freely, they're answering questions, they're asking me questions, they're making spontaneous comments. Like I said, we might work on fading in other adults.

So the teacher is usually one of my first people, especially at the elementary level when kids are with kind of one teacher for most of their day. That's usually the next functional step so that they can talk to that teacher, ask for help, tell them that they don't feel well, those types of things. But then I think about, you know, special teachers like art, music, gym types of teachers that they're seeing not as often but still on a regular basis. People like the school nurse, you know, making sure that they can talk to that person or at least give kind of yes and no answers to things so that if something is wrong, they're able to kind of advocate for themselves. So different adult people like that.

And also working on peers. So some kids will have an easier time with adults and really struggle with peers. Others will have an easier time with peers and really struggle with adults. And so I often tell therapists, you know, try to build the momentum first. Go for what you think you're going to be the most successful with first because we don't want to take a child and, you know, essentially say to them, we're going to work on the thing that's the hardest in the world for you.

This thing that you know is hard and that probably feels really scary and probably makes your whole body feel tense and awful and scary and makes your thoughts kind of race. We're going to do the hardest possible thing. You know, that's not going to be motivating for anybody necessarily. And so starting with thinking about what's motivating for the child. I mean, I've had kids as young as five or six be able to do things where if I give them pictures of everybody in their class, they can sort them into piles of people I want to talk to and people I don't want to talk to right now.

And then from there, we can kind of narrow down or thinking about, you know, are there kids in this child's class who also live in their neighborhood where maybe we would have some good opportunities for if we can talk to them at school, maybe we can also talk to them and practice more at home too, or maybe they're also on the same baseball team. And so they'll have chances to practice there. So thinking about kind of those opportunities where you get more bang for your buck. Because literally the only thing I really remember about like for strategy wise , the first one that comes to my head and I'm thinking, do we even do this still, is I do remember having a student who would talk to appear, get a best friend, so they would talk to the other child and that child would answer for them for a while. Is that something we still use?

It depends a lot on the situation. So I think there's a difference between kind of thinking about short term goals and long term goals. Long term we want this child to build their verbalization skills so they can talk for themselves in any situation that presents itself. However, in the short term, if that's kind of a far off goal for them, we need to think about how are we getting their basic needs met. And so, you know, if they're really struggling with adults and it's taking a really long time to get them verbal with their teacher, but they are able to talk to appear , we call that using a verbal intermediary where the teacher can say, you know, Emily, you need to put your lunch order in.

Did you, are you buying lunch today or did you pack lunch? Go ahead and tell Sam. And then, you know, I turn to Sam and I say, I packed lunch and then Sam says, she packed lunch and then the teacher says, great, great job telling Sam and kind of moves on with their day. So sometimes we need to do that short term just to make sure the student can, you know, get what they need, but still kind of looking at this as this isn't a long term solution. We're not going to stop here.

Like you said, we want to keep working on building those skills with other people. Okay. And is this, I do imagine that therapy is fun. Are we doing a lot of fun activities? We're playing games and all of the, okay.

So what are some of those strategies that you use? Cause again, most of this has got to be just rapport building. Yeah, rapport is huge. Like I said, use of positive reinforcement. So both those verbal labeled praises is really huge, but also early on in therapy, I often start with some kind of like check mark system where every time the kids responding or, you know, sometimes even we start with just nonverbal responses.

Like I said, with some of those kids that have such severe presentations, we're not at the word level yet, we're just working on giving thumbs up and thumbs down, or, you know, using picture cards or things like that initially, they get a check mark every time they do one of those things, they can kind of cash those in for privileges at home or at school or things like that. And then often you can kind of fade those external reinforcement systems over time because as they're more successful, you know, they start to feel that sense of self efficacy and confidence too. And keep in mind that these are kids who really want to communicate, you know, I think a myth that's been out there in the education world, especially is this child won't talk to me, they're choosing not to talk to me, they're being defiant, they're being oppos itional, they're trying to control the situation, it's manipulation, you know, if they can talk at home, they can talk to me kind of stuff. And so, you know, really keeping in mind that these are kids who very much want to communicate and they'll often say as they go through therapy, you know, I wanted to talk to my friends, but my voice was stuck. I couldn't think of the words.

I couldn't get the words out. So that internal motivation starts to kick in then. But yeah, therapy can be lots of fun. Lots of just games and functional activities. One of our favorite things to do is to take surveys.

So especially as you get to a point where you're working on asking people questions and starting to work on generalizing to more unfamiliar people, I'll often make surveys that have questions like what's your favorite kind of ice cream? Are you going on vacation this summer? Things like that. And we'll pop it on a clipboard and we'll go wander around the school and whoever we run into, you know, we'll ask all these questions. And sometimes we'll go into a classroom and we'll survey everybody there.

And so it's a lot of fun and kind of gets the whole building excited about it. So even, you know, like the custodians were like, "Hey, where are you going to come ask us our questions?" And things like that. So that can be a lot of fun. You know, we were doing it one day and there was a meeting going on of several administrators and the principal knew what we were doing. And so she opened the door.

She's like, "Come on in. Why don't you ask us your questions?" So we, you know, asked the superintendent what her favorite kind of ice cream was and things like that. So, yeah, just kind of thinking about what are ways that I can create situations that are functional but also motivating and interesting that will let my student practice these critical skills of, you know, asking for help and things like that. And sometimes you find yourself doing ridiculous things. So when we're working on things like making spontaneous comments or self-advoc acy or asking for things you need, one time I took all the chairs out of my room and then, you know, brought the group of kids in and was like, "Okay, go grab a chair and sit down." They kind of looked around and I just waited until somebody said, like, "Wait, where are the chairs?" You know, and then talked about like, "This is what we do.

If you're in a situation and someone gives you a direction and you don't understand it or you can't follow it, what can we do? What can we say about it? You know, what are some ways that we can handle that situation?" Oh my gosh, I love this so much. This makes me want to go back in the classroom right now. I love that.

That when there was something you just said, of course, it just loves it. Oh, going back to the goals up there. So I always find like this the IEP, I have to write annual goals challenging. And sometimes I feel like it stifles us a little bit because if I could write more frequent goals like I would if I was in a clinic, then I feel like, you know, they'd be a little bit easier to write. What would be some of the like annual goals that we're targeting?

Because like the things you were just talking about, the incremental step by step face, but the ultimate goal is what? Yeah. So again, it depends. And one of the nice things about IEPs is we know they're working documents. So we can do revisions whenever we need to.

So if we do put a goal in place and they make a ton of progress and master it, we can revise and put the next one in place. Similarly, if we put a goal in place and we kind of overshoot and we're starting to look at it and go, "Oh, this might be more than we're able to do in the span of this year." We can kind of revise from there. But I've written goals like in the regular education classroom, the student will ask for help independently three times a day in four out of five days. And then the teacher just has a chart and they check off every time the student asks for help and we kind of progress monitor that way for kind of some earlier goals. It might be in, you know, small group speech therapy sessions.

The student will ask a question to appear, you know, with 80% accuracy or an eight out of 10 trials, you know, for three consecutive speech therapy sessions or things like that. So a lot of our goals tend to focus on first answering questions that tends to be the easiest and then asking questions and then starting to make more spontaneous comments. And once kids can do that, we start to think about more higher level goals. Like can they ask for help? Can they say no to someone?

Can they negotiate with someone and compromise with someone? Can they share their opinion? That's often really hard for many of our kids because there's an added layer of social anxiety and fear of judgment when you're sharing how you feel about something or why you feel a certain way about something. So that's often something we work a little bit more specifically on presenting in front of groups sometimes we need to work more specifically on raising our hands, things like that. Yeah, because that's what I was glad you just went kind of through that like hierarchy and you know, like, you know, the goal I imagine is for most of our students is dismissal.

So it would be getting to that level like, well, I mean, I know it's individual ized, but the harder things being like being able to present in front of a class. Yeah, and I think that's really an area that SLPs have so much expertise in and we bring so much to the table with this because so many of my colleagues that are kind of in the psychology world kind of think of all talking as being equal. And so sometimes there's this mindset of, okay, this kid's able to answer questions, done, we're good. We're done. We fixed it, you know, and we as SLPs know, oh, that's just the beginning of all the, you know, pragmatic functions that kids need or all the types of skills that they need or the levels of language complexity, you know, because it's one thing to say like, what did you do this weekend and the child says play versus what did you do this weekend and the child tells you a whole long narrative of how they played outside and their friend came over and then it started to rain and they had to go back inside and those are very different skills and we know there's a lot of steps to get from one to the other.

And so I think our knowledge in language complexity and, you know, kind of development of pragmatic skills and those types of things and functional communication is really critical there. Yeah. Okay. That's perfect. I'm because I was thinking that same thing.

It's like, look now they're talking to all these different people. They will respond when asked and you're like, you're done. And there is. It is so much more complex than that. There was another advocacy in education.

I imagine that's a huge part of that of what you're doing. It's supporting all the individuals that are in this child's life because you had mentioned that earlier. I've seen that before where there's frustration and a demand and a pressure because how dare you not respond to me. I'm your teacher, you know, kind of mentality. And so yeah.

Yeah. Yeah. I mean, I think there's definitely, you know, professionals who take it as like a challenge to their authority. And then there's also professionals who just kind of take it very personally and feel kind of offended of like, why will this child talk to you in your speech session, but she still can't talk to me or why will she talk to her mom and pick up? But when I say bye so and so she can't wave to me or answer me.

And so there's a lot of just misinformation and assumptions that can be made. So yeah, educating the team is really huge. I've done even school-wide trainings, not only for my school, but for other schools because, you know, early on in the situation, we want to be really mindful of the fact that we don't want to reinforce avoidance of speech. So meaning if you've got a student who's not able to verbally answer questions yet, or at least not from the majority of people, the more that people ask that child a question and they're not able to answer it, the more that reinforces, I need to just avoid these situations. I can't do this.

I'm not good at talking all those types of things. So we want to be really thoughtful about setting them up for success and kind of presenting them with lots of situations to be successful at the level that they're at. So in many cases, I've kind of done a school-wide training, including people like our secretaries and our custodians and our substitute teachers and our paraprofessionals and saying, you know, I know you all know this child and I know you all really, really want to help her and I so appreciate that. And, you know, when she's getting dropped off in the morning, she's walking past three teachers, a paraprofessional and maybe the school counselor who are all saying, "Hi, Emily, how are you? How was your weekend?

What did you do this weekend? Was it raining out there? Backpack today? Are you staying for after school today?" And she can't answer any of those questions. And so now, just by the time she's walked to her classroom, she's had 10 instances of that avoidance getting reinforced and reinforced, which makes it that much harder to overcome.

So instead teaching the staff, like, for now, what I need you to do is just make a comment. Please don't ask a question. Just make a comment. So good to see you, Emily. So glad you're here.

Love the pink shirt today and let it go. And when we get to a point where she's able to answer questions, I will let you know and we will practice and we will come back to you, but we are just not at that point yet. Because generally, people really want to help. They just don't always know how to help. Yeah.

That's perfect. And so this is obviously a very quick overview and we can talk about this forever. But where are some good places to start for resources? If you've got a student or you just want to learn more about this topic, some good places to send those that are listening. Yeah.

So the biggest recommendation I always make is the Selective Mutism Association , which is a national nonprofit organization that it's really their mission to provide materials to educate and train people and how to work with selective mutism, including both families of kids with SM professionals who are working with these kids. And even adolescent and adult individuals who maybe are still struggling with SM or have struggled with it and are kind of figuring out things like that. So Selectivemutism.org is their website. Some of their really great helpful resources are they have many, many webinars that have been recorded and are available for free, both for families and parents, but also for professionals. So a much deeper dive into things like how do we write goals for IEPs?

What does support look like in the school? What accommodations do we need? How do we work on play dates at home? How do we work on extended families? What about working with secondary students and teens where you're not playing board games the whole time?

You know, it's not just all like Legos and Goofy-Dies. So some of those topics are in there. They also recently published the caregivers handbook or the caregivers toolkit and the educators toolkit, which are two free resources that are just really good starting points. So if you've got a student at school, you've got a team saying, "Hey, I think this is going on here. I'm not sure what to do.

I've never had this before." These documents are like 20-ish pages long and they go through kind of, "These are the signs and symptoms. These are some of the common myths. These are the causal factors. This is what you can do to help. These are next steps to direct families towards," things like that.

So those are really helpful resources. I would also say many of the strategies I've been talking about are part of a larger program called Parent Child Interaction Therapy Adapted for SM, so PCITSM. So if you look up the program SM University, it's a free program that's available online that was put together by Dr. Steve Kurtz who created this SM Adaptation of Therapy. It has a video-based training system that families or teachers or clinicians can go through to learn a lot of these skills and to practice a lot of these skills, which are highly researched and highly evidence-based and kind of treating SM.

So that's a really great resource. And then I published a book a couple of years ago called "Treating Selected Mut ism as an SLP." It's available from Floral Publishing and also on Amazon, Embarrassing, Noble and Things. My goal with that was kind of to create a very practical handbook so that if you as the SLP get a transfer student in and it says, "Has a diagnosis of selective mutism?" and you're thinking, "I never learned about this in grad school. I don't know what to do with this." You could pick this up and it kind of goes through the specifics of assessment, treatment, when do we consider dismissal, how do we write goals, what are strategies, how do we work with the rest of the team, collaboration pieces, diagnosing all of those types of things. Fantastic.

I love that so much. I didn't know. We should have started by saying you're an author. I said expert, but my gosh, that's amazing. How's OK?

Definitely look up the book. But how else can any of the listeners find you on social? Do you have a website? I don't have a website at this point. I do have a couple of webinars available through Northern Speech Services and also on the ASHA Learning Pass.

So, again, if people are kind of interested in more video webinar based types of trainings, those are out there. But yeah, that's kind of where I am at this point. Fantastic. I loved this so much. I feel like we covered so much, obviously.

I want to deep dive now into the book. But it's such a great way to... I feel better. I feel like, OK, this is something we can do. I think we sometimes just need to be reminded what's in our will house.

But thank you so much. I appreciate you taking the time to share this with us. And I'm hoping we can do some follow-ups, maybe do a course or something. For an SLP summit would be awesome. So we'll have to talk about that.

Right. That sounds great. I love that. Awesome. Thank you so much.

Thank you. Thanks so much for having me.

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