Some excerpts from the book VOCAL are presented. All rights reserved.
Speaking is not a choice for a child with SM. A child with SM can speak and wants to speak, but is unable to. People who have recovered from SM reported that their throat simply “closed up,” or there was “a lump” blocking their throat for sounds to pass through. Due to extreme fear of speaking, a child with SM will go to extreme measures to avoid speaking, and is unable to report urgent needs, even if she is hurt or being bullied!
Persistent SM does not resolve itself. Studies have shown that SM does persist into adulthood, so early intervention is crucial.
The sooner the better! It is more difficult to treat a child who has been mute for a long time. In fact, few children are “cured” during the early primary school years when appropriate treatment is delayed until after the child turns 7 (Schwartz and Shipon-Blum, 2005). As well, only 30% to 40% of children older than 12 who are diagnosed and treated appropriately will speak to a wide circle of schoolmates (Bergman, 2004). Therefore, early intervention is of utmost importance.
Although the child with SM may require an IEP (Individual Educational Plan), which might include accommodations such as alternative academic assessment, the best place for her is in the regular classroom. Children with SM need the reassurance that they are part of the normal population and that their difficulty speaking will not last forever. If the child has other comorbid disorders such as a learning disability or speech and language delay, additional assistance from a specialist may be needed.
Remember, children with SM are particularly anxious when they feel there is an expectation
for them to speak. Therefore:
- Never force or bribe your child to speak;
- Avoid asking questions that she is unable to respond to through alternative means (i.e., via gestures, written notes, pictures, etc.);
- No matter how well-intended you are, do not say something like “are you going to speak to me today?”
- Do not repeatedly ask a child a question then accept that she is unable to provide an answer. Doing so can adversely strengthen the child’s mutism behaviour. If you do unintentionally asked a child a question to which she fails to respond, quickly answer it yourself;
- Avoid putting the child on the spot or the center of attention. Keep in mind that most children with SM do not wish to be noticed;
- Do not insist on making eye contact initially. Even better, avoid speaking to the child face-to-face.
There are several things you can do to make the child feel more comfortable around you:
- Reassure the child that there is no pressure for her to speak to you.
- Tell her that you understand it is difficult for her to speak at school, because school is a very big place with lots of people, and is very different from home.
- Tell her that there are other children just like her. This will make her feel better as she isn’t the only one.
- Tell her that her difficulty speaking will not last forever.
- Depending on the child’s age and responsiveness, provide her with pictures (or pre-written notes) to convey her needs. Some of the needs include going to the bathroom, answering “yes” and “no.”
- Sit the child with another quiet classmate, or someone she is comfortable with, in a “private” area. Depending on the classroom layout, this area is typically located furthest away from the teacher’s desk, blackboard, classroom doors, and least visible to other students.
- If the child has an older sibling enrolled in the same school, provide plenty of opportunities so that the siblings can spend time together inside school. Some obvious suggestions are:
- Designate the older sibling as the child’s “book buddy,” so that the child can read (or whisper) to her sibling while other students read to their senior book buddies.
- Appoint the older sibling as the lunch monitor for your class.
- Designate the older sibling to collect the attendance sheet from classrooms every day. When the sibling arrives in your classroom, send the child along.
Keep the answers simple and short, downplay the issue, and be positive:
- Of course Mary can speak! She speaks beautifully with her brother Bobby (or family).
- Mary is not used to speaking in front of so many people yet.
- Many children need some time to get used to being here. Mary is just one of them.
Here are some possible ways to assess the child’s academic performance:
- Let the child sort plastic letters in alphabetical order to test her alphabet ability.
- To test the child’s phonological awareness:
- Let the child sort pictures into rhyming groups.
- Let the child use check boxes to indicate whether two words sound the same.
- Ask the child to sort pictures with the same initial sound, and use those pictures to surround that initial.
- If reading or picture-naming is required, invite the parent to administer the assessment in school, so that teacher can directly observe and hear the child’s reading ability.
- If the child is unable to read to her parent at school, provide the parent with detailed instructions, and record the child reading at home with an audio-recorder.
To the surprise of many teachers, the answer is no. Although the child with SM may require an IEP (Individual Educational Plan), such as alternative academic assessment, and or minor adjustments to the curriculum, the best place for her is inside an ordinary classroom.
Although teachers tended to rate reading skills lower in children with SM, ratings of arithmetic, overall academic, and school performance did not differ (Cunningham et al., 2004). This may be due to the fact that children with SM evidence fewer attentional or oppositional problems. They tend to cooperate, follow directions, and finish assignments on time Therefore, there is no need for them to enroll in the special needs class. Doing so may worsen their self-esteem, which may lead to a sense of incompetence, making it harder for them to overcome intervention treatments.
Children with SM need the reassurance that they are just as good as other children, and that their difficulty speaking will not last forever. If the child has other comorbid disorders such as a learning disability or speech and language delay, additional assistance from a specialist may be needed.
While some research has suggested that children with SM seem to feel more comfortable with their peers and female adults, every child is different. For play dates, parents can simply ask the child who she are her favourite classmates. Teachers can help identify with whom the child feels most comfortable inside the school via keen observations. It is important for parents and teachers to communicate with one another before arranging for play dates at home or implementing interventions inside the school involving speech targets.
It is easy to imagine why a child with SM may enjoy gym class (where the focus is on play) over the more structured academic classes that involve reading out loud activities. Hence, in order to help your child start speaking in the context wherein she has never spoken before, it’s important to make the activities fun. This way, your child will more likely be immersed in the activities and less likely be self-conscious about the verbal demands. In a published journal, we stressed the importance for teachers to be the co-players in order to help create an inclusive environment that fosters speech. Because teachers tend to be the most anxiety-provoking individuals, they can lessen the anxiety inherent from their role and promote greater mediums for expressive communication through play!
I personally have simple phobias and was extremely quiet and anxious as a child. It is no wonder that my children have anxieties and SM! I might have suffered from SM as well. Fortunately, where I grew up (in Hong Kong) children were expected to remain quiet and listen to the teachers during classes. Hence, I might have started speaking on my own because there was never any pressure for me to speak inside the classroom. Indeed, many children with a milder version of SM do eventually speak on their own if they were placed in a non-threatening environment where there is no pressure for them to speak.
Because most children with SM are mute inside the classroom, most, if not all of them are very expressive (gestures and or verbal) during recess. Hence, making the classroom less structured may help lessen their anxiety. Also, provide them with plenty of privacy by placing them in a private area where they can sit with their best friends, and furthest away from the teacher and the classroom door. Let them know that they’re not expected to speak unless they want to. Use fun activities that accommodate her needs while also foster her speech.
How do I create an environment that encourages speech when there is another child acting as a “spokesperson” for the child?
Quite often there is a child inside the classroom who acts as a spokesperson for the child with SM. This peer simply jumps in and answers questions for the child with SM, or says, “Mary doesn’t talk.” Although well intended, this can be a tricky situation because we don’t want others to speak for the child. Instead, we want to create an environment that fosters speech!
However, if we think carefully, speaking to one person is better than none. In fact, we can turn this spokesperson “problem” into something that is advantageous to SM intervention. If the child with SM is speaking (or whispering) to her spokesperson, and is encouraged to read, to answer questions via that spokesperson, she will have plenty of opportunity to practice speaking inside school!
If the child is not speaking to the spokesperson, the teacher can create an environment that fosters friendship and communication. For instance, sitting the “spokesperson” next to Mary (the child with SM) in a private area of the classroom can encourage communication. The teacher can regularly send both children to run errands, and help arrange after-school play through both parents. Sooner or later, you will find Mary passing notes, or starting to whisper to her spokesperson!
However, the teacher may need to dissuade the spokesperson from jumping in when a non-verbal response is expected by saying, “Mary can shake or nod her head, so she can tell me herself.” Also, once the child is speaking to her spokesperson regularly, the teacher may want to discourage this pattern of dependent relationship by saying, “Mary can tell me that herself because she needs to practice using her voice more.”
After weeks, and perhaps months of working with the child, no doubt the most exciting moment is to hear the child speak for the first time. Be cautious though, overreacting and public praise can sometimes overwhelm a self-conscious child. When other students in the class jump up and down and shout, “Miss Wood, Mary spoke!” the teacher must pay close attention and observe the reaction on the child’s face. If the child appears to be proud, public praise is appropriate, whereas if the child appears to be overwhelmed, you must quickly but calmly (as if not a big deal) say, “I know Mary can talk, she speaks to her family all the time.”
Keep in mind that if a child “slips” and speaks to you (yes, it does happen!), do not overreact. Show the child that you are pleased but matter-of-fact, and say to the child, “you have a nice voice. Since you spoke to me, I’d like to give you a reward. Do you prefer Smarties or Mars?” or “I love that you spoke to me. It makes me feel special and happy. I’d like to reward you with a surprise. Can you tell me your home number so I can ask your mom for permission?
If the child is hesitant, stay kind but firmly tell her that since she has already spoken, there is no turning back. Give her a reward for that incident, try to avoid making too much eye contact and continue onto similar subjects to evoke similar responses.
The reason behind carrying out intervention not just at school, but also at home and within the community is simple: address symptoms at all its sources at once! If your child is simply not speaking at school, then it makes sense only to carry out interventions within it. However, if your child is not speaking to friends, relatives, and or baby-sitters at home, or away from home, then why not extend the intervention to home and away from home? Remember, selective mutism is “selective”, and every case can be unique. If your child speaks to her friends at home, it does not mean that she will speak to the same friend at school, at the friend’s house, or in the neighbourhood. This is similar to when your child stopped talking to you when someone comes to visit, or when you are away from home (at grandparent’s home, in a grocery store, restaurant etc.). Hence, it is important to carry out interventions in all contexts.
It would be tricking your child if you did not warn her beforehand and ask for her permission prior to using this technique. While this technique may sound intrusive, it is also an exposure technique and can be done gently with your child’s consent and allowing her with some form of control. Often times, your child just need a little encouragement to be brave, and she may become appreciative of this technique in the end. Remember, many children, especially those who have been mute for an extended period may benefit from this technique to help them break the mutism identity as well as the vicious cycle of remaining mute. Your child’s peers will also stop speaking for her upon seeing her speaking in the video. This will completely change the communication pattern, and allow your child to start speaking on her own.
You may wonder whether CBT can be beneficial for your child since it is used for other conditions. Indeed, CBT may involve engaging your child to achieve deep relaxation via relaxation technique or clinical hypnosis. Or, biofeedback and or guided imagery technique may be used to guide your child to imagine an anxious situation, starting from the least stressful part of it and working towards the most anxious part. While CBT was more commonly used historically and may still be used in some treatments, in my professional and personal experiences, it is not ideal for young children.
You know your child best, and based on her anxiety and the inability to speak in social contexts, do you think she would benefit from interacting and speaking with a complete stranger (the therapist)? In addition to this, conventional forms of CBT require a child to share her feelings and thoughts with the therapist through the use of speech. This alone will cause extra stress/anxiety for your child. Indeed, studies have long confirmed that CBT is not effective for children under the age of 10 (Garcia et al., 2004) and may suit older children better (Cohan et al., 2006).