Monday, June 27, 2011

Social Skills Group: Selective Mutism

I have had a few clients with Selective Mutism.  Selective Mutism is a condition in which the child is fully capable of speaking but only does so in selective instances.  Most of the children with this condition (it can linger into adulthood also) will speak to their immediate families but will not speak in public.  It is not clear what the root cause of this disorder  may be.  It is not simply a stubborn or willful child.  It seems more a problem with extreme anxiety and at times shares similarities with a fluency disorder.  I have seen the children appear as if their lips were glued together at times, tight yet with a tremor that suggests they are attempting to speak but cannot. 

I am not an expert on Selective Mutism, but here are some basic treatment principles I have gleaned from my research on this disorder:
1.  Always present to the child an expectation that they will eventually speak, when they are ready.
2.  Do not coax, bribe, reward, threaten, or punish the child for speech or non-speech.
3.  When a child does speak, suppress your excitement.  Calling attention to the speech may cause the child to shut down again. 
4.  Do not whisper about the child with parents or other adults.  This may increase the child's anxiety and cause them to think they have a serious illness or something to be ashamed of. 
5.  Accept the child where he is and give him tools to increase participation.  I teach the use of gestures, signs, PECS, drawing, and writing.  I learned quickly with children who have Apraxia, that augmented communication tends to remove the "pressure" to speak and often frees the child's voice by reducing the anxiety level. 
6.  Do not be discouraged by slow progress or small gains.  It is a "process" in most cases.

Since I have been running several Social Thinking groups, I have recognized the benefits of small group treatment for pragmatic disorders.  It occurred to me that perhaps this same format and many parts of this curriculum might be beneficial to the population experiencing Selective Mutism (SM).  So, I am just beginning a new group of three children with varying degrees of SM. 

PROS: These boys will see that they are not the only person in the world with this kind of difficulty.  They will learn social skills/thinking that will hopefully change their perspectives and reduce their anxieties.

CONS: I anticipate that it will be a relatively quiet group but I hope the noise levels will increase in due time.  I must be careful not to increase their anxieties; this will require me to carefully plan and re-examine each lesson in view of the Selective Mutism issues.

Lessons to be included:

Expected / Unexpected Behavior:  I do not discuss the idea that others have thoughts about us and our behaviors because that would likely exaccerbate their social anxiety.  I do present the idea that certain behaviors are expected in a group and I emphasize the expectation to participate (in some way), to respond when spoken to (in some way), etc.  I list 'not responding' in the unexpected behaviors column.  This serves to establish the expectations and the idea that they are fully capable of doing this in some way.

Problem Scale: Learning to rank problems in degree of severity.  Helping the children to see situations in a proper perspective rather than magnifying things way out of proportion. Hopefully this will serve to reduce anxiety over time.

Being Part of the Group, Body in the Group, Brain in the Group:  I don't anticipate the typical problems seen in other groups with lots of disruptive speaking, moving, etc. as the kids with SM tend to be more introverted.  Instead we will likely need to stress participation as part of being in a group.

Being a Social Detective, Think with my Eyes, Reading Plans:  These lessons address the ability to infer ideas, attitudes, emotions, predict events, understand how others feel and how our behavior (or lack of behavior) affects others.  The hope is that through these lessons, the children will be empowered with a sense of understanding of social contexts, learn to navigate them more easily, and gain confidence through their knowledge. 

Here are some of the resources I will be drawing from, in addition to Michelle Winner's Social Thinking curriculum:

Intertwined throughout the lessons, we will pull in materials addressing relaxation and vocal exercise, dealing with anxiety, and having fun playing games with the other boys.

Class One: Getting to know each other. I had no illusions that the boys would readily speak to each other so we made posters about ourselves (teachers included). I drew my own poster with my stick figure family in crayon and some of my favorite things. I encouraged the boys to do the same and provided a few cut out Boardmaker pictures of some of their favorite things (according to their moms). It went well enough. However, none of them wanted to tell about their posters, so I looked at what they had drawn and tried to tell their stories with a few head nods to confirm... and resistance from others.

Adaptations I made to the typical Social Thinking curriculum:

Expected/Unexpected Behaviors: Add "Speaking and answering questions, or communicating in some way, when being spoken to", "Participating in activities". The plan will be to NOT apply pressure to speak but to at least "put it out there" that speaking is an expected behavior. It is important to always present the expectation that the child is fully capable of speaking and will at some time speak, rather than treat them like fragile "eggshells". However, one must tread carefully between a sense of expectation and pressure to speak.  I will suggest or demonstrate how they can use gesture, writing, or drawing as a means of communication. I have found that providing alternative communication can alleviate some of the anxiety and make verbal communication easier.  (Side note:  If the child with Selective Mutism is new to treatment and deeply  entrenched in his difficulty, the group is not where you should start.  The child will need some individual treatment in order to build some trust with the therapist and most likely will have great difficulty participating in anyway, even in nonverbal ways). 

Class Two:  We discussed the speech mechanism.  Used drawings from a Voice book to discuss the body parts involved in speaking: lungs and how air moves in and out, lips, tongue, jaw, vocal folds.  We discussed that our brains (we) are in control of these body parts; the parts are not in control of us.  Practiced moving (saying sounds) with the parts: ah, oo, ee, ppp, bbb, mmm, ttt, lalala, nnn, duhduhduh, kkkk, ggg....  I am happy to report that all boys, even my most reluctant one, verbally participated in this task.  Then we discussed that sometimes these parts might "seem" to get stuck making it hard to speak, but they really are not stuck.  When we feel stuck, we may to need to "relax" our muscles.  We then practiced a few relaxation techniques:  Deep breaths, slow count to 10, stretches, and happy thoughts.  From there we launched into the Social Thinking lessons on introducing emotions, changing peoples' emotions, the book Miss Nelson is Missing  (I suggest that the use of this book is simply an activity for the group.  We do discuss how the various behaviors affect others but I do not directly emphasize that there mutism is a negative behavior.)  We finished up playing the imitation game with hand gestures. Two of the boys tolerated being the leader and having everyone "watch" and follow him. (This games serves to engage the boys in a group cooperative activity as well as tolerate attention to their hands and actions, not so much their speaking if they do not desire to make sounds.)  All in all, it was a very successful class.

Class Three: Problem Scale. This should be immensely helpful when applied to gauging the size of a problem situation. We discussed problems and our reactions and ranked specific examples.  Interesting to see how each child responds (allowed them to hold up fingers if they did not want to tell me their rating).  One boy rated virtually everything a #4 or #5 (big problem) while another boy ranked everything a #1 problem.  We read Alexander and the Horrible, No Good, Very Bad Day.  I was able to get them all to repeat this line in chorus several times.  (Choral speaking, all together, is often easier for the SM child; this is also related to the term 'vocal contagion' indicating that making noise as a group tends to be contagious and kids will engage in it if others are doing it first and alongside them).

Later we can apply "anxiety" levels to the scale to judge how the child "feels" compared to the "real dangers" inherit in any situation and work to reduce their anxiety levels.

Class Four:  Brain is in control of us and helps us think.  Review Vocal mechanism and the role of our brain to control our bodies.  Discussed how our brain helps us interpret messages about others and our environment: seeing, hearing, feeling, smelling (feel items in bag and guess what they are, smell test, etc).  Brain is powerful and controls our voice and our mouth.  Our voice or mouth do not control us.  Discussed "brain freeze" and the use of our relaxation techniques to battle "brain freeze".

It is going well.  Lots of words, sounds, and participation even from most reluctant speaker; still not full sentences or conversation but we are opening up to the group!

Class Seven:  Today was our last Selective Mutism class.  Everyone is doing well but with school about to begin, we are discharging one client, seeing another at his school, and rolling one over to a Social Skills group.  For our last session I made a booklet on Boardmaker adapting the SuperFlex and Worry Wall characters (from the SuperFlex curriculum) to fit the needs of our group.  We discussed Flexible vs. Inflexible in physical items: rubber band, play-doh, rock, stick, etc.   After reading our story we pretended to put on SuperFlex capes and flew around the room embracing our SuperFlex persona.  The boys seemed to really enjoy and connect with the superhero part of their brains.  Hopefully they will be able to call on SuperFlex capabilities next time they need them.

         Coming soon to TPT store......           

1 comment:

Anonymous said...

great job!