Equipping Children With Verbal And Vocal Skills As A Treatment Approach To Selective Mutism

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In my last article, I describe selective mutism (SM) as social communication anxiety, as per Dr. Elisa Shipon-Blum. Approximately 1/142 children receive a diagnosis of SM.

Due to the severe anxiety, these children may appear sullen or “shut down” in uncomfortable social situations such as the school setting. Additionally, even though they may not necessarily exhibit any of these traits when unprompted, children with SM typically do not speak in settings and with people with whom they do not feel comfortable. To be truly effective in social situations where speech is expected, children must use their voices creatively beyond the ability to say simple words and form sentences. We want their personalities to shine through language that represents who they are and how they wish to express themselves. Unfortunately, for many children with SM, fear of expressive language marks their disorder.

One way to disentangle this communication breakdown for children with SM is to first evaluate the production of voice, speech, and language to determine how vocalization and verbalization are affected. I will report a strategy for expanding expressive language output developed by Dr. Evelyn Klein, Dr. Sharon Lee Armstrong, and Dr. Elisa Shipon-Blum and another strategy for initiating vocalization developed by Dr. Cesar Ruiz and Dr. Evelyn Klein. This article will continue with the results from a study about expanding expressive language output.

What we already know:

  • Voice The ability to initiate phonation (from the larynx) for speech production
  • Speech The production of speech sounds to convey our thoughts via words and sentences through speech articulation and fluency
  • Language – The comprehension and expression of our thoughts (using semantics, syntax, morphology, and pragmatic language)

For assessing speech & language abilities in children with SM, Klein, Armstrong, & Shipon-Blum (2013) recruited thirty-three participants from the Selective Mutism Anxiety Research & Treatment Center (SMart Center) in conjunction with the Selective Mutism Research Institute (SMRI). These participants had a diagnosis of SM, a mean age of 7.3 years with an even distribution of girls and boys. The principal investigators administered standardized language tests, which included the PPVT-4 (Peabody Picture Vocabulary Test), the EVT-2 (Expressive Vocabulary Test), and the TNL (Test of Narrative Language), and number recall sub-tests from the TAPS-3 (Test of Auditory Processing Skills).

Outcomes: Many children exhibited some form of communication deficit. To break it down further by type of deficit, 25% exhibited language deficits, 35% had both speech articulation and language deficits, 21% had speech articulation, voice, and fluency (stuttering-like) deficits, and 19% had no speech or language deficits. The investigators were able to identify these problems as the children were speaking when alone with parents in the clinic assessment room. Specific difficulties with language included:

  • Conveying information using decontextualized language (language that requires talking about things that are not in the present)
  • Using compound and complex sentences structures
  • Using sufficient words per sentence
  • Retelling a story
  • Making up a story about a picture
  • Using imagination to covey thoughts

Following these findings, Klein, Armstrong, Gordon, Kennedy, Satko, & Shipon-Blum developed the EXPRESS Program (Expanding Receptive & Expressive Skills through Stories), which they describe as a story-based, language-rich treatment approach to expand communication and spoken language formulation for children with SM or recovering from it. They recommend identifying a key-worker in the school (e.g. a speech-language pathologist) who understands the communication deficits affected by SM to administer EXPRESS.

For each activity in EXPRESS, children progress from non-vocal to indirect vocalization, to direct vocalization (limited), to scripted vocalization, and finally to spontaneous vocalization. Each EXPRESS story has five activities:

  • Listening to Story – Children listen as a popular, engaging story is read to them.
  • Vocabulary Building – Children learn vocabulary words during structured interactions.
  • Questioning-Answer Routines – Children respond to questions about the story using story grammar (i.e. characters, setting, events, internal responses, plans of action, consequences, and resolutions).
  • Formulate Sentences – Children generate sentences with targeted grammar using simple, compound, and complex sentences.
  • Generate a Story – Children contribute to a story at their level of ability, progressing from non-vocal to narrative story telling.

Children who have varying degrees of SM gain confidence by improving their receptive and expressive language abilities with EXPRESS. We need to be aware that anxiety impairs working memory and executive functioning. Anxiety also derails generating of ideas, putting ideas into words and sentences, speaking with clear articulation, voicing, and fluency, and using language for different purposes (Klein, Armstrong, & Shipon-Blum, 2013). The negative effects on vocal and verbal performance due to the child’s anxiety may reinforce the anxiety thereby causing the child to withdraw.

According to Dr. Ruiz, behaviors associated with selective mutism may also result from vocal tension related to anxiety that affects laryngeal control. Therefore, muteness in children with SM may occur due to speech and language demands or to social anxiety and physiological tension in the vocal mechanism that can make it difficult and uncomfortable for those with SM to vocalize (Ruiz & Klein, 2014).

Dr. Ruiz recommends the following criteria to free the voice from laryngeal tension:

  • Focus on vocalization instead of talking (verbalizing). Teach the child how voice is made and that it can be generated with greater ease through humming, initially.
  • Gain control of the voice in non-word tasks first. Making sounds is easier.
  • Reduce anxiety related to speaking by systematically approaching voicing with Apps such as Bla-Bla-Bla and Speak Up Too in which the voice activates the game.
  • Work on relaxation and generalization strategies to expand vocal production.

Many of our children with SM have anxiety, leading to impairment in working memory, executive functioning, and verbal fluency. These children lose self-confidence and avoid speaking situations, perpetuating the anxiety. In addition to the anxiety, persistent deficits in verbal fluency can affect a child’s social, emotional and academic well-being and success. Vocal tension is a physical manifestation of the stress brought on by these factors. Building receptive and expressive language skills as well as teaching techniques to lower laryngeal tension can help break the cycle and free our children from their silence in a variety of settings outside the comfort of their homes.

Klein, E. R., Armstrong, S. L., & Shipon-Blum, E. (2013). Assessing spoken language competence in children with selective mutism: Using parents as test presenters. Communication Disorders Quarterly, 34(3), 184-195.

Klein, E. R., Armstrong, S. L., Skira, K., & Gordon, J. (2017). Social communication anxiety treatment (S-CAT) for children and families with selective mutism: A pilot study. Clinical Child Psychology and Psychiatry, 22(1), 90-108. Doi: 10.1177/1359104516633497

Ruiz, C., & Klein, E. R. (2014). The effects of anxiety on voice production: A retrospective case report of selective mutism. Pennsylvania Speech-Language-Hearing Association Journal, 4, 19-26.