We are very pleased to welcome Suzanne Hungerford, Ph.D., CCC/SLP,
as our guest host for the SLP chat tonight, Monday, March 7, 2005.
She will be addressing the topic of Selective Mutism.

Suzanne Hungerford, Ph.D., CCC/SLP is Associate Professor of
Communication Disorders and Sciences at Plattsburgh State
University of New York.  She is also Clinical Supervisor in the
Auditory and Language Processing Clinic in the Speech and Hearing
Center at Plattsburgh State.  She teaches graduate and undergraduate
courses in evaluation and language disorders, including a graduate
course in Socio-Communicative, Cognitive, and Behavioral Correlates
of Communication Disorders. Her interest in selective mutism led to
a seminar presentation at the  American Speech-Language-Hearing
Association Convention entitled "A Socio-Communication Intervention
Model for Selective Mutism".

Dr. Hungerford has provided us with handouts about Selective Mutism.
The links to these handouts may be found below the transcript.

<Robin> Welcome! We are chatting tonight about the topic Selective Mutism with chat host,
          Suzanne Hungerford, Ph.D., CCC/SLP.
<Robin> Dr. Hungerford, please give us some background information on this topic of Selective Mutism,
          including the definition, incidence, etc.
<Suzanne Hungerford> The American Psychiatric Association's diagnostic criteria for Selective Mutism (SM)
          are pretty straightforward.  Here are the highlights: child does not speak in situations in which speaking
          is expected (school), child speaks in other situations (typically home).
<Suzanne Hungerford> Problem persists for at least a month, problem interferes with normal educational or social
          functioning, and problem is not caused to some other disorder (e.g., stuttering, autism).
<Suzanne Hungerford> Speech/language pathology definition:  Selective Mutism (SM) is a profound pragmatic
          communication disorder. (That's my opinion).
<Suzanne Hungerford> Causal factors:  It is generally believed that most cases of SM are due to severe social
          anxiety, although there is still some argument about that in the literature.
<Suzanne Hungerford> Risk factors: Having family member with social anxiety disorder, social isolation, 
          multilingualism, and others. About 30-50% of kids with SM have a speech/language disorder/delay.
<debbie> Would you say then that the onset could be seen at any time or do you see this in a particular
          language development stage?
<Suzanne Hungerford> Debbie, usually, it is diagnosed when kids enter school and the problem becomes obvious,
          but usually there are signs before that (social anxiety).
<Suzanne Hungerford> Some kids are severe and their problem is more than muteness.  They may not engage
          nonverbally either, and may even turn into little immovable statues in the presence of others. 
          Others gesture, write, or even whisper.
<debbie> I see
<Robin> Is this more common in boys than girls?
<Suzanne Hungerford> Girls, about 3:1  (sort of the opposite of most other communication disorders).
<Suzanne Hungerford> I think it is more useful to think of SM not as a problem with speech, per se, but as a
          global interaction/pragmatic communication disorder.
<Suzanne Hungerford> That way, we start to see therapy targets that we might not have seen before:
          joint attention, nonverbal turn-taking, etc. , and these targets may be represent the level
          at which we need to start to be successful with these kids.
<Robin> Dr. Hungerford, tell us about the evaluation process....which professionals are involved?
<Suzanne Hungerford> Evaluation and therapy should be a team effort: psychologist, teachers, SLP, psychiatrist
          or pediatrician (if medications are prescribed).
<Suzanne Hungerford> SLPs need to assess/describe: the pragmatic communication disorder, speech/language,
          and speech-related anxiety (as you would with a person who stutters).
<Suzanne Hungerford> How?  Parent interview, direct observation at school and at home, standardized testing
          if the child will point (PPVT, Lindamood Aud. Conceptualization Test, etc.), analysis of recorded
          language and narrative sample from home, portfolio analysis.
<freitags> Is there a certain age/grade in which a team should look into doing an evaluation...especially
          for a multilingual child?
<Suzanne Hungerford> Once SM is identified (one month of not talking in school) therapy should begin.  There's
          evidence that kids that get late intervention tend to be chronic.
<myra> Is it necessary to wait one month if the parents are willing to get help faster?
<Suzanne Hungerford> The American Psychological Association states that SM shouldn't be diagnosed before
          one month of not talking.  But, I think that we don't necessarily need the psychological diagnosis
          before beginning work.  If the child hasn't talked in 3 weeks, that's an obvious pragmatic
          communication disorder, and we could start working on that.
<myra> Ok...good... I don't personally see a need to wait one month if parents/teachers/SLPs/ all agree that
          treatment may help.
<evelyn> In SM, the child is silent all the time?
<Suzanne Hungerford> The definition of SM is that the child speaks readily in some situations (home, typically),
          but not others (school, typically).
<evelyn w> Ok. So the problem is more psychological than speech related?
<Suzanne Hungerford> There seem to be degrees of SM: kids that don't speak at all in some situations and have
          little nonverbal interaction, and those that may gesture, write, even whisper.
<Robin> Some would argue that treating SM is out of our scope of practice....
<evelyn w> Or at least not primarily our scope...
<Suzanne Hungerford> Ahhh, the million dollar question.  SM is most likely due to severe anxiety in most cases -
          does this make it a psychological disorder? Yes. Is it also a communication disorder?  Yes.  Just like
          aphasia is both a neurologic and a communication disorder.
<agold> So if the child is able to use speech/language correctly (meaning their speech/language is not disordered),
          how do they qualify for services?
<Suzanne Hungerford> If you agree that the communication impairment of aphasia should be treated by the SLP,
          you can probably agree that SM should be treated by the SLP, even if the causal factors are neurologic
          or psychologic.
<agold> ok
<debbie> We, as SLP's, need to educate the team.  It has been my experience in the past that the psychologist
          has been the one who feels it is more psychological in nature and a speech/language evaluation would not
          be warranted.
<myra> This all relates to what I was going to ask... if they have good communication skills otherwise, what do
          we target?  What is our role?
<Suzanne Hungerford> Consider SM to be a pragmatic communication disorder that impacts academic and social success.
<evelyn w> No matter what the cause, if language is involved...so are we!
<Suzanne Hungerford> Right, if the kids can't communicate - call in the SLP.  That's my opinion.
<myra> But I'm confused by that.... if they can communicate with the SLP, how do we treat them (if we can't be
          in the situation that renders them mute?)?
<Suzanne Hungerford> Usually they don't initially communicate with us, either.  Once they do start
          interacting/communicating with us, we need to generalize that behavior to other situations/people.
<Suzanne Hungerford> Also consider that many of these kids - 50% - have speech/language problems that may be
          contributing to their SM.  We can help treat those too.
<AdrienneFSU> I think your earlier analogy to stuttering was good, Dr. Hungerford.
<Dave G.> You could use similar arguments about stuttering or autism.
<AdrienneFSU> Often people who stutter won't do it around the SLP, especially once they feel comfortable.
<myra> I do find anxiety-related issues to be extremely interesting... selective mutism and stuttering,
          for example.
<Robin> Please tell us more about treatment.          
<Suzanne Hungerford> Treatment should target communication at a very broad level - most publications come
          from psychology and they target speech behavior directly.  I think we can contribute by targeting
          communication, broadly  interaction skills.
<myra> I once taught a 4 year old selectively mute.... EXTREMELY interesting to have had this experience.
<debi> For the 50% who have speech/language impairments with SM, do you find more are language based or
          fluency based?
<Suzanne Hungerford> Debi, language and articulation.
<myra> So... broad treatment... do SLP's ever get involved in areas that would be considered more along the
          lines of behavior therapy?  (I'm guessing not... leave it to the psychologists?)
<Suzanne Hungerford> SLPs know that communication is more than just verbal behavior: it is a complex interplay
          of communicative pressures, social background, communicative competence, social anxiety...
<Ela> Do you treat SM togethter with a psychologist who works with the family?
<Suzanne Hungerford> Most of the research shows that a behavioral approach is the best with these kids. 
          They usually don't start talking with psychotherapy alone.
<Suzanne Hungerford> Nevertheless, there should be a psych person on the team who can deal with some of the
          anxiety and social issues.
<myra> That's interesting... that psychotherapy alone isn't enough.  What is recommended as the
          "best case scenario?"
<Suzanne Hungerford> There should be a team approach.  The SLP can be an essential part of that team. 
          We have had some luck working FIRST on nonverbal interaction: joint attention, nonverbal turn taking,
          etc. and THEN moving on to more complex interaction and verbal communication.
<Robin> Can you give us an example of some of the goals you address in treatment?          
<Suzanne Hungerford> Some examples of goals:  child will take turn to put together puzzle with therapist;
          child will roll ball back and forth while facing therapist; child will play a musical instrument (toy)
          in therapy band...
<Suzanne Hungerford> These sound pretty rudimentary, but they represent the level at which the child and you
          will have some success - you can build from there.  E.g., child will make speech noises as part of a game;
          child will say  yes/no in a game context.
<Robin> Thank you for those examples.
<myra> Are there documented cases in which speech-language therapy alone is enough for the child to overcome this?
<Suzanne Hungerford> Yes.  I presented a case at the ASHA Convention, 2003, and there were two posters that I saw
          at ASHA 2004.  But, as a profession, I don't think we've done a very good job documenting our successes
          with these children, and we need to do that.  I think that oftentimes we do work alone, unfortunately,
          because some parents are reluctant to build a team that includes psychology/psychiatry.
<Suzanne Hungerford> We recommend "baby steps" - if the child stops progressing we just assume we have made
          too big a leap in communication pressure.
<Suzanne Hungerford> Communication pressure can come from a variety of sources: physical context (classroom,
          hallway, playground), type of communication required (sharing personal vs. nonpersonal information,
          sharing known information vs. novel information, rote/rehearsed vs. spontaneous), who is present
          (peers, teacher, principal), communicative functions required (answering, asking, requesting),
          communication/interaction modality (nonverbal turn-taking, joint attention, parallel play, head nods,
          writing, whispering).
<debbie> I've been in the SLP field for 20 years and have only had 2 cases.  I agree with Dr. Hungerford that the
          best approach is a pragmatic based one, concentrating first on communicative intents, then communicative
<Suzanne Hungerford> One thing that really seems to be counterproductive is pressuring the child to speak or
          constantly asking them "why" they're not talking.  Better: let the reinforcement "do the talking".
<Suzanne Hungerford> One thing I want to say - SM tends to be pretty treatment resistent - it is hard not to get
          frustrated, but you can't give up.
<Robin> How long do you see a client if there is no progress?
<Suzanne Hungerford> I think that we see more progress when we start working at those rudimentary levels of
          interaction first. I would say, keep working for a long time, if you can keep the child on your caseload
          and still document some progress.
<Suzanne Hungerford> You'll document more progress if you target those "baby steps" toward interaction/communication.
<Robin> Thank you
<myra> I read of an interesting approach...
<myra> the child's voice is recorded in a place where they are comfortable (perhaps by the parents) and their
          recorded voice is spliced into recordings with the teachers voice for example.... and then the child
          listens to it as thought it were a conversation that took place.
<myra> The literature seemed to say this was successful.  Are you familiar with this approach?
<Suzanne Hungerford> Yes, thanks, myra.  That's called 'video feedforward'.  Videotaping and splicing so the
          child looks like she's talking to the teacher, for example.
<myra> Right... I couldn't think of the name but that's exactly it... have you used that?
<Robin> Is this approach used frequently?
<Suzanne Hungerford>  I'm not sure, Robin.  It would be nice to know what most clinicians are using out there.
          Again, we need to document more of our work in formats like convention presentations. 
<Suzanne Hungerford> Some kids with SM refuse to be videotaped, though.
<AdrienneFSU> If the child is okay with it, do you use it?
<Suzanne Hungerford>  You mean okay with videotaping?  Yes, I think it is a good idea.
<AdrienneFSU> Yes- thanks...what is the theory for why that works? Kids seeing themselves commnicating effectively?
<Suzanne Hungerford> Adrienne - it's desensitization - they see themselves as effective communicators, and start
          to change expectations of themselves.
<AdrienneFSU> I see, thanks.
<myra> Re: video feedforward... one article I read said it is better to use audio because it's easier to make
          the spliced conversation flow (no interference from changing backgrounds, e.g.)... perhaps a child
          would be more comfortable being audio recorded.
<Suzanne Hungerford> Yes, we have used audiotape - seems less intimidating than video.  We've used a spliced
          audiotape of a child reading one page of a book, then the clinician reading the other page of the
          book, so it sounds like they are taking turns in this interactive routine.
<Ela> Suzann, do you usually get cooperation from the parents?
<Suzanne Hungerford> Cooperation from parents...well, sometimes.  I just read a study that showed that parents
          of SM kids often have social anxiety themselves, this might affect their interactions with professionals.
<Ela> My experience has been that this is how the child exercises control in their family, and controls the Mom.
          I had a child tell the  that he will stop talking to her if she continued to bring him to speech therapy.
<Suzanne Hungerford> Ela, some folks believe that in some kids there is an oppositional component.
<debbie> My experiences with SM have also been the child seeks to "control".
<myra> I haven't read anything that talks about control .... that sounds like a separate issue to me that the
          child has learned to use to his/her advantage.
<Suzanne Hungerford> I think the model of anxiety causing SM is more useful than thinking of it as oppositional. 
          If we believe the latter, we tend to get more frustrated with the kids and the situation:  better to
          think "what can I do to enable this child to talk."
<Ela> Have you had positive results using behavior techniques without psychological assistance?
<Suzanne Hungerford> Ela, yes.  We have had families that refuse to have psychologists involved, and we've been
          the only professional - with success.
<Steph> Is there any research about how often it occurs that people with SM have another sibling who also have SM?
<Suzanne Hungerford> There are so few cases of SM, it's hard to make generalities.  Re siblings, there is some
          evidence that twins are more susceptible.
<myra> Do these children typically have several environments in which they don't speak?  I mean, are they mute
          in most places outside the home?
<Suzanne Hungerford> Many kids are mute most places out of the home.  Some are only mute in school or with
          certain individuals (teacher, for example).
<myra> I see, thanks.
<AdrienneFSU> Do you ever include siblings- or other kids that the SM child does talk around?
<Suzanne Hungerford>  It is a good idea to bring someone with whom the child currently talks into the situation in
          which the child doesn't talk (therapy room, classroom).  That sibling, then, is a "discriminative stimulus"
          for talking in the new situation.
<Robin> We have been chatting for nearly an hour...are there any more questions for Dr. Hungerford?
<myra> That was a lot of info... thank you SO much, Dr. Hungerford!
<Robin> Thank you to Dr. Hungerford, for sharing her expertise with us tonight!
<Suzanne Hungerford> You're welcome!  It's been fun.  Wish we had much more time!
<debbie> Thank you Dr. Hungerford.
<Robin> Is there anything else about Selective Mutism you'd like to share with us tonight?
<Suzanne Hungerford> Attitude is important.  Be patient.  Expect progress, but don't get too frustrated when
          progress is slow.
<Ela> Thank you for sharing your expertise with us, Dr. Hungerford.
<evelyn w> Excellent chat..thank you Dr. H. so much!
<AdrienneFSU> Thank you so much!
<agold> Thank you for all the great info. Dr. Hungerford.
<Robin> Thank you all for coming and asking such interesting questions
<Suzanne Hungerford> Thank you all for your great discussion.
<Steph> Thank you, Dr. Hungerford.
<Suzanne Hungerford> Welcome!
<Robin> Goodnight all!

Selective Mutism Handout