What is Selective Mutism?

Dr. Elisa Shipon-Blum www.selectivemutismcenter.org ~ smartcenter@selectivemutism.org

Selective Mutism is a complex childhood anxiety disorder characterized by a childs inability to speak and communicate effectively in select social settings, such as school.These children are able to speakand communicate in settings where they are comfortable, secure and relaxed. More than 90% of children with Selective Mutism also have social phobia or social anxiety.This disorder is quite debilitating and painful to the child.Children and adolescents with Selective Mutism have an actual FEAR of speaking and of social interactions where there is an expectation to speak and communicate.

Many children with Selective Mutism have great difficulty responding or initiating communication in a nonverbal manner; therefore social engagement may be compromised in many children when confronted by others or in a setting that is overwhelming or they sense a feeling of expectation. Not all children manifest their anxiety in the same way.Some may be completely mute and unable to speak or communicate to anyone in a social setting, others may be able to speak to a select few or perhaps whisper.Some children may stand motionless with fear, as they are confronted with specific social settings. They may freeze, be expressionless, unemotional and may be socially isolated. Less severely affected children, may look relaxed, carefree and socialize with one or a few children but are unable to speakand effectively communicate to teachers and most or all peers. When compared to the typically shy and timid child, most children with Selective Mutism are at the extreme end of the spectrum for timidity and shyness. Why does a child develop Selective Mutism? The majority of children with Selective Mutism have a genetic predisposition to anxiety. In other words, they have inherited a tendency to be anxious from one or more family members.Very often, these children show signs of severe anxiety, such as separation anxiety, frequent tantrums and crying, moodiness, inflexibility, sleep problems,and extreme shyness from infancy on. Children with Selective Mutism often have severely inhibited temperaments. Studies show that individuals with inhibited temperaments are more prone to anxiety than those without shy temperaments. Most, if not all, of the distinctive behavioral characteristics that children with Selective Mutism portray can be explained by the studied hypothesis that children with inhibited temperaments

have a decreased threshold of excitability in the almond-shaped area of the brain called the amygdala.When confronted with a fearful scenario, the amygdala receives signals of potential danger (from the sympathetic nervous system) and begins to set off a series of reactions that will help individuals protect themselves.In the case of children with Selective Mutism, the fearful scenarios are social settings such as birthday parties, school, family gatherings, routine errands, etc. Some children with Selective Mutism have Sensory Integration Dysfunction (DSI) which means they have trouble processing specific sensory information and may be sensitive to sounds, lights, and touch, taste and smells. Some children have difficulty modulating sensory input which may affect their emotional responses. DSI may cause a child to misinterpret environmental and social cues. This can lead to Inflexibility, frustration and anxiety. The anxiety experienced may cause a child to shut down, avoid and withdraw from a situation, or it may cause him/her to act out, have tantrums and manifest negative behaviors. Some children (20-30%) with Selective Mutism have subtle speech and/or language abnormalities such as receptive and/or expressive language abnormalities and language delays. Some may have subtle learning disabilities including auditory processing disorder.In most of these cases, the children have inhibited temperaments (prone to shyness and anxiety).The added stress of the speech/language disorder learning disability, or processing disorder may cause the child to feel that much more anxious and perhaps insecure or uncomfortable in situations where there is an expectation to speak. More studies are necessary to fully assess speech and language abnormalities and Selective Mutism as well as processing disorders and Selective Mutism.It is important to note that there are many children with Selective Mutism who are early speakers without ANY speech delays/disorders or processing disorders. Preliminary research from work at the Selective Mutism Anxiety Research and Treatment Center (SMart Center) indicates that there is a proportion of children with Selective Mutism who come from bilingual/multilingual families, have spent time in a foreign country, and/or have been exposed to another language during their formative language development (ages 2 4 years old.)These children are usually innately temperamentally inhibited but the additional stress of speaking another language and being insecure with their skills is enough to cause an increased anxiety level and mutism. A small percentage of children with Selective Mutism do not seem to be the least bit shy.Many of these children perform and do whatever they can to get others attention and are described as professional mimes! Reasons for mutism in these children are not proven, but preliminary research from the SMart Center indicates that these children may have other reasons for mutism. For example, years of living mute and therefore have ingrained mute behavior despite their lack of social anxiety symptoms or

other developmental/speech problems.These children are literally stuck in the nonverbal stage of communication.

Selective Mutism is therefore a symptom. Children are rarely 'just mute.' Emphasis needs to be on CAUSES of the mutism and propagating factors of mutism. Studies have shown NO evidence that the cause of Selective Mutism is related to abuse, neglect or trauma. What is the difference between Selective Mutism and traumatic mutism? Children who suffer from Selective Mutism speak in at least one setting and are rarely mute in all settings. Most have inhibited temperaments and manifest social anxiety.For children with Selective Mutism, their mutism is a means of avoiding the anxious feelings elicited by expectations and social encounters. Children with traumatic mutism usually develop mutism suddenly in ALL situations.An example would be a child who witnesses the death of a grandparent or other traumatic event, is unable to process the event and becomes mute in all settings. It is important to understand that some children with Selective Mutism may start out with mutism in school and other social settings. Due to negative reinforcement of their mutism, misunderstandings from those around them and perhaps heightened stress within their environment, they may develop mutism in all settings. These children have progressive mutism and are mute in/out of the home with all people, including parents and siblings. What behavior characteristics does a child with Selective Mutism portray in social settings? It is important to realize that the majority of children with Selective Mutism are as normal and are as socially appropriate as any other child when in a comfortable environment.Parents will often comment how boisterous, social, funny, inquisitive, extremely verbal, and even bossy and stubborn these children are at home!What differentiates most children with Selective Mutism is their severe behavioral inhibition and inability to speak and communicate comfortably in most social settings.

Some children with Selective Mutism feel as though they are on stage every minute of the day!This can be quite heart wrenching for both the child and parents involved.Often, these children show signs of anxiety before and during most social events.Physical symptoms and negative behaviors are common before school or social outings.

It is important for parents and teachers to understand that the physical and behavioral symptoms are due to anxiety and treatment needs to focus on helping the child learn the coping skills to combat anxious feelings. It is common for many children with Selective Mutism to have a blank facial expression and never seem to smile.Many have stiff or awkward body language when in a social setting and seem very uncomfortable or unhappy.Some will turn their heads, chew or twirl their hair, avoid eye contact, or withdraw into a corner or away from the group seemingly more interested in playing alone. Others are less avoidant and do not seem as uncomfortable. They may play with one or a few children and be very participatory in groups.These children will still be mute or barely communicate with most classmates and teachers. As social relationships are built and a child develops one or a few friendships, he/she may interact and perhaps whisper or speak to a few children in school or other settings but seem to be disinterested or ignore other classroom peers. Over time, these children learn to cope and participate in certain social settings. They usually perform nonverbally or by talking quietly to a select few.Social relationships become very difficult as children with Selective Mutism grow older. As peers begin dating and socializing more, children with Selective Mutism may remain more aloof, isolated and alone. Children with Selective Mutism often have tremendous difficulty initiating and may hesitate to respond even nonverbally.This can be quite frustrating to the child as time goes by.The childs nonverbal communication may go on for many years, becoming more ingrained and reinforced unless the child is properly diagnosed and treated.Ingrained behavior often manifests itself by a child looking and acting normally but communicating nonverbally.This particular child cannot just start speaking.Treatment needs to center on methods to help the child unlearn the present mute behavior. What are the most common characteristics of children with Selective Mutism? Most, if not all, of the characteristics of children with Selective Mutism can be attributed to anxiety.

Temperamental Inhibition -Timid, cautious in new and unfamiliar situations, restrained, usually evident from infancy on. Separation anxiety as a young child. Social Anxiety Symptoms - Over 90% of children with Selective Mutism have social anxiety. Uncomfortable being introduced to people, teased or criticized, being the center of attention, bringing attention to himself/herself, perfectionist (afraid to make a mistake), shy bladder syndrome (Paruresis), eating issues (embarrassed to eat in front of others,)

Social Being -Most children with Selective Mutism want friends, and need friends. *Differentiates Selective Mutism from other disorders such as the autistic spectrum disorders. Most children with Selective Mutism have appropriate social skills, but some do not and need help in developing proper social skills.

Physical Symptoms - MUTISM, tummy ache, nausea, vomiting, joint pains, headaches, chest pain, shortness of breath, diarrhea, nervous feelings, scared feelings Appearance - Many children with Selective Mutism have a frozen-looking, blank expressionless face, stiff, awkward body language with lack of eye contact when feeling anxious. This is especially true for younger children in the beginning of the school year or when suddenly approached by an unfamiliar person. * They often appear like animal in the wild where they stand motionless with fear! The older the child, the less likely they are to exhibit stiff, frozen body language..Also, the more comfortable a child is in a setting, the less likely a child will look anxious. For example, the young child who is comfortable and adjusted in school, yet is mute, may seem relaxed, but mutism is still present. *A hypothesis: heightened sympathetic response causes muscle tension and vocal cord paralysis.

Emotional - When the child is young, he/she may not seem upset about mutism since peers are more accepting. As children age, inner turmoil often develops and they may develop the negative ramifications of untreated anxiety. (see below)

Developmental Delays - A proportion of children with Selective Mutism have developmental delays. Some have multiple delays and have the diagnosis of an autistic spectrum disorder, such as Pervasive Developmental Disorder, Aspergers, or Autism. Delays include motor, communication and/or social development.

Sensory Integration Dysfunction (DSI) symptoms/Processing Difficulties/Delays: For many children with SM, sensory processing difficulties are the underlying reason for 'shut down' and mutism.In larger, more crowded environments where multiple stimuli is present (such as the classroom setting), where the child feels an expectation, sensory modulation specifically, sensory defensiveness exists. Anxiety is created causing a 'freeze' mode to take place. The ultimate 'freeze mode' is MUTISM.

Common symptoms: Picky eater, bowel and bladder issues, sensitive to crowds, lights (hands over eyes, avoids bright lights)sounds (dislikes loud sounds, hands over ears, comments that it seems loud), touch (being bumped by others, hair brushing, tags, socks, etc), heightened senses. I.e., perceptive, sensitive, Self-regulation difficulties, (act outing, defiant, disobedient, easily frustrated, stubborn, inflexible, etc)

Within the classroom, a child with sensory difficulties may demonstrate one or more of the following symptoms; withdrawal, playing alone or not playing at all, hesitation in responding (even nonverbally), distractibility, difficulty following a series of directions or staying on task, difficulty completing tasks.Experience at the Smart Center dictates that sensory processing difficulties may or may not cause 'learning' or academic difficulties. Many children, especially, highly intelligent children can compensate academically and actually do quite well. MANY focus on their academic skills, often leaving behind 'the social interaction' within school. This tends to be more obvious as the child ages.

What is crucial to understand is that many of these symptoms may NOT exist in a comfortable and predictable setting, such as at home.

In some children, there are processing problems, such as auditory processing disorder, that cause learning issues as well as heightened stress.

Behavioral Children with Selective Mutism are often i nflexible and stubborn, moody, , bossy, assertive and domineering at home. They may also exhibit dramatic mood swings, crying spells, withdrawal, avoidance, denial, and procrastination. These children have a need for inner control, order and

structure, and may resist change or have difficulty with transitions.Some children may act, silly or act out negatively in school, parties, in front of family and friends . WHY? These children have developed maladaptive coping mechanisms to combat their anxiety.

Co-Morbid Anxieties - Separation anxiety, Obsessive Compulsive Disorder (OCD), hoarding, Trichotillomania (hair pulling, skin picking), Generalized Anxiety Disorder Specific phobias, Panic Disorder. Communication Difficulties Some children may have difficulty responding nonverbally to others. i.e., cannot point/nod in response to a teachers question, or indicate thank you by mouthing words. For many, waving hello/goodbye is extremely difficult. However, this is situational. This same child can not only respond nonverbally when comfortable, but can chatter nonstop! Some children may have Difficulty initiating nonverbally- when anxious. i.e. has difficulty or is unable to initiate play with peers or going up to teacher to indicate need or want.

Social Engagement difficulties - When one truly examines the characteristics of a child with Selective Mutism, it is obvious that many are unable to socially engage properly.When confronted by a stranger or less familiar individual, a child may withdrawal, avoid eye contact and 'shut down' not only leaving a child speechless but preventing him/her from engaging with another individual. Greeting others, initiating needs/wants etc are often impossible for many children. Many shadow their parent in social environments often avoiding any social interaction at all. The common example given is; 'A child in grocery story can sing, laugh and talk loudly, but as soon as someone confronts him/her, the child freezes, avoids and withdrawals from social interaction.' As the child ages, freezing and shut down rarely exist, but the child remains either noncommunicative or will respond nonverbally after an indeterminate amount of warm up time.

MUTISM is just one of the many characteristics that children with Selective Mutism portray. When are most children diagnosed as having Selective Mutism? Most children are diagnosed between 3 and 8 years old.In retrospect, it is often noted that these children were temperamentally inhibited and severely anxious in social settings as infants and toddlers, but adults thought they were just very shy.Most children have a history of separation anxiety and being slow to warm up. Often it is not until children enter school and there is an expectation to perform, interact and speak, that Selective Mutism becomes more obvious.What often happens is teachers tell parents the child is not talking or interacting with the other children.In other situations, parents will notice, early on, that their child is not speaking to most individuals outside the home. If mutism persists for more than a month, a parent should bring this to the attention of their childs physician. Why do so few teachers, therapists and physicians understand Selective Mutism? Studies of Selective Mutism are scarce. Most research results are based on subjective findings based on a limited number of children.In addition, textbook descriptions are often nonexistent or information is limited, and in many situations, the information is inaccurate and misleading. As a result, few people

truly understand Selective Mutism.Professionals and teachers will often tell a parent, the child is just shy, or they will outgrow their silence.Others interpret the mutism as a means of being oppositional and defiant, manipulative or controlling.Some professionals erroneously view Selective Mutism as a variant of autism or an indication of severe learning disabilities. For most children who are truly affected by Selective Mutism, this is completely wrong and inappropriate! Research at the SMart Center indicates that children who seem oppositiona in nature often have parents, teachers, and/ortreating professionals who have pressured them to speak for months, perhaps years.Mutism not only persists in these children, but is negatively reinforced.These children may develop oppositional behaviors out of a combination of frustration, their own inability to make sense of their mutism, and OTHERS pressuring them to speak. As a result of the scarcity and, often, inaccuracy of information in the published literature, children with Selective Mutism may be misdiagnosed and mismanaged.In many circumstances, parents will wait and hope their child outgrows their mutism (and may even by advised to do so by well-meaning, but uninformed professionals). However, without proper recognition and treatment, most of these children do NOT outgrow Selective Mutism and end up going through years without speaking, interacting normally, or developing appropriate social skills. In fact, many individuals who suffer from Selective Mutism and social anxiety who do not get proper treatment to develop necessary coping skills may develop the negative ramifications of untreated anxiety.(See below) Why is it so important to have my child diagnosed when he/she is so young? Our findings indicate that the earlier a child is treated for Selective Mutism, the quicker the response to treatment, and the better the overall prognosis.If a child remains mute for many years, his/her behavior can become a conditioned response where the child literally gets used to non-verbalizing.In other words, Selective Mutism can become a difficult habit to break! Because Selective Mutism is an anxiety disorder, if left untreated, it can have negative consequences throughout the childs life and, unfortunately, pave the way for an array of academic, social and emotional repercussions such as:

Worsening anxiety Depression and manifestations of other anxiety disorders Social isolation and withdrawal Poor self-esteem and self-confidence School refusal, poor academic performance, and the possibility of quitting school Underachievement academically and in the work place Self-medication with drugs and/or alcohol Suicidal thoughts and possible suicide

Our main objective is to diagnose children early so they can receive proper treatment at an early age, develop proper coping skills, and overcome their anxiety. According to the US Surgeon General, our country is in a state of emergency as far as childrens mental health is concerned. 10% of children suffer from mental disorders, but less than 5% of these children are actually receiving treatment. Anxiety disorders are the most common mental illnesses among children and adolescents. If parents suspect their child has Selective Mutism, what should they do? Parents should initially remove all pressure and expectations for the child to speak, conveying to their child that they understand he/she is scared and it is hard to get the words out and that they will help their child through this difficult time. Praise the childs efforts and accomplishments, support and acknowledge the difficulties and frustrations. Parents should speak with their family physician or pediatrician and/or seek out a psychiatrist or a therapist who has experience with Selective Mutism.However, please note that having experience with Selective Mutism does not guarantee that the treatment approach and understanding is correct.In fact, a clinician with less experience, yet who has an excellent understanding of Selective Mutism may be an ideal choice for your child! What are the key questions to ask a potential therapist or physician? Do your homework! You will have a much better idea what to look for if you understand Selective Mutism. Educate yourself as much as possible before seeing any professional.Parents should read as much information as they can about Selective Mutism.The SMG~CANs website at
www.selectivemutism.org has countless pages of information and it is updated on a regular basis.

Key questions to ask include:

What are your areas of expertise? Have you ever treated a child with Selective Mutism? If so, how many and what are your success rates? What are your views on Selective Mutism? In other words, what are some of the reasons a child manifests mutism? What is your treatment approach to Selective Mutism? What will be my role as a parent? What is the teachers role? Etc. What is your opinion on medication in treating Selective Mutism and when do you consider medication? Can you supply me with references of families you have worked with? KEY!!

A key question to ask a therapist is 'HOW will you work with my child to help him/her progress communicatively?' Children do not progress communicatively without learning coping skills. Simply lowering anxiety is NOT enough to enable the child to begin engaging socially, learning to progress to verbal communication and feeling comfortable in an environment. SKILLS must be taught. Caution: When speaking to potential treating professionals, please be cautious of those who see Selective Mutism as a controlling/manipulative behavior. Treatment approaches based on discipline and forcing a child to speak are inappropriate and will only heighten anxiety and negatively reinforce mute behavior. How is a child evaluated for Selective Mutism? A trained professional familiar with Selective Mutism will have a parental interview. Emphasis will be on social interaction and developmental history, other manifestations of anxiety, behavioral characteristics (shy temperament), home life description (family stress, divorce, death, etc.) and medical history. From the results of the initial interview, the professional will often see the child. Children with Selective Mutism may or may not speak to the diagnosing professional. Whether a child DOES or DOES NOT speak to the evaluating physician does not really matter.An astute professional should be able to assess interpersonal communication skills and build rapport quite easily and, if given at least one session and possibly viewing videotapes from home, can rule in or out Selective Mutism as a diagnosis. Because 20-30% of children with Selective Mutism have an abnormality with speech and language, a thorough speech and language evaluation is often ordered.If motor/sensory issues exist an occupational therapy evaluation is also recommended.A complete physical exam (including hearing), standardized testing, psycho-educational testing as well as a thorough developmental screening are often recommended if the diagnosis is not clear. What are the diagnostic criteria for Selective Mutism? DSM-IV-TR (2000) Defines Selective Mutism as follows: 1. 2. 3. 4. Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations. The disturbance interferes with educational or occupational achievement or with social communication. The duration of the disturbance is at least 1 month (not limited to the first month of school). The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

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The disturbance is not better accounted for by a Communication Disorder (e.g., stuttering) and does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder.

Associated features of Selective Mutism may include excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling or oppositional behavior, particularly at home. There may be severe impairment in social and school functioning. Teasing or goading by peers is common. Although children with this disorder generally have normal language skills, there may occasionally be an associated Communication Disorder (e.g., Phonological Disorder, Expressive Language Disorder, or Mixed Receptive- Expressive Language Disorder) or a general medical condition that causes abnormalities of articulation. Mental Retardation, hospitalization or extreme psychosocial stressors may be associated with the disorder. In addition, in clinical settings children with Selective Mutism are almost always given an additional diagnosis of Anxiety Disorder, especially Social Phobia is common. (DSM-IV-TR) (APA, 2000)

Authors note: The above criteria are quite vague/nonspecific and should not be used alone to rule in or rule out the diagnosis of Selective Mutism. As mentioned earlier, children with Selective Mutism manifest many behavioral characteristics other than mutism. In addition, since children with Selective Mutism often have difficulty responding and/or initiating nonverbally, Selective Mutism can be viewed as a communication disorder. In addition, children with autism, PDD-NOS, Aspergers and other developmental disorders can manifest mutism that is selective in location.
How is Selective Mutism treated? The main goals of treatment should be to lower anxiety, increase self-esteem and increase social confidence and communication. Emphasis should never be on getting a child to talk. ALL expectations for verbalization should be removed. With lowered anxiety, confidence, and the use of appropriate tactics/techniques, communication will increase as the child progresses from nonverbal to verbal communication. Treatment approaches should be individualized, but the majority of children are treated using a combination of: 1. Behavioral Therapy: Positive Reinforcement and Desensitization techniques are the primary behavior treatments for Selective Mutism, as well as removing all pressure to speak.Emphasis should be on understanding the child and acknowledging their anxiety.Introducing the child to social environments in subtle and non-threatening ways is an excellent way to help the child feel more comfortable, i.e., Parents can take the child into school when few people are around to get the child to practice speaking.Eventually, bring a friend or two to school and allow the children to play when other children are not present.Small

groups with only a small number of children help, as well as allowing parents to spend time with the child within the class.After the child is speaking quite normally, the teacher, and then the students are gradually introduced into the group setting.Positive reinforcement for verbalization should be introduced when, and only when, anxiety is lowered and the child feels comfortable and is obviously ready for some subtle encouragement. 2. Play Therapy, Psychotherapy, and other psychological approaches :These can be effective if all pressure for verbalization is removed and emphasis is on helping the child relax and open up.Confronting mutism in a non-threatening way is important.These children are SCARED, and the focus should be to help them identify their level of being scared' in a particular situation.Helping them to realize that you understand and are there to help them relieves tremendous pressure. Cognitive Behavioral Therapy: CBT trained therapists help children modify their behavior by helping them redirect their fears and worries into positive thoughts.CBT needs to incorporate awareness and acknowledgement of anxiety and mutism.Most children with Selective Mutism worry about others hearing their voice, asking them questions about why they do not talk and trying to force them to speak.The focus should be on emphasizing the childs positive attributes, building confidence in social settings, and lowering overall anxiety and worries. Medication: Studies indicate that the most effective approach to treatment is a combination of behavioral techniques and medication.Often behavioral techniques are used for an indeterminate amount of time prior to the addition of medication.If children are not making enough progress with behavioral therapy alone, medication may be recommended to reduce the anxiety level.Serotonin reuptake inhibitors (SSRIs) such as Prozac, Paxil, Celexa, Luvox, and Zoloft are very effective in the treatment of anxiety disorders.Similar to the SSRIs, there are other drugs that affect one or more neurotransmitters such as serotonin, norepinephrine, GABA, and dopamine, etc. which are also proving to be affective. Examples are Effexor XR and Buspar.Both classes of drugs work well in children who have a true biochemical imbalance. This seems to be the case in the majority of children with Selective Mutism.Very often, we have seen positive effects in as little as a week! Medication is used as a jump start with the hope that, as we lower anxiety via medication, we can implement behavioral techniques more easily and successfully! Goals for the duration of treatment with medication are usually 9-12 months. Self-esteem boosters: Parents should emphasize their childs positive attributes.For example, if your child is artistic, then by all means show off the artwork!Have a special wall to display your childs masterpieces; perhaps you can even have a special exhibition!Have them explain their artwork to family members and close friends. This promotes more verbalization practice, as well as helps with confidence! Frequent socialization: Encourage as much socialization as possible without pushing your child. Arrange frequent play dates with classmates or even small group interactions with individuals the child knows well.The goals is for your child to feel comfortable enough with the classmates so that verbalization will occur.Most children with Selective Mutism will talk to friends in their own home.As the child gets increasingly comfortable speaking to one child, invite another child over, and then have two or three children at a time!Transfer speaking into the school via set tactics/techniques.For some children, Social Skill therapy is necessary and often helpful in accomplishing increased communication. School involvement: Parents need to educate teachers and school personnel about Selective Mutism!You must be an advocate for your child.The school needs to understand that children

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with Selective Mutism are not being defiant or stubborn by not speaking, that they truly CANNOT speak.Explain to the teacher that a child needs to feel that it is alright for them not to speak.Nonverbal communication is acceptable in the beginning. As the child progresses with treatment, the teacher should be involved in the treatment plan with verbalization being encouraged in subtle, non-threatening ways.An Individualized Educational Plan or 504 Plan may be necessary to help accommodate your childs inability to communicate verbally and to help the child progress communicatively as well as build social comfort. 8. Family involvement and parental acceptance: Family members must be involved in the entire treatment process! Very often changes in parenting styles and expectations are necessary to accommodate the needs of the child.Remember, never pressure or force your child to speakthis will only cause more anxiety.Convey to your child that you are there for them.Spend one on one time, especially at night, when all pressure is off and engage your child in discussions about their feelings.Allowing your child to open up helps relieve stress.A parents acceptance and understanding is crucial for the child!

Social Communication Anxiety Therapy (SCAT): This is the philosophy of treatment implemented at

the Selective Mutism Anxiety Research and Treatment Center (SMart Center) This treatment includes development of an individualized treatment plan that focuses on the whole child and incorporates a TEAM approach involving the child, parent, school personnel and treating professional.A combination of the above recommended therapeutic tactics/techniques are implemented to enable for social comfort and progression of communication comfort (nonverbalverbal) in various social settings in and out of school. Because anxiety levels change from situation to situation, and often from one person to the next, methods often change from one social situation to another. Therefore, by lowering anxiety, increasing self-esteem as well as increasing communication and social confidence within a variety of REAL WORLD settings, the child suffering in silence will develop necessary coping skills to enable for proper social, emotional, developmental and academic functioning. It is important to realize that with proper diagnosis and treatment, the prognosis for overcoming Selective Mutism is excellent! Author: Dr. Elisa Shipon-Blum is President and Director of the Selective Mutism Anxiety Research and
Treatment Center (SMart Center). Many of the findings in this pamphlet are based on findings from

treatment at the SMart Center of hundreds of children with Selective Mutism. She is also Founder and Director Emeritus of the SMG~CAN and a Clinical Assistant Professor of Psychology and Family Medicine PCOM. Dr. Shipon-Blums initial interest in Selective Mutism was personal. Her experiences trying to get help for her daughter made the need for research, development of appropriate/effective treatment strategies and dissemination of information about this social-communication disorder abundantly clear.

What is Social Communication Anxiety Treatment (SCAT)?

Social Communication Anxiety Therapy (SCAT) is the philosophy of treatment developed by Dr. Elisa
Shipon-Blum and implemented at the Selective Mutism Anxiety Research and Treatment Center

(SMart Center) www.selectivemutismcenter.org. SCAT is based on the concept that Selective Mutism is a social communication anxiety disorder that is more than just not speaking. Dr. Shipon-Blum has created the SM-Stages of Social Communication
Comfort Scale (C) that describes the various stages of social communication that are possible for a

child suffering from Selective Mutism. The Social Communication BRIDGE (C) illustrates this concept in a visual form. Children suffering from Selective Mutism (SM) CHANGE their level of social communication based on the setting and expectations from others WITHIN a setting. Therefore, a child may have difficulty socially engaging, communicating nonverbally and perhaps cannot communicate at all when feeling anxious or uncomfortable. For some children, MUTISM is the most noted symptoms. Meaning, they ARE able to engage and have astute nonverbal skills (professional mimes!). These children are STUCK in the nonverbal stage of communication and suffer from a subtype of SM called: SPEECH PHOBIA. Therefore, although mutism is the most noted symptom, it merely touches on the surface of our children! A complete understanding of the child is necessary to develop an appropriate treatment plan and school based accommodations/interventions. According to Dr. Shipon-Blum's work, after a complete evaluation (consisting of various assessment forms-parent/teacher; parent and child interview), treatment needs to address three key questions. --WHY did a child develop SM? (influencing, precipitating and maintaining factors) --WHY does Selective Mutism persist despite being in active treatment and parent/teacher awareness? And finally, --WHAT can be done at home, the real world and within school to help the child build the coping skills and overcome their social communication challenges? To HELP a child suffering in silence an understanding of which stage the child is IN during particular social encounters. The Social Communication Anxiety Inventory can be used to determine the stage of social communication.

Treatment is THEN developed via the WHOLE child approach where, under the direction of the outside treatment professional, the child, parents and school personnel work together. Dr. Shipon-Blum emphasizes that although anxiety lowering is key it is often NOT enough, especially as children age. Over time, many children with Selective Mutism no longer feel 'anxious' but mutism and often lack of proper social engagement continues to exist in select settings. Children with SM need strategies/interventions to progress from nonverbal to spoken communication. This is the TRANSITIONAL stage of communication and interestingly enough, It is this aspect that is often missing from most treatment plans. In other words, HOW do you help a child progress from NONVERBAL to verbal communication? Quite frankly, time in the therapy office is simply NOT enough. The office setting is used to help prepare the child for the OUTside world. To develop the strategies to help the child unlearn their conditioned behavior. THEN, in the REAL WORLD and within the SCHOOL setting, the strategies/interventions are implemented. Strategies and interventions are developed based on WHERE the child is on the SOCIAL COMMUNICATION BRIDGE and are meant to be a desensitizing method as well as a vehicle to UNLEARN conditioned behavior. SCAT incorporates anxiety lowering techniques, methods to build self-esteem and strategies/interventions to help with social comfort and communication progression, such as 'Bridging' from shut down to nonverbal communication and then TRANSITIONING into spoken communication via verbal intermediaries, ritual sound shaping and possibly the use of augmentative devices etc. The KEY concept that children with SM need to understand, feel in control and have choice in their treatment (age dependent) are a critical component of SCAT. SCAT provides CHOICE to the child and helps to transfer the child's NEED for control INTO the strategies and interventions! Therefore GAMES and GOALS (based on age) via the use of ritualistic and controlled methods (I.e., use of strategy charts: Example 1, Example 2) are used to help develop social comfort and progress into speech. Silent goals (environmental changes) and active goals (child directed goals based on CHOICE and CONTROL) are used within the SCAT program.

Every child is different and therefore an individualized treatment plan needs to be developed that incorporates HOME (parent education, environmental changes), Addressing the child's unique needs and SCHOOL (teacher education, accommodations/interventions). Therefore, by lowering anxiety, increasing self-esteem as well as increasing communication and social confidence within a variety of REAL WORLD settings, the child suffering in silence will develop necessary coping skills to enable for proper social, emotional and academic functioning.

Frequently Asked Questions

Topics:

At the SMart Center Initial Consultations School Services -- In-office and on-site evaluations, development of accommodations, & interventions

(IEP/504 Plan)
Treatment Follow-Ups and Convenience Consultations Medication Questions Learning more about Selective Mutism!

At the SMart Center

The treatment used at the SMart Center is: Social Communication Anxiety Therapy (SCAT) that has been used successfully on 1500+ children/teens. SCAT evolved over time while working with children/teens with SM. Dr. E's belief that SM is "more than just not speaking" has fueled the development of SCAT. We encourage you to read about our philosophy of treatment. What is the success rate of SCAT? Based on patient data, for ALL children who go through the complete course of recommended treatment that includes: 1. 2. 3. 4. 5. Consistent recommended follow-ups. Parent education Education of school personnel about SM and individual child's needs Development of school accommodations and interventions (Note: Academic achievement is dependent upon the correct placement and appropriate accommodations) Child involvement and willingness to receive help.

Over 95% of patients have overcome their silence, are verbal communicators and are now significantly more comfortable socially. Most no longer require school accommodations to aid in communication!

What is Social Communication Anxiety Therapy (SCAT)? I have taken my child to many other professionals and not one has used SCAT with my child. Why is this? Quite simply, Dr. E has developed SCAT from the multitude of data and clinical information gathered from working with so many children with SM. Since clinical experience precedes research, it is common for clinical efficacy to exist prior to documented research. Fortunately, research is presently being done via the SMRI that is confirming SCAT's effectiveness! Understand that SCAT is not ONE type of therapy technique but involves various types of treatment strategies and interventions that are proven within the scientific literature. For example: Systemic desensitization, modeling, fading, positive reinforcement, etc. etc. that enable the child to development social engagement skills and to progress communicatively in a stepwise manner in the 'real world' and within the school setting. Treatment is individualized and based on the child's particular needs. SM Conferences, workshops, professional trainings are done throughout the year to help educate parents, treating professionals and educators about SCAT. Dr. E also trains treating professionals regularly via teleconference and in-person direct trainings. Fortunately, SCAT Is becoming more popular and more professionals are realizing the effectiveness! As more research is published, many more professionals will begin to understand and adapt SCAT as a form of treatment! I am interested in references from families who have gone through treatment at the SMart Center. Is this possible? Absolutely! Please contact us directly at: SMartCenter@selectivemutism.org and place 'references' on the subject line. Another option is to post on the forum of the SMG~CAN or any of the Yahoo e-groups. Since Dr. E is well known in the field and has treated so many children & teens you are certain to encounter others who have gone through or are going thru treatment at the SMart Center! Your office is located in the NE suburbs of Philadelphia, PA. Do you treat children from other locations? Absolutely! The average distance to our office is over 2 1/2 hours...with many traveling via train or

plane to reach our location. We are proud to state that we have treated children and their families from almost every continent in the world! In addition, we perform many long distance teleconferences or video conferencing for families unable to present for an in-person consultation and school personnel from out of state. We do not live close to the SMart Center. can my child still be seen for an evaluation and treatment? Absolutely! Over 3/4 of the families travel long distance to the SMart Center! We can do evaluations either in-person or via teleconference. Please see our initial consultation
information.

If we live out of state or quite far from the SMart Center, how are follow-up appointments arranged. We can't possibly be traveling to the office every week! Since most families are seen every two weeks to every month, you could schedule follow-ups in a variety of different ways. Some families present for the initial appointment (for long distance families, we recommend a two-day initial appointment that consists of 2 hours the first day and 1-2 hours the second day). Follow up can begin with a teleconference approximately 3-4 weeks later. We often recommend a 30-60 minute teleconference with school personnel as well. Depending on the treatment approach recommended you can present monthly or every 3 months..or possibily consult via teleconference ongoing (When this is done, we recommend that you have a local clinician who you and your child can work with to follow up and implement strategies) What is the average range of the children that receive treatment at the SMart Center? The age range for children/teens in our practice is 3 years old to 19 years of age. In rare and unusual situations, we have worked with young adults. How long do most children receive treatment at the SMart Center? This question is impossible to answer. However, based on patients who have been seen at the SMart Center over the past many years, the average time frame for treatment is approximately 6-12 visits or every two- four weeks for 7-12 months. For less impaired children treatment has been as short as 4-6 visits. For more impaired children, especially older children, some have needed every two to four week treatment for up to or more than a year. Approximately 1 in 10 children require more than a year of treatment. Therefore, most children are discharged from the SMart Center after an average of 10-12 sessions.

Also note that the more consistent parents are in follow-up appointments, the more involved the school is in our efforts and the more a child is willing to partake in treatment, the easier and faster the child progresses communicatively and feels more comfortable socially. We have had mildly impaired children who have had sporadic and poor follow-ups and therefore need significantly more treatment then a more severely impaired child who attended treatment regularly and did their goals/games in between treatment sessions consistently. Keep in mind that every child is different and many children who are seen at the SMart Center have already seen multiple professionals in the past. Also note that if a patient begins at an every two week appointment interval, this does not mean that your child will be seen that often throughout the course of treatment. Patients usually 'graduate' to monthly approximately half-way through treatment. Please describe the typical treatment course for a child who receives treatment at the SMart Center: (View Typical Treatment Course) Results from your initial consultation will help our professionals develop a unique treatment plan for your child that is based on SCAT. Families leave the SMart Center at their first visit with beginning treatment recommendations. Based on whether your initial appointment was a Comprehensive or Per Service consult will dictate what you will be provided. Most families consult again approximately 4 weeks after their initial appointment. This gives families time to implement treatment recommendations and for school personnel to begin with recommendations. You will receive a confirmation email for your scheduled follow-up appointment prior to your next appt that will include access to the SM Follow-up Questionnaire (c) and the SM -School Evaluation Form(c). These should be filled out prior to each follow up visit to enable Dr. E to be updated so that time during your consultation is spent on treatment not "catch-up." In addition, results of the questionnaires help Dr. E develop a treatment focus for your upcoming session. Note: The SM - School Evaluation Form should be filled out at least every other visit or per your clinicians' request. During your in-person visit at the SMart Center, your child's session will usually begin with the parent(s) present. Parents will have the opportunity to meet with the clinician at each visit to discuss questions/concerns.

During each follow-up visit, your doctor or therapist will work with your child (and YOU) to develop games/goals that will be worked on during the time between treatment sessions. Parents will be provided with an APPOINTMENT SUMMARY, accompanying handouts and other printed material when necessary. Since the school is so key in the treatment, you will often get information for school personnel to update school based interventions. Your child is given rewards (small toys, stickers, candy, etc) after each visit to reward him/her for their hard work during their session. You are encouraged and your child is encouraged to write us emails as often as you like but at a minimum of once weekly in the beginning of treatment. Your child's teacher, school psychologist, etc are encouraged to update your doctor or therapist by email as often as they like.

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Initial Consultations

For immediate information on fees/services -->GO OR contact us via email or phone: 215-887-5748 for information on fees for the services listed below!)
I am not sure which consultation format to choose. Any advice? There are Four types of initial appointments for child/teen evaluations. 1. 2. 3. 4. Comprehensive: In-Person only Per Service: In-Person, Teleconference School Evaluations Ask the Doc: NON patient consultation.

ALL initial consultations include evaluation of various parent/teacher assessment forms, review of past (relevant) records, parent Interview, child evaluation (In person/Video) and, in some cases, IEP/504 review and/or discussion with outside treatment professionals and/or school personnel.

1) Comprehensive Evaluation: This format is for children who require a full evaluation and comprehensive report. Ideal for children who have never been diagnosed, for children who have been diagnosed but past treatment has failed or minimal progress has been made and parent would like another full evaluation/report. This is also IDEAL for families who are NOT able to present to the SMart Center for ongoing Follow-UP appointments. The comprehensive report is an excellent way to provide detailed information to other treating professionals and/or school personnel working with your child. Comprehensive Evaluation appointments include time spent evaluating multiple parent/teacher assessment forms, a 2-hour office visit and the development of a comprehensive report. The Comprehensive Report consists of: Summary of relevant history, summary of child evaluation results, explanation of child's stages of social communication from setting to setting, Assessment results (explanation of results of SM CDQ, and symptom inventory, multiple 'anxiety' forms (parent/teacher), summary of etiology (causes), precipitating and propagating factors, Diagnosis (if applies) and specific recommendations for home/school, approach to treatment, Multiple handouts with beginning goal/game charts and treatment follow-up recommendations. The average length report (not including multiple handouts/game/goal charts) is 10-16 pages in length.
2) Per Service Consultation: This format is ideal for:

A. Families who are searching for "additional recommendations" and a different treatment approach and simply need to "just begin" a new treatment or need treatment advice. B. For school personnel in need of advice on their students current social communication status and recommendations for school based accommodations and interventions. C. Second opinions, evaluations to rule in/out SM, evaluations without a "detailed report." school accommodation recommendations, (504 plans, IEP plans, school oriented questions) or treatment recommendations/questions, letter writing, expert testifying, etc. This consult is ideal for children who have already had comprehensive evaluations/report and treatment in the past. Following the evaluation, families or school personnel will receive a written or grid-like Appointment Summary that depends on the format most relevant to the child or student. Per Service consultations are based on time and includes the evaluation of multiple assessment forms, review of relevant past records, and the development of the appointment summary. The average time

in the office is usually two hours, but one hour appointments can be arranged. The average time within the school is usually two hours, one hour observing the child and 1-2 hours consulting with school personnel. The average length report (not including multiple handouts/game/goal charts) is 3-5 pages. 3) School evaluations can be in the form of:
Per Service Consultations or

School on-site evaluations. SMart Center staff will present at the child's school, observe the child and meet with school personnel to discuss findings and suggest school based accommodations, interventions. If requested, our staff can be present for 504 and IEP meetings either at the school or via arranged teleconference. ** Similar to Per Service Consultation above. 4) Ask the Doc consult A nonpatient consultation that is ideal for parents, school personnel or treatment professionals who are interested in a Question/Answer type consultation. This format is ideal for: A. Parent are in active treatment with a local therapist but have unanswered questions or need more advice. B. School personnel who have specific questions related to a student with SM. C. Treatment professionals who are working directly with a child or teen with SM and are in need of advice on treatment strategies and direction. The Ask the Doc format includes a the assessment of a brief questionnaire. There are no reports or summaries following the Ask the Doc consultation; however, handouts may be provided. There is NO Doctor/Patient relationship established with an ASK THE DOC consult. What is the process for scheduling an appointment?
Please review information on services/fees.

If you would then like to schedule an appointment, contact our office via email:
smartcenter@selectivemutism.org or call our front desk at: 215-887-5748 . Provide your email and

other contact information. We will then contact you back via EMAIL or phone depending upon your requests. Once we schedule you an appointment we will send you an email (or letter if requested) that will include ALL of your appointment details. You will be given instructions on what is required for your consultation in terms of specific assessment forms, etc. Due to the tremendous demand on our services, we require a $100 deposit to hold your scheduled appointment.

This deposit is refundable if you cancel your appointment prior to 2 weeks of your scheduled date. If you cancel within 2 weeks, you forfeit your initial deposit regardless of the reason. If your child is ill or you have another urgent situation, we will do our best to reschedule you however, we cannot guarantee a time frame for rescheduling. NO-SHOW appointments forfeit their deposit with no chance for rescheduling. Your Deposit must be received within ONE week of scheduling (postmarked). This is the families responsibility. Your deposit guarantees your appointment slot. Please note that if you schedule an appointment and we need to make a change in the professional performing your consultation or the date of your appointment, we will inform you of the change ASAP. You can then decide if you would like to keep your appointment or change to an alternative date. If requested, we will return any deposits regardless of the time frame prior to the appointment. What if after I choose the Ask the Doc initial format, I decide to pursue regular treatment? This happens often. Families will need to fill out the SM-CDQ, the SM School Eval form and perhaps other recommended assessment forms. Depending upon what was accomplished during the Ask the Doc consultation, will dictate the level of service to begin treatment. Can I schedule and appointment with a particular doctor or therapist? You can certainly make a request for a specific treatment professional however, based on scheduling and a professional's availability will dictate whether we can honor your request. You will be informed at the time of appointment scheduling who you will be seeing at the SMart Center. If a staff change needs to occur, we will inform you as soon as possible. I am very interested in speaking to parents who have gone through treatment at the SMart Center. Is this possible? Very possible and also highly recommended! Dr. E and our other clinicians have wonderful relationships with the children and parents she works with and most are more than happy to correspond with another parent who is "in the same shoes" they were in not too long ago. Please speak to your doctor or therapist about this during your consultation. She will match you with another parent or a few parents with a child similar to yours. We encourage patients to communicate with other children/teens who have had SM or who are still undergoing treatment. Your therapist or doctor will mention this to you during your consultation. if your child desires a pen pal, we will do our best to find a match for your child!
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School Services
(For immediate information on fees/services-->GO OR contact us via email or phone: 21... for information on fees for the services listed below!)

We have a student who we believe has SM. Can we send the child to your center or do you do on-site evaluations? Fortunately we do both! You can certainly send the family to the center, do a phone consultation or perhaps hire our staff to come to your school to do a full evaluation. Please note that school on-site evaluations are limited to: PA, NJ, NY, DE We would like to hire your staff to come to our school to consult about a student. We need help with the development of accommodations and interventions. What is the process? SMart Center staff will present at the child's school, observe the child and meet with school personnel to discuss findings and suggest school based accommodations, interventions. If requested, our staff can be present for 504 and IEP meetings either at the school or via arranged teleconference. (Similar to Per Service Consultation, above.) Our staff needs help in implementing interventions. Can the Smart Center help? Absolutely! Our staff can consult with school personnel either via PHONE or on-site. On an as-needed or scheduled consultant basis our staff can present regularly to work directly with the student and school staff! Some of the services we provide are: Direct staff training, friendship-based groups, social pragmatic work with students during scheduled small group time, facilitation of communication strategies during class time, One on one work with the student to work on specific interventions both in-class and out-of-class, Buddy-work, etc. You may also consider on-site trainings for staff such as workshops and webinars! Accommodations (IEP/504 Development) I am not sure whether my child/STUDENT needs an IEP or a 504 plan. How do I know which,

if either, is necessary? If the child has SM that is impacting on his/her emotional, social and possibly academic well-being, then your child most definitely needs some form of accommodations. Dr. E or another one of our professional staff can provide expert opinion after performing an initial consultation. You should ask as many questions as you can during your consultation. If requested, your clinician will provide a written report with recommendations or help develop the 504 or IEP plan. (For information on 504/IEP
development)

If our professional staff believes your child should have testing for possible special education services and an IEP or 504 accommodations you will be provided with a letter that you can submit to your school principal or other relevant school personnel. This letter will inform the school of your requests which will then be followed up on according to IDEA. Most school personnel welcome suggestions on the development of accommodations and school based interventions. We can help in this process by being present at your school meeting either in person or via teleconference. It is important to note that accommodations are necessary but specific school based interventions are also highly recommended to help the child PROGRESS communicatively and to build social comfort. Without interventions, progress may be limited.

If my child has qualified for an IEP or perhaps a 504 plan and we need recommendations for accommodations and school-based interventions, which consultation format do you recommend? 1. The Per Service (in-person or phone/video) and Comprehensive Consultation (inperson only) are initial consultations that enable for an evaluation of your child. These are not 'accommodation plans.' These consultation choices enable for an evaluation that will help our staff determine your child's specific treatment/accommodation needs. Consultations with school personnel to develop school accommodations and interventions, etc are then billed at an hourly rate.

Note: There is no child who just needs an IEP or 504 accommodations. This is not treatment. Your child should be involved in treatment aside from any school accommodations. an IEP. However, accommodations and school-based interventions should complement what is being done in therapy and during the times between therapy when 'in the real world.''

What if my school teacher or another school professional wants to speak to my treatment professional, Can he/she just call her during the day?

No, we ask that you schedule a short phone call with our scheduling department. Our Professional staff's intense schedule does not allow for 'sudden' calls unless there is a true emergency. Again, based on reasons for the call, the family will be billed for any time spent consulting. What is the SM - School Evaluation form? This is the questionnaire that Dr. Shipon-Blum developed to help assess the child social comfort, communication level, academic performance, overall anxiety level, etc within the school environment. Teacher's should fill out this form as often as your therapist or doctor needs. Information submitted helps inform your clinician of your child's situation in school. This information is then used to plan for your upcoming consultation which will then enable for updated school based interventions. View SMSchool Evaluation Form

Professionals are welcome to use the SM School Eval form to assess child's social, communication, response to accommodations/interventions and academic status within the school environment. Respect to copyright is required.
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Follow-Up Consultations

How often are children/teens seen for follow-up visits? Most children/teens are seen every 4-6 weeks with Dr. Shipon-Blum. For children/teens who need more frequent follow-ups visits can be scheduled every 2 weeks. Associates at the Smart Center are also available for clinicial follow-ups for families who request more frequent visits. What is included in a follow-up consultation?

Evaluation of the SM Follow-Up Form for parents to fill out. Evaluation of the SM School Eval form for teacher(s) to fill out. This is usually done prior to each appointment Evaluation of older child/teen Follow-Up form (*When appropriate) Unlimited email updates to Dr. E or other staff members. 15-30 min meeting with Intake coordinator to review progress (this can be done on the phone prior to appointment as well) 55-60 min office visit (or teleconference)

Written appointment summary that includes new or tweaked games/goals, recommendations for school staff

Why is my child NOT seen weekly or multiple times weekly? Dr. E's clinical experience dictates that children need time in-between sessions to work on treatment goals/games both at home and within the school setting. Therefore, children are seen every two-four weeks at the SMart Center. What If I want my child to be seen more frequently or I feel I need more help with the games/goals can this be done? Of course. When you consult with Dr. E (or associates) please mention this. We will then schedule accordingly. For many patients, in-between visits with Dr. E, they see one of our associates for in-person or Real World appointments (helping the child with games/goals within the real world). Also, teleconferencing is available on a scheduled basis. Bottom line, Your needs will be met at the Smart Center. We are conscious of the varied needs of our families. We will do our best to accommodate all! What If I feel I need an appointment outside of my regular scheduled appointment. Ie, some issues have come up or I have additional questions. How is this handled? No worries. We offer our patients the flexibility of what we call, 'Convenience Consultations.' These are appointments that are scheduled no more than two weeks in advance and are on a first come/first served basis. These appointments are prior to our regularly scheduled appointments. These appointments range from 10-30 min. If more time is needed, we can extend assuming time is available. These appointments are usually a teleconference consutlation, but in-person consultations are available for those who request. If interested in a Convenience Consutlation, Please call our Direct Patient Line (supplied to all our patients and located in the Established Patient Section of our website) or email us at:
smartcenter@selectivemutism.org .

We will then schedule you accordingly. Where can I locate the Follow-Up forms that need to be filled out and how do I submit them? All follow up forms are located at the following link:
http://www.drelisashiponblum.citymax.com/AllForms.html

Directions on submission are indicated on the link above.

You will also be supplied the link to the SM- Follow Up Forms when our office sends you an email confirmation. This is approximately 3-7 days prior to your appt. You can also access the SM-Follow Up Questionnaire directly from the first page of our website. Simply click on 'Smart Center patients---> Established patients--> You will see the link to the FOLLOW-UP forms on the top right side of the grid. How do I schedule my Follow-Up appointments? Please email our scheduling dept at: SMartCenter@selectivemutism.org. We will then contact you back by email and begin the scheduling process. We usually schedule out approximately 3 months to ensure that you are in our schedule. If you prefer telephone correspondence, please call our Direct Patient Line (Provided to all our established patients and located in the Established Patient section of our website). You can reach our Front Desk Call Center at: 215-887-5748 . What is the office policy for appointment canceling? Families must let us know about cancellations within 3 days of a scheduled appointment. Obviously children will get sick, travel may be difficult due to weather, etc. However, we ask that if you need to change or cancel an appt that you give us as much notice as possible. As you know, we have a long waiting list for appointments and the sooner you let us know, we can inform another patient in need that an appt space has opened up. If a parent has cancelled with minimal notice more than 50% of the time, we will ask for payment upfront and patients will be responsible for an office visit charge. If a new patient (a patient scheduled for an initial consultation or a patient who has been under our care for less than 2 months) does not show-up for a confirmed appt, no new appointments will be scheduled unless full payment is made in advance. Our policies are strict since Dr. E has limited office time and our demand for services is high.
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Medication Questions

** For those with many questions on medication, we suggest the NEW CD-ROM/Audio CD's presented by Dr. E., Medication: Why, When and HOW to use Safely and Effectively in the Treatment of
Selective Mutism.

What percentage of patients at the SMart Center are placed on medication? Based on our present patient population, for approximately 30-40% of patients, medication is recommended as an adjunct. However, please keep in mind the following: 1. Since children/teens with SM are our entire focus, we see patients of varying degrees of severity. Due to Dr. Shipon-Blum's specialty, many families who present to the Smart Center have been to multiple treatment professionals in the past and minimal progress has been made. By the time many present at the Smart Center, they have exhausted many forms of treatment. The older the child, The more severe and co-morbid problems that exist, the more likely medication may be recommended. The younger the child, the less co-morbid problems that exist the less likely medication will be recommended.

2. 3.

If my child needs medication, can our child receive medication and monitoring at the SMart Center. Absolutely! Dr. Shipon-Blum is a medical doctor. Therefore in addition to providing SCAT, she will prescribe medication if necessary. Monitoring is individualized and done carefully and ranges from every two weeks/once per month in the beginning of treatment to every three months once stable. Monitoring is done very carefully. Dr. E requires parents to update via email or phone (to staff) every week (in beginning of medication usage) to indicate child's tolerance and response to medication. What if we are against medication, but Dr. E recommends medication, will my child not be treated at the SMart Center? Dr. E respects your decision whether to use or not to use medication as an adjunct to treatment. However, many parents are uninformed about 'medication' and form opinions without completely understanding. If Dr. E recommends medication and a parent is against medication, Dr. E will simply ask the parent to read about the medication and to ask her about the questions they may have. IF after a thorough understanding, parents are still against the use of medication, treatment will continue without medication being used. What types of medication are used at the SMart Center? If medication is recommended, 99% of patients are placed on a Selective Serotonin Reuptake Inhibitor (SSRI) (i.e., Prozac, Zoloft, Paxil, Celexa, etc) or a medication very closely related to an SSRI (I.e., Effexor)

Why is medication recommended? Medication is used as an adjunct to help lower anxiety just enough to do the necessary behavior therapy necessary to build coping skills. For some children/teens, anxiety is so high, that a short course of medication enables for the lowered anxiety needed to accomplish therapy. How long does a child remain on medication? The goal is 6-12 months depending upon clinical response. How does Dr. E monitor medication? Very Carefully! Dr. E believes that 'less is more.' and manages 95% of her patients on less than the equivalent of 20mg of Fluoxetine (Prozac). Prior to using medication, Dr. E will ask a series of questions to be sure medication is safe to use with your child. She will exam your child, supply you with a handout, answer your questions about medication and will explain to you the purpose and how medication will be used. Side effects will be discussed in detail. Your child will return within 2 weeks of beginning medication. Dr. E will ask you to email her after the first few days of beginning medication. Prior to your follow-up visit, you will be asked to fill out the SM-Follow-Up Eval that assesses your child's treatment progress and clinical response to the medication. At your visit, after treatment status and degree of progress has been determined, Dr. E will exam your child and determine whether to continue present dosage, increase or decrease the dosage. It is very rare to have to decrease dosage.
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Learning about Selective Mutism!

There are multiple ways to learn more about Selective Mutism.

Please visit the SMart Mart for products that include books/DVD's and CD's from a recent 6 hour Selective Mutism conference. We also have a handout section on our website. --> GO. For support and ways to 'get connected' visit the nonprofit organization, visit the Selective Mutism
Group (SMG) site.

Assessment & Testing

Purpose: Academic testing to aid in proper school placement, development of IEP or 504 plan, to enable for a better understanding of childs individual needs within the school setting to enable for academic success.

Dr. Shipon-Blum now offers a nonverbal assessment tool to help assess:

Cognitive skills School readiness Conceptual and basic skills

Results of the test correlate with IQ and academic level of achievement. Written Report will include:

Specific areas of academic strengths weaknesses, Scores and Percentages (compared to other children) Assessment of anxiety level during testing Recommendations for school personnel, based on childs reactions during testing and overall scores, to help accommodate child within the school setting.

Time for testing - 60 minutes to be added to appointment time or scheduled for another day. Parents provided with a written report with scores, percentages and recommendations. In addition to academic assessment testing, we offer a range of diagnostic/therapeutic evaluations (CLICK HERE) for consultation formats.

Right From the Mouths of our Silent Babes

By Dr. Elisa Shipon-Blum

Children/teens with Selective Mutism are consistently asked why they do not speak. Individuals often believe that if they continuously ask these children to speak or question them over and over that they will automatically begin speaking. The assumption here is that these children CAN speak, re perhaps being stubborn and if continuously questioned and told what to do, these children will eventually speak. Unfortunately, the individuals who believe this tactic will work are hugely mistaken and are only propagating mutism and inner anxiety. Children with Selective Mutism do not automatically begin speaking when prompted. If they do eventually utter a sound or whisper from coercion the anxiety that is created is often so tremendous that more internal anxiety is created which in turn, propagates mutism. Has anyone ever wondered how a child/teen with Selective Mutism truly feels when he/she is in school or other social situations where mutism is evident? Having asked hundreds of children with Selective Mutism how they feel when uncomfortable has elicited interesting responses.

Out of 100 children with SM, below is the term used by children/teens that indicate how they feel when in school or other settings where mutism is evident. SCARED - 50% of the time, DONT KNOW - 25% of the time 'IT'S Hard or Difficult' - 15% of the time DONT WANT TO -10% of the time Varied answers come up 5% of the time

The responses of these children from all over the world should indicate that these children are fearful when confronted with social situations. Being scared and nervous (75%) of the responses elicited are typical feelings of anxiety that come over these children. IF these children are anxious, then how would frequent questioning, asking and insisting that these children speak help SM children? It wont.

It should be obvious that treating these children from an anxiety perspective using various behavioral techniques would be the best way to help a child suffering from SM. IF this is all true, then why are so many children still suffering in silence???? ANSWER: Not enough Parents, teachers and treating professionals truly understand Selective Mutism. The SMART-CENTER and the Selective Mutism Group Childhood Anxiety Network (SMG~CAN) are trying to educate and promote the public awareness of Selective Mutism in order to RID THE SILENCE of Selective Mutism. Please help us disseminate information to educate teachers and treating professionals in order to help SM children overcome their anxiety.
www.selectivemutism.org Sminfo@selectivemutism.org