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Selec%ve Mu%sm 101 Rachel Busman, PsyD Director, Selec ,ve Mu,sm Service Amanda Mintzer, PsyD Postdoctoral Fellow
Selec%ve Mu%sm 101
Rachel Busman, PsyD Director, Selec,ve Mu,sm Service
Amanda Mintzer, PsyD Postdoctoral Fel low
Child Mind Ins:tute
The only independent nonprofit organiza%on exclusively dedicated to transforming mental health care for children everywhere.
To help children reach their full poten%al we must:
• Develop more effec%ve treatments for childhood psychiatric and learning disorders.
• Empower children, families and teachers with the scien%fically sound informa%on they need.
• Build the science of healthy brain development.
The Child Mind Ins,tute does not accept funding from the pharmaceu,cal industry.
“The Child Mind Ins%tute dares to imagine a world where no child suffers from mental illness.”
-‐Brooke Garber Neidich, Chair, Child Mind Ins%tute
Founded in 2009
Upcoming Events
Free Workshops
For more informa%on, please visit
childmind.org/workshop-‐series
Helping Kids Stay Organized Presented by David Anderson, PhD, Senior Director of ADHD and Disrup%ve Behavior Disorders Center Wednesday, October 22, 2014 6:15 PM – 7:30 PM
Upcoming Events
Free Workshops
For more informa%on, please visit
childmind.org/workshop-‐series
Brave Buddies – Long Program Presented by Rachel Busman, PysD, Director of the Selec%ve Mu%sm Service Saturday, February 14th through Tuesday, February 17th (Presidents Day weekend) 9:00 AM – 2:00 PM
Upcoming Events
Free Workshops
For more informa%on, please visit
childmind.org/workshop-‐series
Building Brave Muscles: Behavioral Treatment for Selec:ve Mu:sm Presented by Laura Kirmayer, MA, Director of the Brave Buddies Program Wednesday, November 19, 2014 Time: 06:15 PM — 07:30 PM
Outline for our Time Together • Selec%ve Mu%sm 101 • Diagnos%c Assessment of Selec%ve Mu%sm
• Treatment Outline • Groups and Intensives • Implementa%on in School
• Q and A
What is Selec:ve Mu:sm (SM)?
• Persistent failure to speak in specific social situa%ons when speaking is expected (e.g. school, extra-‐curricular ac%vi%es, play dates) but speaks fluently in other situa%ons (e.g. home)
• Fluid speech in other situa%ons (oeen at home and in familiar places)
• Not due to primary speech and language problems • Not due to English as a second language • Not due to lack of knowledge or discomfort with the language
Why do we care about selec:ve mu:sm (SM)? • Because children with SM clam up in public but typically talk like fabulous lifle chaferboxes at home
• Because children with SM suffer in silence • Because SM is relentless if you have it • It’s highly interfering • Just try not talking for a day • Count how many people you talked to today.
• 2 unanswered ques%ons per minute= • 20 unanswered ques%ons per 10 minutes= • 720 unanswered ques%ons per day= • 130,120 unanswered ques%ons per school year! • Prac%ce anything 130,120 %mes and see if you get “good” at it….. Overlearning!
Let’s Do the Math
Debunk The Myths
• Elec%ve Mu%sm/ willful behavior • Selec%ve Mu%sm = Social Phobia • Trauma Related • Child will “out grow” of the behavior • Shy • Au%sm • Cogni%ve Deficits • Language Disorders
Prevalence • Research suggests between .7% to 2% in early elementary school
• Typically diagnosed around age 3
• One and a half to two %mes more likely in girls than boys
Nature AND Nurture
• Pre-‐disposi%on to be behaviorally inhibited and/or to other anxiety disorders
• Detectable incredibly early in life
• Incredibly stable pafern of response
• Parental Anxiety
• The environment’s role in shaping the inhibited stance
• Nega%ve Reinforcement Cycle
Current conceptualiza%on of SM
Child is prompted to talk or engage
Child gets (too)
anxious
Child avoids
Adult rescues*
Child’s and adult’s anxiety are lowered*
Nega:ve reinforcement
Behavioral Conceptualiza:on
Why do children con:nue not to speak?
• Selective Mutism is a learned response • SM is a long series of negatively reinforced
interactions – Becomes automatic – Rapid fire on a daily basis
Enabling is our natural ins:nct (excluding sociopaths!) • When we see someone in distress it is our natural reac%on to offer help…rescue them – Parents and teachers are KNOWN for this!
• Enabling plays a role in maintaining the silence (saving child from the anxiety)
• Examples of good inten%ons gone bad: – Speaking for the child – Not calling on the child – Mind reading
Rigid Rules
• Kids with SM divide the world into those they talk with and those they don’t
• Boundaries are not fluid
• Mul%ple variables influence these boundaries
The Contamina:on Effect
People, Places, and Ac:vi:es
• Unique varia%ons from child to child
• Treatment needs to be individualized to these varia%ons – Same goal and same approach, but different star%ng points and different sized steps
People
Haves • Parents • Siblings
Have-‐Nots • Peers • Rela%ves • Neighbors • Family Friends • Teachers • *Strangers
Places
• Safety zones • Sensi%vity to surroundings can result in really drama%c
differences even within a sepng • Frequently observable shies in presenta%on depending on
degree of comfort • These boundaries tend to be rigid
Ac:vi:es
• Ac%vi%es they feel confident or comfortable engaging • Less self-‐conscious ac%vi%es • Less structured ac%vi%es • Ac%vi%es that involve physical ac%vity and produce laughter
oeen result in more engagement and less inhibi%on
Treatment Goals: • Increase number of people, sepngs, and situa%ons in which child speaks responsively and spontaneously
• Develop the child’s capacity to manage anxiety related to speaking so that child is able to overcome its impact (distress tolerance)
• Decrease inhibi%on • Diminish anxiety (maybe)
Current Research on Effec:ve Treatment • Cogni%ve Behavioral Treatment (CBT)
– *8 years and above (requires meta-‐cogni%on and well-‐developed verbal skills)
• Behavioral Treatment – *2 to 7 years
• Psychopharmacology
Ineffec:ve Interven:ons
• Forcing, coaxing or demanding that a child speak • Embarrassing the child for not speaking • Manipula%ng the child to speak • Punishment for not speaking • Demanding verbal manners such as; “thank you,”“please,” “hello,” and “good-‐bye”
Treatment Outline
• Diagnos%c Evalua%on – 3 hour Clinical Interview with Caregivers
• Video, K-‐SADS, ADIS, SM Interview, SMQ, SSQ, SL Screen, PSI, CBCL – 1 hour Selec%ve Mu%sm Behavioral Observa%on Task with child and
caregivers • (SMBOT)
• Feedback and treatment recommenda%ons – Psychopharmacology
• Sessions 1-‐2: – Explain format of treatment approach – Psychoeduca%on (start and throughout) – Parent training in distress tolerance – Parent training in Behavioral Skills
• Homework: crea%ng map and daily prac%ce
Treatment Outline (con:nued)
• Sessions 3-‐7: – Code 5 minutes of CDI, Coach 10 minutes of CDI – Code 5 minutes of VDI, Coach 10 minutes of VDI – Fade in to session – Review homework, weekly graphs and talking map
• Session 8 – Assess progress and reassess treatment goals
• Sessions 9-‐16 – Introduce Targeted Prac%ce – School-‐based and community based interven%ons – Targeted prac%ce groups and Brave Buddies intensives
• Gradua%on and Boosters
SM Behavioral Observa:on Task
• Func%onal Behavioral Assessment • Informed by DPICS from PCIT* • 4 situa%ons (approx. 5 minutes each)
– Warm-‐up: Parent and Child – Responsive Speech: Parent and Child – Confederate: Parent, Child, and Stranger – CDI and VDI Trial: Parent, Child, and Stranger
• Clinician codes throughout each situa%on in 1 minute intervals
*Eyberg
SM Behavioral Observa:on Task (SMBOT)
For BOTH parent and child-‐ • Non-‐verbal communica%on
– Point, nod, gesture, laugh, shrug, sounds • Rate of responsive speech • Rate of spontaneous speech • Volume • Latency • Response rate to type of ques%on • Behavioral inhibi%on
Psychoeduca:on and Parent Training • Parents and caregivers (important for all to be doing the same
thing) • Transparent & Collabora%ve • Debunk Myths and Discuss Behavioral Conceptualiza%on • Review session format/treatment plan • Distress tolerance • Behavioral skills • Create Talking Map and Homework Tracker (review sample of
weekly graphs)
Treatment as Usual
• How we begin… • Avoid Contamina%on Effect • No Ques%ons Please!
– Remove the expecta%on to speak and build comfort level
• Gradually and Systema%cally – Sensi%ze child to our presence and to verbalize in our presence through the use of PRIDE skills
Familiar with PCIT?
Parent-Child Interaction Therapy
SM Behavioral Skill Modules
• Child Directed Interac%on (CDI) – Reward/ Reinforcement
• Verbaliza%on Directed Interac%on (VDI) – Exposure/ Approach Task – Effec%ve sequences when asking child to speak
• Fade-‐in – Passing the ‘talking baton’ – Generaliza%on
• Targeted Exposures
Child Directed Interac:on (CDI) PRIDE Skills • Praise -‐ Labeled Praise (LP) • Reflect (RF) • Describe-‐ Behavior Descrip%ons (BD) • Imitate • Enthusiasm
****AVOID • Ques%ons, commands, cri%cism, sarcasm
The POWER of the skills
• Labeled Praise: – increase behavior you are praising – increases self esteem
• Behavioral Descrip%on: – lets child lead – shows interest – models good speech and vocabulary – Afen%on skills – Organiza%onal skills
The POWER of the Skills (2)
• Reflect Verbaliza%ons: • IMITATE with ENTHUSIASM
– Child leads conversa%on – Models verbaliza%on and listening – *Increases verbal communica%on – Demonstrates acceptance and understanding
For Any Verbaliza:on….
• REFLECT it and LABELED PRAISE it – “Chocolate Ice Cream! Thank you for telling me which flavor you are ea%ng.”
• RELFLECT, LABELED PRAISE and add a s%cker for brave talking!
Behavioral Reinforcement • Target Talking • Brave Talking earns Brave Bucks= Prizes • *debunk myths about extrinsic mo%vators and use of reinforcement
Verbaliza:on Directed Interac:ons (VDI) -‐Specific set of “Do” skills that builds on the SM-‐CDI “Do” skills, adding specific prompts to verbalize and providing valid opportuni%es for the child to respond. -‐ Op%mizes opportuni%es for a child to provide a verbal response -‐ Minimizes opportuni%es that inadvertently discourage verbal responding Used in each session aeer the child has had an opportunity to warm up with SM-‐CDI. Even when a counselor deems that a child is ready for VDIs within a given session, she s%ll uses LP, RF, and BD in her skills repertoire, combining CDIs and VDIs.
3 Types of Ques:ons
• Yes/No – “Do you want chocolate ice cream?”
• Forced Choice – “Do you want to get chocolate or vanilla?”
• Open-‐Ended – “What type of ice cream do you want to have?”
Direct Command for Verbaliza:on
• DVC • “Tell me what flavor you want.”
Forced Choice or Open Ended Ques%on /or
Direct Verbal Command or Prompt for Verbaliza%on
Effec:ve VDI Sequence
Wait 5 Seconds….
• The longest 5 seconds ever…
• Distress tolerance (for YOU and child)
Forced Choice or Open Ended Ques%on /or
Direct Verbal Command or Prompt for Verbaliza%on
Verbal Response No Response Nonverbal Response
Effec:ve VDI Sequence
Forced Choice or Open Ended Ques%on /or
Direct Verbal Command or Prompt for Verbaliza%on
Verbal Response
Reflec%on and Labeled Praise
No Response
Wait 5 seconds Reformat or Repeat
Ques%on
Nonverbal Response
Acknowledge Gesture and Neutral Probe for
Verbal
No response/ nonverbal
Wait 5 seconds and “Plan B”
Verbal Response
Reflec%on and Labeled Praise
Effec:ve VDI Sequence
Exposure Steps
Prize from Prize Store (end of day) Reward Ac%vity (3x/day)
S%cker/Point/”Brave Buck” (Immediately)
Labeled Praise (+/-‐ Reflec%on)
Brave Talking
Valid prompts*: (Forced Choice or Open Ended + 5”)
Fade in: A Ladder of Bravery
• No expecta%on to speak (no ques%ons) • Speak to parent in our presence • Speak to us with parent in the room • Speak to us with parent no longer in the room • Speak to us with a second person in the room…
– *enabling versus accommoda%ng
Targeted Prac:ce
• The Special Sauce – Exposure: An exposure is an Approach Task that helps the child successfully encounter or experience the very thing that they have been avoiding
• Success-‐ oriented • Repe%%on-‐Consistency-‐Momentum • Select 1-‐2 per situa%on/event
Targeted Prac:ce Example
Counselor: We are going to have a treat today. We are going to get ice cream. Do you want chocolate, vanilla, or something else? Child: Chocolate. Counselor: Chocolate! Thanks for telling me. Do you want it in a cup or a cone? Child: A cone Counselor: Great job telling me you chocolate ice cream in a cone. So when we get to store the person will ask say, “What can I get you?” What would you say back to him? Child: Chocolate ice cream Counselor: Did you want it in a cup or cone? Child: A cone Counselor: Great job ordering your ice cream. Let’s try again!
Targeted Prac:ce Example Cont.
• PRACTICE, PRACTICE, PRACTICE
Role play in the classroom/treatment room
Role play in the lobby of your building
Role play on the street
Role play in the doorway of the ice cream store
Role play at the counter
Order ice cream
Games that Elicit Verbaliza:ons (when ready!) • Go Fish • Zingo • Hangman • Headbandz • Guess Who • Surveys of Favorites • Spot It • Tell Tale
Hypothesis Tes:ng
• If a child exhibits any kind of resistant behavior or doesn’t answer when prompted to talk or engage in an exposure, explore and test hypotheses about the behavior.
• It is important to rule out other reasons for the behavior that are not related to the child’s SM or anxious avoidance.
• Hypothesis tes%ng also helps to pinpoint poten%al mechanisms maintaining the child’s SM (e.g., a fear of guessing, a fear of sta%ng the wrong answer, a fear of verbalizing in front of peers, etc.). This would help to further tailor goals and interven%ons for each child.
Accommoda:ng versus Enabling
• Telling order to parent before ordering directly to waiter (taking steps to approach this)
• Wri%ng a response to a ques%on from teacher while in the process of prac%cing Brave Talking
• Using IPad to show recorded show and tell while prac%cing this at home
-‐ Always ordering for your child
-‐ Using notes to communicate with teacher all year long
-‐ Never par%cipa%ng in show and tell
Accommoda:ng versus Enabling
The following are examples of accommodation vs. enabling.
A. A child verbalizes during morning meeting in a barely audible whisper. Her counselor reflects the verbalization so that the others in the group can hear exactly what she said.
a. This is accommodation if the child has not yet consistently verbalized during morning meeting and/or is working on the goal of verbalizing in front of peers.
b. This is enabling if the child has already incorporated this behavior into her repertoire and is working on volume as her target behavior.
B. A child is prompted to verbalize during morning meeting and says, “I don’t want to.” The counselor says, “Great job telling me that you don’t want to.”
a. This is accommodation if the child has not yet demonstrated an ability to say “I don’t want to,” or “I don’t know,” in which case she has reached a goal with this verbalization.
b. This is enabling if “I don’t want to,” is functioning as an avoidance behavior and she needs practice just deciding among options, which is a common comorbid problem for children with SM.
C. A child is interviewing a peer for her Brave Buddies Workbook. The counselor points to the next question, but the child does not read it. The counselor leans in to the child and whispers the question in her ear.
a. This is accommodation if the child did not ask the question due to difficulty reading from her workbook.
b. This is enabling if the child did not have a skills deficit in reading.
Adjunc:ve Treatment to Treatment As Usual • Brave Buddies
– October 17th, 2014: One Day • Individual Intensives • Targeted Prac%ce Groups
A New Student…
• A new sepng can be an amazing opportunity for momentum (frog leaps)
• Begin building familiarity with sepng and teachers asap (avoid contamina%on!) – Coordinate visits for the student before the school year starts (with parent)
– Verbaliza%ons in the school building to parent – Verbaliza%ons in classroom to parent – Verbaliza%ons in presence of teacher – Pass the baton…
• Possibly have a familiar peer join the sessions
Taking it to the classroom…
• Allow a 5-‐10 minute “warm-‐up” – No ques%ons!
• A predictable daily rou%ne • Lots of praise for any non verbal interac%ons (ini%a%ng play with another child, sounds, whispers, laughter)
• Build on strengths with lots of labeled praise (reading, sense of humor…)
• Normalize and validate fear with en%re class – Increase feelings iden%fica%on and awareness
Some Tips to Set Up Class For Success… • Meet child in classroom alone and graduate to verbaliza%ons
– “passing the baton” • Meet child in class with a peer and graduate to verbaliza%ons
– Building momentum! • Sea%ng of child in the room • Pairing child with a partner, a “buddy” (ideally a peer the child is familiar
with) • Sepng up non-‐verbal plan for bathroom, emergency’s, requests for
help… • Once we are ready for verbaliza%ons…
– Asking several forced choice ques%ons to peers prior to child – Plan a forced choice ques%on, wai%ng 5 seconds and then moving on – Labeled praise aeer verbaliza%on!
Helpful Resources
• Selec%ve Mu%sm Group (SMG) www.selec%vemu%sm.org • Child Mind Ins%tute (CMI)
www.childmind.org
• American Academy of Child and Adolescent Psychiatry (AACAP) www.aacap.org
• Parent-‐Child Interac%on Therapy Interna%onal – www.pcit.org
