How do you know whether your child has selective mutism or is just shy in certain situations?
Joining me today to discuss selective mutism—an anxiety disorder that is characterized by the inability or refusal to speak in certain situations, despite being capable of speech in other settings—is Dr. Carmen Tumialan Lynas. Dr. Tumialan Lynas is a clinical psychologist and anxiety specialist and the founder of Advanced Therapeutic Solutions.
Recognizing the symptoms of selective mutism (SM) is crucial in order to provide appropriate support. If you think your child may have SM, you won’t want to miss this episode that covers what to look out for and how to help children so they can overcome their communication challenges and thrive!
Dr. Sarah (00:00):
Hey there. Before we jump into today’s episode, I wanted to let you know that I’m hosting a free live virtual workshop, Navigating the Summer-to-School Transition: Empowering Parents of 2-7 Year Olds this Tuesday, August 1st, to register for this free workshop, go to drsarahbren.com/back-to-school or hop on Instagram and DM me the word “SCHOOL” and you can sign up for this free workshop and learn all the things that you can start doing now to make for a smoother and more successful transition in the fall.
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When your child is shy, it’s natural for parents to want to encourage them to open up. But what if it’s moving beyond shy to where your child won’t speak at all in certain situations over a prolonged period of time? In these instances, children may have selective mutism. Joining me today is Dr. Carmen Tumialan Lynas. Dr. Linus is a clinical psychologist and anxiety specialist who founded Advanced Therapeutic Solutions and their selective mutism program, which provides appropriate and effective selective mutism treatment. In this episode, we’ll talk about a few technical terms. PCIT stands for Parent-Child Interaction Therapy and it references a treatment modality where the focus is on establishing warmth in a parent’s relationship with their child through first learning and applying skills to help children feel good about themselves, and then teaching them how to accept parental limits, follow directions, and engage in appropriate behavior in public.
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And then we’ll be talking about PCIT-SM, which is a specific adaptation of PCIT specifically for treating selective mutism. So this episode is going to dive deep into different treatment modalities, what to look out for if you suspect your child might have selective mutism or if you want to kind of discern whether your child is maybe perhaps on the shyer, more anxious side of the spectrum or if they’re actually moving into that space of selective mutism. And we’re also going to talk about tips that parents and extended family can use to help support children with selective mutism. So this episode is chock full of information and guidance, whether your child has selective mutism or not.
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Hi, I’m Dr. Sarah Bren, a clinical psychologist and mom of two. In this podcast, I’ve taken all of my clinical experience, current research on brain science and child psychology and the insights I’ve gained on my own parenting journey and distilled everything down into easy to understand and actionable parenting insights. So you can tune out the noise and tune into your own authentic parenting voice with confidence and calm. This is Securely Attached.
(04:39):
Hello, welcome to the podcast. Really glad to have our guest today, Dr. Carmen Tumialan Lynas is here. She’s a clinical psychologist, she’s an anxiety specialist, and we are going to have a really exciting conversation, I think about a topic that’s very confusing to people and that is selective mutism. So thank you for coming on. I know you have a lot of knowledge on this very specific diagnosis.
Dr. Carmen (05:13):
Well, thanks so much for having me. I’m always looking forward to talking about selective mutism and sharing the information that we’re learning as we’re learning it and spreading that awareness out there. So thank you for having me.
Dr. Sarah (05:26):
Yeah, so the reason why, I mean, I’ve been wanting to do an episode on selective mutism for a while, but I got this letter from a listener and you were the first person I thought of to reach out to address this, but I’ll read the letter just so people can kind of get a sense of why, what we’re going to be talking about today. But this woman Holly wrote in, she said, I’ve been enjoying your podcast and have a lovely relationship with my smart, funny, bossy two year old daughter. However, I’ve recently discovered that she has selective mutism well-meaning people have been encouraging her to speak, engage and answer questions when she simply can’t. In fact, this encouragement makes it even harder for her to speak. I would absolutely love it if you would consider doing a podcast on selective mutism. A better understanding would not only help children with selective mutism, but also shy and reserved children too. So what might be helpful to just start in defining and explaining a little bit about what selective mutism is and how we understand it sort of clinically?
Dr. Carmen (06:33):
Sure. So selective mutism is it’s an anxiety disorder characterized by not speaking. So the first diagnostic criterion is there’s a failure to speak despite being able to speak. And that failure to speak is usually first identified in children when they start school. So they’re talking at home, they seem to be, parents see them as speaking normally in the home setting and familiar settings. And then when they first start preschool or kindergarten, then they get the report from the school that their child isn’t talking. So it’s usually first identified between around the ages two to five, and it has to last longer than the first month of school. So typically developing kids, usually it’s not unusual for kids ages two to five to be reticent to engage in the beginning when they transition to school and mostly within that first month of school, they start to verbalize and they’re able to verbalize.
(07:37):
So it’s the kids that go beyond that first month of not talking and then extends to an additional month and they’re still not verbalizing that can start to potentially meet criteria for selective mutism. The tricky part is that sometimes the kids will warm up and socially engage, but they’re socially engaging and still not talking. So that can sometimes be tricky. It also can be tricky because it can look normative for a toddler not to be talking so much or to be more on the quiet side. So sometimes educators take a wait and see approach and think, well, let’s just see if the child maybe next year they’ll, they’ll be more engaged. And those who are looking less normative as they get older, then parents are informed, Hey, it’s been a few years and haven’t spoken. What we’re seeing now is that more educators are being more aware about selective mutism and they may catch it earlier, which is fantastic. We’re seeing more preschools as a result of that. But for the most part, there’s still a lot of people don’t understand the condition and how it might look. So you could have child who looks really, really scared and not engaging, or you can have a child who looks really, really social and warmed up but just not verbalizing.
Dr. Sarah (09:04):
So what is the difference then between, for people wondering selective mutism versus being shy? Those kids that are slow to warm up, it has to be longer than a month threshold in school, but some kids who are very slow to warm up temperamentally don’t actually have selective mutism. So how do you parse that part out?
Dr. Carmen (09:27):
Shy kids warm up. And the difference is that, so if you’ve got a shy child who tends to be quieter but then warms up, their personality doesn’t change depending on the environment. Well, let me qualify that. All of our personalities change depending on where we are. We’re our work person at work, we’re our home person at home, at home, and we’re a student at school, but isn’t huge difference in those personalities in the way we are in those settings. Whereas a child with select mutism, oftentimes the parents will say, they are so not like that at home. They are so different at home. Like your listener said, my two year old is deter a determined child. And so not like this, but out in public it’s different. And so I think that that’s a big indicator is if you see a completely different chatty, there’s an abundance of speech at home and then there’s zero or very minimal speech outside and a very different kind of reserved personality, flat affect, that’s something else.
(10:48):
And a shy child doesn’t have such huge discrepancies like that and and they’re functioning, there isn’t that impairment. So that’s the other pieces that select mutism. If there’s impairment and academic functioning and social functioning, then it becomes considered meeting more of the diagnostic criteria. Versus a shy child can be shy but still function and be able to answer questions in class, do their oral presentations in class. They may not like it. They may need to use their coping strategies to get through it, but it can still manage. And whereas a child with select mutism, that becomes more of an emotion regulation issue where the mutism is considered a way to regulate during that pressure, but then they’re not speaking.
Dr. Sarah (11:44):
I’m interested. So we talk a lot about emotion regulation and anxiety on this podcast. And what you’re saying makes me think back to the idea that anxiety is, if we really think about it, the way that we manifest anxiety symptoms is an attempt at surviving. It’s an attempt at adapting to a level of discomfort that’s not like that’s overwhelming to us. And so while we look at a child who they have selective mutism and their anxiety is manifesting in that way, might look as though they are not trying and not doing things. In fact, the absence of the speech is an attempt of the nervous system trying to preserve itself in the face of this intense panic or fear. And so they almost sort of shut down as a way of preserving their sense of safety and control, which is hard because as parents then, or the environment perhaps wants to really pull more, pull more, pull more, try to elicit the speech. It’s kind of like when I talk a lot about how if a kid is having a total meltdown, not related to speech and anxiety, but just like if you behavioral issue, they wanted this thing, you said no, they’re totally melting down.
(13:12):
In that state of complete dysregulation. That’s not the time to ask them to engage in a skill. We kind of have to lower our expectations in that moment of dysregulation. And even though in elective mutism, the quiet, the mutism is not this explosive tantrum, it’s a similar state of dysregulation. It doesn’t look explosive like a meltdown or a tantrum. It’s an internal sort of shutting down. It’s still dysregulation. It’s not a regulated nervous system. And so using interventions that kind of first reset the nervous system, reestablish a sense of safety, move a child into a more regulated state to then build skills and practice the skills speaking would probably be a helpful way of thinking about this. Where are expectations lie based on how regulated their nervous system is?
Dr. Carmen (14:05):
Absolutely. And that that’s a nice segue to just the behavioral conceptualization of selective mutism. So A becomes a learned response. And once, so when we see a toddler, a two-year-old or three-year-old with symptoms of selective mutism, usually it’s pretty, sometimes there isn’t anything else going on. But the SM, however, there’s a high comorbidity with other anxiety disorders and specifically with social anxiety. So as the kids get older, then we see these other anxiety disorders creep up. But behaviorally speaking, just focusing on the select mutism, if the child is expected or when the child is expected to speak or engage, they become too anxious and they are either giving out signals, looking down, looking away, hi, if they’re little, they might be hiding behind their mom or dad or burying their face in their mom or dad’s thigh or something just kind of trying to hide.
(15:03):
And then the adults, we read that as, oh, this child’s uncomfortable. I’m going to back off. So the environment backs off and then the adult, the parent might rescue and speak for the child or may make excuses like, oh, she’s just shy and to protect their child as well from that expectation. And then everyone feels better. But it’s short term because now we’ve just soothed this child. But then now we’ve also negatively reinforced the mutism and that negative reinforcement also gets misinterpreted as well. So negative means something is taken away, which is the expectation to engage is taken away, the anxiety is taken away, but the reinforcement part means that a behavior is increasing and the behavior that increases is the mutism. And then the child learns through this repetition of when I grab onto my mom or dad or just be quiet or look away or look down the environment knows to back off.
(16:07):
And that is how it is, just survival. Survival, not that they’re consciously that the child is consciously aware of this, it’s just they’re in survival mode. And so the flip to that when we educate parents and teachers is that we teach them the approach that, so that’s an avoidance, that’s an anxious avoidance pattern that kids can get stuck in and family can get stuck in positive reinforcement. So positive means something’s being added and what’s being added are those stickers, that external reward for enduring and hanging in there, this kind of strange different experience, this unfamiliar experience, but yet it feels good and pleasing because it feels rewarding that you’re getting to play and engage and get your needs met more directly than through someone, which is rewarding. And you’re also getting, when you’re a kid, those physical rewards are also reinforcing. So you’ve got the positive piece that’s added, the reward and the reinforcement piece, the behavior that’s increasing is the talking.
Dr. Sarah (17:12):
One of the things, and this is how you and I actually know each other is because we both trained in space, which is Supportive Parenting for Anxious Childhood Emotions, which takes sort of a different approach. And it sounds like the way that you are looking at treating selective mutism is this very holistic wraparound treatment of both doing something like working directly with the child, but then also this sort of environmental element which is working not so much with the child, but in helping the people who make up their world. So like the parents and then through the parents, the larger environment through something like space where we’re actually looking at the accommodations, the parents hitting that anxiety snooze button the child wants to avoid, they feel flooded with anxiety at the request of others to speak. That elicits that defense protective mechanism of going to the parent and hiding or shutting down or doing some behavior on the part of the child that elicits the environment to turn off their anxiety for them, take the request away, make it stop help of them to avoid the trigger for that anxiety.
(18:30):
They feel relief and it reinforces that cycle. They return to that same strategy the next time they feel anxious, which is probably going to be very frequently since kids are being spoken to and asked to speak all the time constantly, sometimes appropriately, and sometimes kind of intrusively. And so parents really do get illicit. Their sort of parent instincts get activated when their children show them anxiety. We want to rescue, want to keep them from feeling that distress. We jump in, we help them feel better, we reduce the anxiety in the moment. I sometimes call it hitting the snooze button. It’s not turning off the alarm, it’s just hitting the snooze button in a couple more minutes. It’s going to come right back and we have to do it again and again and again. And so we see this sort of loop get created. And what I love about space is it addresses the parental snooze button hitting.
(19:29):
And so I feel like there’s a way in which the two can coexist. I recognize with something like selective mutism, and maybe we should also talk a little bit about how to conceptualize. We have to remember selective mutism is just another type of anxiety disorder. So it’s probably not just manifesting in mutism, it’s probably showing up in anxiety in other ways. And parents are probably accommodating that distress and that anxiety, that desire to avoid the anxiety in a lot of different ways, which is why I love space because it just gives the parrot so many more tools.
Dr. Carmen (20:05):
Absolutely, yes.
Dr. Sarah (20:06):
So can you talk a little bit about how you would use space in a situation for selective mutism and how that kind of contributes to this sort of a wraparound, integrative approach to treating select mutism?
Dr. Carmen (20:22):
Absolutely. So one of the things that, the common question we get is, but my child talks with me, so why do I need to know this? It’s not me. It’s at school. They’re not talking. And so it is teaching the parent what helps set up their child for the success, for that confidence to face something that is intimidating so that they can stay regulated. So with schools, we educate the school on the same skills that we educate the parents on. So PCIT-SM. So that’s the adaptation of PCIT for mutism was developed by Steven Kurtz and he uses the CDI the first phase, the child directed interaction phase as the same as PCIT. And then the second phase is verbal directed interaction where there’s a specific prompting protocol that is used that pulls that speech a little bit easier than just the way we typically talk with kids.
(21:28):
So it’s teaching parents those skills and the school, those skills, and I’ll just call it the prompting protocol. That’s what we use here. And so the first step is the child. There’s distress related to talking and communicating, let’s just say in school since that’s where it happens most, mostly and identified mostly there. And then the school does what natural people do. And when someone’s not talking is that they accommodate. So the school will accommodate by allowing the child to just answer non-verbally with their head nods or head shakes or pointing, and then they are interpreting those gestures. Or a student is interpreting those gestures and talking for that student. Or if the student is old enough to write, the student might be writing and then handing it to someone to read it. So in all those ways, someone is talking for that child and the school is that’s their natural accommodation that they fall into.
(22:22):
The child then gets their needs met. So everyone’s feeling good because there’s a reduction in that distress. They get their needs met, but then what the child learns is ultimately the only way I can get my needs met is doing it this way, is someone talking for me, doing it for me? So that increased dependence then increases the symptoms and the child continues to avoid. The school continues to accommodate. So the flip side to that is we teach the school. So when you notice that there’s this, there’s going, there’s distress related to the not talking. And then when there’s this distress, instead of just accommodating, we call it, let’s use a supportive accommodation that leads to graduated steps towards talking. So you’re still accommodating, but you’re accommodating in a way that leads to fading out writing or fading out the nonverbal gestures. Using this prompting protocol, which simply put means you’re either posing open-ended questions or forced choice questions.
(23:30):
So for example, saying what’s your favorite color would be an open-ended question. If there’s no response, you can follow up with choices. Is it red or green? If there’s no response and you have to make sure that there’s enough wait time in between, instead of firing off questions back to back, say there’s still no response and you waited about five seconds, then you can even add, is it red, green or something else? Because maybe the choices you’re offering might not be the right choices, but now if you’ve said something else, the child may repeat back something else. They may not be able to say their color just yet, but you’ve given them sort of this graduated way to answer. And then the next step is repeating back what they said. So we talk to people in question marks. If a child said, I went to the zoo on Saturday, our natural response is, oh, you went to the zoo on Saturday with a question mark.
(24:22):
And a typically developing child will answer and say, yeah, I saw the bears and the lions, and they’ll just elaborate. Whereas a reluctant kid who’s a reluctant to engage in that way may not answer. And so if you repeat back instead with a statement, all you’re doing is validating that you heard what they said with no expectation for them to elaborate, but they might elaborate, it’s still open. So if a child said, I went to the zoo on Saturday, a reflection, an appropriate reflection would be, you went to the zoo on Saturday. That sounds amazing. I love the zoo. And so you’re not expecting any more engagement, you’re just accepting what they gave you and praising that and saying, I love that you told me you went to the zoo.
Dr. Sarah (25:08):
Right. Which is sounds so interesting. I recognize when you’re talking about PCIT-SM, it’s a really structured and manualized treatment protocol and it’s very behavioral based. And with a lot of anxiety disorders, we use that route. We want to understandably kind of reinforce certain behaviors. But I think, and a lot of times, well on this podcast and a lot of the ways that I like to conceptualize things in terms of helping parents understand a child is yes, we need to know behaviors, we have to understand behaviors, but I think it’s super important to be able to look below the surface and understand what’s the root cause of this behavior. And usually, like we were saying before, it’s like whether it’s a behavioral tantrum or it’s shutting down, and I’m not speaking, it’s this attempt to regulate and albeit perhaps not a very effective one, it doesn’t actually work. It kind of keeps me anxious.
(26:21):
But when we look in real life interactions and outside of the therapy room, not at a therapist, but the way that parents can interact with their kids who aren’t going to do a behavioral sticker chart every single time their kids talk, we need to figure out ways to create that relational safety to set up their nervous system for being able to take more risks, tolerate more distress to tolerate more anxiety. Can you speak a little bit about things outside of the therapeutic space that parents can do to kind of understand what’s an appropriate ask for a child with selective mutism? What’s over accommodating? How do we scaffold them in real life outside of therapy ways?
Dr. Carmen (27:09):
Sure. So I think the first step is before you expose anyone to their phobia, they need to like you. God, not if you like the person you’re going to go through this with, then you’re more likely to get further. So that’s how we explain building rapport with the kiddos. So in PCIT, that building rapport phase is done through what’s called P.R.I.D.E. skills. And pride skills is an acronym for P stands for labeled praise, and that’s labeling what it is that you are seeing that you want to keep seeing. So I love that you shared your toy with Susan. It makes me feel have good feelings about playing or something like that. The you’re labeling what it is that you like seeing. The R stands for reflection, and that’s reflecting back in statement form what you heard your child say. So if your child said, I want Cheerios for breakfast, the reflection would be, you want Cheerios for breakfast, and the labeled praise might be, thanks for letting me know what you want for breakfast.
(28:12):
And then the I in PRIDE stands for imitation. So that’s imitating what your child is doing when you’re working with a child with select mutism. If you’re a therapist or a student, the child might not be talking to you right away, but you can imitate what they’re doing. So if they’re drawing something and you say, I love that you’re drawing that flower, I’m going to draw a flower just like you, and I’m going to use exactly the same colors, I’m going to try to copy you. Exactly. Now you’re imitating what they’re doing, you’re joining them, but there’s no expectation to engage. And parents can do the same. I love the way you cleaned up the crumbs. I’m going to clean up my side just like you, and you’re copying them. And then D stands for descriptions, and those are behavioral descriptions with the child being the subject of that behavior.
(29:00):
So if the child is pushing their car down the train tracks, a behavioral description would be you’re pushing the car down the track and now you’re turning right, and now you turn the other way. Those are appropriate descriptions. If you’re saying the train is going down the tracks, now the child isn’t the subject of that. So the description is that the child is the subject of the statement. You’re brushing your teeth so nicely. I love the way you put toothpaste on your toothbrush. Those are all behavioral descriptions. And then the E and pride stands for the overall tone of enjoyment. So when we prescribe this special playtime for parents to have with their children, they’re practicing these pride skills. And by doing so, there’s no expectation on the child. The child just gets to play, and the onus is on the parent to withhold directing their child because we’re so used to saying, let’s play with this over here, or let’s do it this way.
(29:57):
But playtime is child time. When they get to be in charge, they have to listen to the parent directives the rest of the time. So that’s really is the golden time to build up the child’s confidence and the rapport so that when it is time to do something challenging, they’re ready to rise to that challenge. And they’re more motivated to do so because they want to preserve that good rapport that they have with that person. So that would be the skills that we teach parents. This is what you can do at home is you can really pump up that confidence. And then when they go out to that social event or the grocery store, the family gathering, they can warm up their child in the same way. So they might say to their family members, we’re going to need some before you come at us, we’re going to need some warmup time, some time where we’re just going to play first and then we’ll go into the next room or something.
(30:52):
So the child might then play in a separate room where parents can use those pride skills, get them warmed up, maybe the other family members are coming in and out of the room, the extended family members so that the child is just kind of warming up without any expectation to engage just yet. And then eventually, as the child is warming up and talking with their parents and talking in front of the extended family members, that’s where parents might move into setting up the prompts where they might ask, they might say to, let’s say grandmother, oh, grandma, go ahead and ask kiddo what their favorite toy is right here, or something that they’ve already talked about. And then grandma might ask, could ask it, child doesn’t answer. Mom can re-prompt with, is it the car or the train? Then the child may answer train in front of grandma, which then grandma can reflect train, I love trains too.
(31:47):
And now you’ve got an added partner in that interaction where the child is speaking first in front of the family member, the extended family member before directly too. And so it’s these graduated steps that can naturally occur and feel more natural when the child is young. When the child is older, it gets a lot harder to do that. So we do talk through that in therapy on how to adapt that procedure. But for younger kids, it can, parents have found that they can naturally go with that flow and follow that the way the child is feeling and kind of serve as that intermediary between the person that they’re not talking to directly yet. And then the next step is fading for the parent to fade out so that then the child is speaking more directly to that other family member without the parent serving as that bridge. So I call it we coach parents as verbally fading out. So physically they may still be there, but they’re not talking anymore. They’re talking less and they’re allowing the other person to do more of the reflections and the questions and then physically fading out, but never sneaking out. Sometimes parents will say, oh, they look fine, I’m going to sneak out. But then that can create a rupture in the trust and it can backfire, so…
Dr. Sarah (33:09):
Right, because it can activate the anxiety system, which then gets them quiet again, because the whole idea is what you’re describing, whether it’s using the pride skills or folding in sort of supporters, if you will, because space talk, we’ll call those that grandma that comes in as a supporter or layering in these other people. What we’re doing is we’re increasing their sense of safety in these typically challenging scenarios.
Dr. Carmen (33:42):
Can I reframe that?
Dr. Sarah (33:43):
Yeah, help me see if I can…
Dr. Carmen (33:45):
I think this is the part that I think makes it hard for parents when they hear the word safety, your child is safe.
(33:58):
And so what we are aiming for is for your child to feel comfortable with how their body is feeling in that moment of discomfort when expected to engage. So I have just my clinical observations. I’ve been more nowadays saying to parents, it’s not about teaching and reinforcing the idea that the child is safe or for them to think, well, I’m safe. It’s more that I can handle feeling this unfamiliar feeling and still talk. I can handle feeling uncomfortable and still do my class presentation. And the reason why I make that a point is that part of our intervention, one of the accommodations that schools make per our recommendation is having a fade in with the new teacher, for example. So before the meet and greet, before school starts, let’s have a school exposure session with the new teacher and pass the verbal baton to the new teacher.
(35:09):
And then now we’ve got that set up and they’re more likely to start the year speaking versus being mute. However, then students and parents may think, I’ve got to do that, do that every year. And the only way I can talk to my teacher is if I have this private meeting with the teacher. It’s like, well, no, you don’t need it anymore. The next step now is to start school. Everybody else starts school and learn that you can handle that discomfort. So I just wanted to point that out because I think that people here safe and well, the child is safe, and even if they’re feeling unsafe, that’s a false alarm. They are safe. It’s more just, I got to recognize this. I can be familiar with this discomfort and know I can keep doing it.
Dr. Sarah (35:54):
And I think that is a really good distinction, and I’m glad you brought it up. I think from in my mind, and I’m so used to talking about it, I forget to think about how most parents might hear that word. When I say safety, I’m talking about the perceived safety that’s coming through the amygdala, the threat response or the brain. The brain has to scan the environment and say safety, danger, safety, danger all the time. And so when you have an anxiety disorder, that amygdala, that threat detector is a little bit kind of got some faulty wiring, and it reads danger in ambiguous situations, like when in doubt, assume danger. And so when I’m talking about safety, I’m talking about helping the brain sort of recalibrate so that it’s better equipped to be real accurate in determining this is safe. I might be feeling anxious, I might be feeling discomfort, I might be feeling pressure to speak.
(36:51):
That’s all uncomfortable. And my body doesn’t like that, but my amygdala, my threat detector isn’t saying, oh gosh, this uncomfortable feelings here. Go into fight or flight, go into shutdown, do this sort of dysregulated panic. So yes, it’s a very important sort of semantic, it’s a subtle distinction in the words, but when I say safety, I’m talking about helping the brain read discomfort as also safe or anxiousness as also safe. But that’s a long process of practicing and retooling the brain. So yes, I think your point that when parents are hearing, well, your kid needs to feel safe, they’re like, well, they are safe. We’re sitting in my mom’s living room playing the truck, they’re totally safe. And the kid, their amygdala is saying, we’re not safe. I can’t talk. I got to shut down. Because they feel eyes on them or they feel expectations on them. And that’s very overwhelming. So yeah, it’s like how do we help a child’s brain to perceive discomfort and anxiety as safe? We do that sort of slowly over time with the help of their environment.
Dr. Carmen (38:09):
Absolutely. It’s extinction learning. It’s for them to learn. When I feel anxious, I can also have fun and engage with grandma, and it feels really good and I can feel both. And then I can feel just more of the fun. And I heard a parent describe it as afterwards the child felt like they were it. She used the word exhilarated, just this finally being able to just directly interact with someone and it felt good. And even though it felt scary at first. And I think that that is when you think about things in your life that have been so intimidating and so scary, and then you approached it and it was successful, or maybe it wasn’t so successful, maybe it was really hard to get through, but you got through it and then you feel even more confident and stronger. So we aim to increase, we replace that word safety with comfortable being uncomfortable and then confidence that I can feel uncomfortable and get through.
(39:21):
And that’s our main goal. And I think that the diagnostic criteria, like all the other anxiety disorders in the DSM all have anxiety in their definition. There’s excessive anxiety. They, there’s facing the anxiety provoking stimulus with extreme distress. There’s all these words in the diagnostic criteria, whereas for selective mutualism, there’s no mention of anxiety at all. And I think that as a result, people focus so much on that first criterion of not talking, that once the child is talking, there’s a misconception that they’re done, they’re cured, they’re fine, they don’t have anxiety anymore. But then it can also manifest, like you said, in other ways. And with space, that’s where we can identify where that might be creeping up. So when I did space with a few family members or a few families at selective mutism, we had two treat. We had the child-focused treatment done by one therapist and then the space treatment by the other therapist, where interestingly, the speaking, the target, the accommodation wasn’t focused on the speaking at first, it was focused on something else that was a little bit more doable for the family to start with because not talking for your child who needs you to talk for them, that’s a really hard habit to break, especially if they’re older.
(40:53):
So sometimes other work needs to be done with the child first, and we work on removing the accommodations for other things that the child should be doing on their own, but they’re not yet. And then that helps to build the confidence in the parent that, oh, when I peeled this accommodation away, they actually were able to show that they could handle feeling uncomfortable when they were getting their own backpacks prepped for school instead of me having to do it. And so when the parents build their own confidence and the child builds their confidence, then they’re ready for those harder targets, which might be the speaking targets. So yeah, that’s where space kind of comes in is just broadening the understanding of where else is anxiety manifesting and how are you accommodating it and how can you peel those accommodations away, pumping up the confidence and then hitting those harder goals.
Dr. Sarah (41:48):
Yeah, that makes so much sense. I think every time we help a child survive a uncomfortable feeling and get to the other side and help them sort of reflect, Ooh, that was tough and I did it. I guess I am a kid who can handle that much anxiety in this setting the reflection piece, that debrief piece is so critical. We have to help them rewrite the blueprint. If the blueprint is I’m a kid who can’t handle feeling anxious, then I’m going to always avoid situations that I might feel anxious in. But if I start to rewrite, well, I was able to do that and I was able to feel anxious, that much anxiety for that amount of time in that setting. Once, okay, well I could do that. And then maybe we do another accommodation pull on the part of the parents. So we stop rescuing them from having anxiety in this setting, and the child then feels anxious and gets to the other side of that anxiety, and we help them consolidate.
(42:51):
We help them integrate that piece into their blueprint. I’m a kid who can feel anxious in this setting, and I was okay, and it might’ve been hard, but I made it through. I can handle that feeling. And then we start to, so you’re basically building up their internal sort of compass or their internal blueprint as, oh, I am a kid who can handle feeling this feeling. I might not like it. I don’t like to feel distressed, I don’t like to feel anxious, but I get to the other side and I can get there. I’m okay.
Dr. Carmen (43:24):
Exactly. I’m a kid who can do hard things. I can manage. There is another way, just having that kind of coping talk. And with older kids, we use Philip Kendall’s coping cat a lot in helping them set up the exposure with identifying the situation in which they’re going to do that new behavior. So we are aiming to generalize speaking across people, places, and activities. With younger kids, we don’t get to do so much of that consolidation because they’re too little. What they learn through experience, they learn through the behavior. We do community sessions where we take them out into the community and order their own ice cream or play do those other behaviors that they’re used to doing with their parents, but now they’re doing it with someone else. So now we’re extending that exposure and allowing for more generalization. And with older kids, usually seven and up, we can do more of that CBT that the exposure and then consolidating after the exposure to help them really, like you said, rewrite their blueprint and learn, oh, I can handle this. And I surprised myself. I wasn’t sure how I was going to do it, and I did it and I figured it out. I had one kid we just kept saying, figure out, figure it out. And he finally said, I’m a good figure outer, and I love it. I’m like, you’re a good figure outer. That’s great.
Dr. Sarah (44:53):
And there’s that. There’s the pride skills right there. You’re reflecting back to them, you’re deli, you’re en enjoying and in delighting in their accomplishment. Yeah, you’re not asking anything of them. You’re just saying, yeah, you are a good figure outer, you can do this. We’re reflecting back to them this confidence that we see them as a capable person. And that I think is something that is undervalued as how effective it can be in supporting kids who have anxiety. It’s seeing them as capable of feeling anxious and being okay. Yes, absolutely. Not necessarily saying, oh gosh, well if you’re anxious, we should make you not feel anxious. We should take that away from you.
Dr. Carmen (45:32):
Right? It’s that it’s getting stuck in that area where you want to protect your child, but at the same time, you also want them to be independent and confident adults. And so it’s like, well, now how do I get there if I also want to make sure they’re not feeling this discomfort? The other piece is sometimes the older kids can get stuck in having someone speaking for them. So they may make progress in speaking and speaking really loudly in front of others, but still rely on that one person that’s being their spokesperson for them. And sometimes parents can get stuck in that with their child. So we’ve had cases where the child has made great progress. They are speaking in school, they’re able to order their lunch in the school line and all of that, but when they’re with their parent and they’re out with their parent, their parent is, they’re still pulling for their parents to place that order at the restaurant or they’re still whispering to their parent instead of to the cashier.
(46:33):
And so really prepping the child to apply it in this new setting because there’s that rigidity that is present in selective mutism that I think a lot of parents would agree. There’s like once their child gets their mind set on something, it’s so hard to shift it. And so that rigidity, those boundaries are there really strongly sometimes. And so having space to help parents change their behavior and still feel successful. So going back to the example of an older child who’s not yet ordering directly, even though they can and do it in other settings except for when their parents are there, say the waiter comes and says, okay, what would you like to order? And the child tries to or whispers to the parent, but the parent is now in space mode and not repeating what their child says. And then the waiter repeats the question, the child points to the menu, the waiter asks, oh, mac and cheese, the child nods and the waiter takes okay, mac and cheese and walks away and has got the order. So now the child’s got their needs met and the parent still stayed true to their space. They didn’t speak for them. So it’s also reminding them, well, you hit the space goal it the other environment picked up and did the nonverbal piece. So we’ll work on that with the child.
Dr. Sarah (47:53):
Right. It’s hard. I mean, I think to your point in maybe another scenario where we’re not dealing with selective mutism, but in different type of anxiety because in space we use space for all the different anxiety disorders like social anxiety, generalized anxiety disorder, separation anxiety, and OCD, all of those things. Those tend to not elicit as much accommodation from the environment. Environment as left mutism. And so usually when we modify the parents’ accommodation behaviors, when we control for that, we kind of are done, right? Yeah. The child doesn’t have to navigate their anxiety in a world without their parents rescuing them. Sometimes we have to go to the school and say, Hey, we have to also minimize the teacher isn’t going to let you go to the bathroom three times in class because that’s how you are managing your anxiety in the classroom.
(48:45):
That’s an accommodation. The teacher’s going to pull in a way that’s supportive and will we’ll help you to stay in the classroom for as long as you can tolerate without going to the bathroom. Right? That would be maybe the SPACE accommodation target for a different type of anxiety. But with selective mutism, I hear what you’re saying. There’s this very complex layer of we as human beings out in this world, we love to fill in the blanks for people linguistically. If someone isn’t saying the thing, we’ll finish their sentence for them or we’ll restate the question in another way or so we do do that, and I think it makes it, a parent can do all the work of not accommodating, but then you get out in the waiter just naturally in a so out of social nicety will figure out how to get that kid to tell ’em what they need without having to talk. So it is like you have to control for a lot of more variables with elective mutism. I see how that could be particularly tricky.
Dr. Carmen (49:50):
Yeah, you do. And then what we do with that in treatment is that we get the data, okay, so what happened? How did it go? How else did the child order directly or did they rely on some other accommodation? And then what can we do to address that? So sometimes the homework is identify the restaurants you’re going to go to, identify the place you’re going to go get your ice cream or whatnot and go talk to them before you go and let them know, Hey, I usually say when we do community exposures, I say, I’ve got a kid with special needs coming in, and when I just say special needs, people’s ears perk up how I help. They want to help. So I’ve got a kid with special needs coming, here’s what I need from you. We’re working on talking in public. If you can pose, they’re going to come order their ice cream.
(50:38):
If you can please ask them if they want that ice cream or a different ice cream, that would be golden if you can. And if you forget and don’t do that, I’ll reframe it for you. So then that way they kind of know something different’s about to happen. And then later on when we go into the ice cream store that day prepped and they’ll understand if I kind of put my finger up and tell them to wait while I reframe the question, it’s not so unusual. So they get that pre-alert and sometimes the homework for parents is identify the places they’re going to do this and educate them. How are you going to say it? So it’s almost role-playing out how will you present this? And sometimes parents will feel really uncomfortable doing it. Of course it is uncomfortable to go in and say, Hey, I’m about to practice this. Would you mind helping? Because we don’t want to impose, we don’t want to do something that’s so out of the ordinary.
Dr. Sarah (51:33):
And it’s labor intensive. It’s very labor intensive from the part of the parent to be able to come up with, okay, not only do I have to, I’ve got to find a place that I feel comfortable enough making this ask and that has the capacity to accommodate my needs in this moment. It’s kind of got to be a neighborhood spot that you kind of have a relationship with the people. It’s hard. It’s not always easy. So I’m wondering too, like, and ultimately I think if we’re going to distill this down to its most elemental part, it’s like how do we as both as a team of parents and therapists come together to really kind of draw map of the landscape of where these accommodations are occurring and come up with these sort of targeted plans for modifying one at a time, finding your supporter, whether it’s the vendor at the ice cream shop or grandma or the school or the babysitter. It doesn’t always have to be, there’s not just one way to do it, right? Because that’s the whole beauty of space or any of these experiences is like we do it in one setting, we do it in another setting, we do it in another setting, and we start to generalize it to all settings. So if you don’t want to have a conversation with your local deli, you know, could find other ways to create supporters who can help the environment to not accommodate. But I love this approach and I think it’s, it’s empowering to parents. It allows them to do something. I can change my behavior. I can elicit a supporter to sort of change their behavior. It’s a lot harder to get my kid to change their behavior and it still works. So that’s I think very helpful because with kids with selective mutism, there’s that rigidity and it’s like, I can’t force my kid to do this, and you can’t, so you’ve got to work around it.
Dr. Carmen (53:30):
And sometimes there’s a time and place for it too, right? So like you said earlier, when your child is dysregulated, that is not the time to prompt them. That is not the time to have expectations. And so also reading the situation where is there time to have this prompting graded exposure where if they can’t answer just then that we’ll take a break first and practice, then come back, is there time for that? Because if there isn’t, then the expectation is just prompt for the nonverbal interaction point to the ice cream that you want. And if they point, that’s not a failure to respond because you just directed for that nonverbal. But if you say, what ice cream do you want and they pointed, then that’s where you’re reinforcing the mutism. So it’s even just like if there’s isn’t time to set up this expectation, then don’t set up that expectation.
(54:24):
Go meet them where they’re at with what they can do. And then if a situation is going where you’re feeling like, oh, this is not, I feel like I’m failing. I feel like he’s failing to speak or she’s failing, that’s where you switch over to observer mode to collect the data. Because then when you collect that data, you can process it later and come up with a targeted plan to do at another point. And then also remember, that’s not forever. This is just to get the ball rolling and then things get better and improve and go much quicker later on.
Dr. Sarah (54:59):
Yes, that makes so much sense. So if people are listening to this and they’re like, oh my gosh, I maybe I didn’t realize my kid has selective mutism, or I knew they had this diagnosis, but we haven’t really been treating it or we’ve been treating it but it’s not working. What would be your recommendation to parents who are navigating this diagnosis? And also if they want to work with you, how can they do that?
Dr. Carmen (55:24):
Certainly, I first have to say there’s a wonderful association called Selective Mutism Association and has numerous free resources and parent trainings and parents support groups that definitely parents who suspect their children of having selective mutism. They should definitely go to that website. And it’s selectivemutism.org. There’s also, Steven Kurtz has a free online training, and I believe it takes about 90 minutes to go through, and it is called Selective Mutism Learning University. And it teaches the basics of child directed interaction and verbal directed interaction. So those two places would be the best places to start. And then if there is progress, great, but if your child is not responding and you need to seek out additional treatment, we, our website is advancedtherapeuticsolutions.org, and we are located in Chicago. We’re just outside of Chicago area. We do home community and school sessions. So even though we’re based in a suburb called Oakbrook, we do travel, we go out to you and try to also educate schools because we want to make sure that the school environment is actually conducive for your child’s progress as well.
Dr. Sarah (56:45):
So I love that. That’s amazing. So it sounds like, and if you went to selectivemutism.org, would you be able to find someone who is licensed in your state if they’re not in Illinois.
Dr. Carmen (56:54):
They would be able to find a provider in their location, so they have a whole treating professional provider finder and they can enter their location. And there are people that we also do telehealth. There are others who do this through telehealth as well.
Dr. Sarah (57:11):
That’s so good to know. Okay. Well, thank you so much. This was super informative and I really appreciate you coming on and sharing all of this with us.
Dr. Carmen (57:18):
Thanks for having me.
Dr. Sarah (57:24):
Thank you so much for listening. If you enjoyed this episode with Dr. Carmen Tumialan Lynas, let me know. Your ratings and reviews of the Securely Attached podcast are a huge help. It’s support from listeners like you that helps us reach more parents with guidance, encouragement, and support. I’ll see you right back here Thursday for another segment of Beyond the Sessions here on Securely Attached where I will be answering a specific listener question. And of course, don’t be a stranger.
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