Unspoken Words: Ask Dr. E #2

“Ask Dr E” is where our community can ask Dr. Elisa Shipon-Blum any question they have on any topic relating to Selective Mutism. We have received some amazing questions and now, we are giving the segment more life by giving it its own series on our podcast! In the second installment of our Ask Dr E podcast series, Dr. Elisa Shipon-Blum answers five questions relating to teenagers with Selective Mutism.


Episode Transcription 

Brandon: All right. Question number one this week is we’ve been trying for years to find an appropriate effective therapy for my now 15 year old15-year-old. How does C B T work for a child that doesn’t engage verbally with the doctor?

Dr. E: Okay. This is a wonderful question. A lot of families reach out with very similar type of questions, where the focus is on why isn’t my child verbalizing with the doctor or the dentist, or the teacher, or an aunt and uncle, and the overwhelming focus is verbal, verbal, verbal. Selective mutism is a social communication anxiety, and I would want to understand this 15 year15-year old’s baseline stage, what are they able to do in that particular setting?

If we can start there and understand that we’re not going to be focusing right away on verbal, maybe this 15 year old15-year-old really doesn’t engage even non-verbally with somebody, maybe they’re very anxious, they’re shut down. Maybe if you ask a choice to try to bring them into the conversation just to. Basic choice. 

They’re not even able to turn to you and tell you. SoSo, I’d want to understand the baseline stage and think about the bridge. . I also feel that perhaps there’s been a lot of pressure and expectation for speech now for a 15 year old15-year-old that can speak. For example, let’s say the doctor says, how old are you now? 

And your child is able after some time to be able to answer quiet one or two words. That’s, that’s good. What I have learned over time is that teenagers over time, Areare able to speak. They’re just not necessarily elaborative initiative. Expressive and in irregular volume. And their lack of comfort with verbalization is probably a result of the lack of opportunity. 

So, seeing a doctor and authority figure can be really tough if your child. doesn’t have a lot of experience with doctors, dentists and so forth. especially in lieu of Covid, definitely kind of backing up and working to prepare for a setting. One thing we do with older kids is something called an action plan. 

Where are we going? what? Who is going to be there? What are questions that somebody could ask you? What are the answers to those questions? And what can you ask? SoSo, we wannawant to really prepare in advance for social situation and also train parents to be able to offer maybe a simple choice question if your child gets a little nervous. 

So, Youyou know, it gets awkward when it’s really basic questions like, how old are you? What grade are you in? What’s your school’s name? SoSo, practicing that is important. Also, educating the doctors, making sure that the doctors that you see, the dentists that you see are aware of your child’s selected mutism, and maybe in this case they’re complete inability to speak. 

So, no matter how much you prepare in it, very positive way, your child is still mute. That is something we have to work in with in therapy that we really need to help your child progress across the bridge. So, if your child has selected mutism and they’re in, let’s say, stage one where they’re non-verbal and maybe not even comfortably non-verbal, we definitely want to make sure that those interacting with them are aware. 

So, educating through the about my child and some of the older kids and teens actually create their own. She called about me that they’re confident in giving that like, I have difficulty communicating. Please ask me questions in this way. By far, that’s not the majority. So as a parent of a 15 year old or any age child, I would recommend educating others who do interact. 

It could be coaches, it could be teachers, it could be extended family members. Dentists, doctors, especially authority figures and those that they don’t see much about the best ways to interact. And for a child that’s not verbal, asking a yes, no question, just to be able to get them through that moment. 

We’re not looking at the doctor’s office as a time to kind of hit the jackpot and progressing into speech. We just need to get through that moment in that time. So that’s not where we’re going to practice our goals. At least not. Right now, of course, that’s an area that we’re going to progress in, but that may not be the area that you’re really trying to prompt. 

Next steps in communication because of the anxiety of going to a doctor. So almost bridging down, accepting where they’re at is what I recommend. So, asking yes/ no questions. Giving them the opportunity to write their answer and show it, to be able to point, to be able to gesture even for you to turn and ask a choice question to bring them into conversation. 

And that’s something we would talk to your child about their comfort in doing this because again, a really big part of treatment is their involvement in this. But I do want to mention something that we’re talking a lot about older kids, and I do need to say that the older the child. 

Teens, even adults, the more they need to be involved in this. We as adults cannot set the world up for them in every situation. They need to be actively involved in their goal setting, their awareness to what they’re doing, how they’re doing it, when they’re doing it, where they’re doing it, their acknowledgement, and their assessment of their feelings, and really respecting that. 

When I work with teenagers, actually any age child, three-year-olds, it does it, they. They have to relate to a feeling and using that ability to rate and grade their feelings, in this case, a zero to five, perhaps, where five is the hardest and zero is the easiest, and really trusting them. So, knowing we’re going to go to the doctor, I’d want to talk to your child about this, and plan out that visit in a very positive, upbeat manner and help them accomplish what they can do by trusting their feelings, acknowledging, assessing it, rating it. 

Being able to talk through the different stages and what they’re comfortable with, knowing that we’re going to be giving them a little more than, let’s say a zero of, in terms of comfort, five is the hardest, but maybe working towards a two or a three out a five to be able to get through situations. Also, the older the child, the more it’s difficult versus scary to do because the behavior becomes very conditioned. And I did mention that the older they get, the more they’re involved in active goals, and the more cognitive this is, the more they’re aware of their feelings, how they react to their feelings, and how do we help them change their behaviors. 

Internal motivation is really important. So going to the dentist or the doctor isn’t exactly motivating for them necessarily. So that not, may not be an area that they’re even willing to practice anything in terms of goals. SoSo, they do need to be motivated in their treatment and finding areas that they can be motivated in. 

SoSo, it is important because external motivation as you get older isn’t as. It isn’t as effective as it is with younger kids. So that internal motivation, helping them realize what they wannawant to accomplish and what their goals are, so I hope that’s helpful. 

Brandon: Question number two is more about school and and teenager, teenagers in school. My child’s teachers and principal believe that SM is a form of defiance when my son is unable to read aloud in the classroom. They seem to get very frustrated with him. Recently, my son was was removed from the classroom because he refused to read out loud. My, my son feels profound shameshame, and this is causing him severe depression. Recently the school said that if my son does not speak in the classroom when called upon, they will terminate his enrollment. I am to the point of total defeat. Is there any hope for my almost 16 year old16-year-old son?

Dr. E: Well, first of all, let’s address this last question. Is there any hope for my almost 16? Absolutely. We work with teens, we work with adults, and they absolutely can reach their potential. Is it a little more difficult with older individuals? Of course, they’re more conditioned, they’re more defensive, they’re more avoidant.

But my first recommendation here is to find somebody that you can work with because it sounds like you’re almost on your own island here. Trying to figure out ways to not only help your son, but you’re also feeling really defeated and struggling, so you need to be working with. Two different types of people in my mind right now. 

One is somebody that can really work with you, with your son to be able to understand the selective mutism and frankly overcome it. There’s absolute hope, but if you’re doing this on your own, that’s really going to be difficult, and I can’t give you the prognosis there. If you’re not being guided by somebody that’s an expert in this area, especially working with teenagers, so you definitely need to find somebody you can work with to help you, to help your son. 

Also, it sounds like you’re also going through a lot of struggles. Having a therapist or someone you can work with to help you with your own internal struggles, that’ll give you a way to be strong. It’s similar to when you’re on an airplane and you have to have. and the pilot talks about having the oxygen on you before you can help everyone next to you. 

You need your own source of support and help. And from your question, I’m wondering if you’re somewhat of a lone ranger and really going through this on your own. And you are also mentioning your son’s depression. SoSo, in addition to the selected mutism, we definitely need to help your son in terms of depression, but I can understand how defeating this feels. 

The other aspect to this question is when you’re working with somebody, they can really help you in terms of guiding you for appropriate school-based accommodations and interventions. But what you’re struggling with here is that your school’s seeing this as a defiance, so it almost means it doesn’t even mean anything right now in terms of accommodations and interventions. 

We’re not even there yet because they’re seeing this all wrong. If this is a public school, and any school in general, you have the right to have accommodations and interventions. You have the right to a free and appropriate education. I will say with private schools, you’re much more limited in terms of what they’re able or willing to do. 

But in a public school, they need to provide accommodations and interventions. However, this school needs an education. So, either one of two things is going on with this school. One, there’s a consultant that they’re working with that sees SM from a defiant standpoint. And that’s who’s guiding them in this diagnosis and dealing with your son or two, they don’t have anybody guiding them. 

And this is just their preconceived notion of what SM is that this child, your child is choosing and refusing to speak, which comes across as defiance. And what ha what’s happening is your son is feeling that sense of. Kind of disappointment from them and most likely picking up because many of our kids with SM are very, very highly sensitive and perceptive and aware. 

So that kind of feedback they’re getting from. , the school staff is not a good feedback. It’s not positive, it’s not upbeat. It’s, it’s more of like, you’re doing this on purpose, you’re bad. You’re, you know, creating, you’re a problem. And that’s how he’s feeling. So of course, it’s leading to, in the place he spends most of his time in school, it’s becoming depressed. 

So, to sum up the answers to this, you need to be finding somebody to work with that can guide you. an expert in this field can help you. To educate the school properly. A really easy thing for you to do right now is go on, selected mutism center.org, our resource section. We have so many resources of what SM is and what SM isn’t, and share with them in an objective fashion. 

What SM is that SM is a social communication anxiety disorder, and that. There are factors into why somebody develops this and why it’s maintained. But in addition, there are stages of social communication that an individual functions and verbal is just one stage, and you need to objectively give them that. 

And if you’ve already done that, also selected mutism.org, the nonprofit organization. Has a ton of resources for professionals, for teachers, for parents to really share those resources. Again, objectively, it’s not you coming to them and saying, this is what you need to do for my son. 

This is an objective way of giving them materials, scheduling a meeting, going through it. If you’re still struggling. again, the expert you work with to help, you should be able to guide you through this in terms of scheduling a meeting, talking with your school, educating them. Often schools just don’t know. 

Unfortunately, the term SM is lousylousy, and they focus on speaking and not speaking, and that old cons, preconceived idea of children are choosing and refusing this, that’s still there. For individuals that don’t understand this, they still see it that way and it’s sad, but. Working with somebody that can guide you, almost your lifeline. 

That’s really the first thing. I mean, that’s all we do every day is we work with families, work with schools, and I suggest you find someone to work with to help guide you. You may as a, in addition, you may need to work with an advocate that helps you, but I can’t emphasize enough the importance of working with someone with knowledge in this area, but also to help your son build those coping skills to be able to really. 

Use skills, develop skills to progress communicatively so that your son is able to communicate verbally, but also develop school-based accommodations and interventions so that they can do their schoolwork and function in school in an upbeat positive manner. 

Brandon: All right. Question number three is on parenting and treatment Outside of school, my teenager speaks to his friends in a regular voice. Yet in school, he only whispers to those same friends. Why do you think he’s only whispering in school? And how can a parent support getting their teenager to talk in a regular voice inside the school setting? 

Dr. E: The good news here is that your child has friends that he speaks to, so that’s wonderful. He already has his buddies. That connection. The reason your son is whispering in school is twofold. One, he never built up the verbal confidence with enough. Of other individuals. SoSo, in other words, he’s got his buddy, so he’s turning to them, he’s talking to them, but he doesn’t have the verbal connection, confidence to speak to others.

So, let’s say your son is friends with three people and they’re in his class. He’s built that verbal confidence with them. He’s able to talk, but the whispering occurs because he doesn’t have it with those other individuals. When I see this happen, It’sit’s also a result of that sense of expectation for speech that probably started when he was younger. 

You need to speak, you should speak. The teacher’s trying to get him to speak. So that anxiety within the school setting is something that’s existed from when he is younger. SoSo, it may not appear as anxiety now, but that condition not speaking in school is there. But the wonderful news is you’ve, he’s progressed into speech with at least three kids. 

How we can utilize that one is sitting near those peers in class, the teacher asking a question. If he’s able to answer the teacher, that’s great, but if not, the teacher can ask a question, prompt him to write and read it, or prompt a question, ask a choice. Prompt him to tell Robert and Robert. And he ends up turning and teaching the teacher to repeat without eye contact. 

So, there are strategies your teachers can use to bring him into verbal with a peer in class. Now as teenagers, they get self-conscious, right? So, we have to be careful of how we utilize a verbal intermediary. But there needs to be effort to expand his comfort and communication with more kids. So, what I would be doing, since he’s got these, let’s say three kids, he’s already verbal with, I don’t know the number. 

 We want to work on kids four, five, and six. So as much as we can in as many classes as we can, parent and group your son with as many new kids as possible. Maybe keeping one child that he is verbal with and then having. , small group interactions as much as possible through projects, through clubs, to expand his comfort, but also his verbal communication, his, cuz because I believe he’ll verbalize as we expand because he’s already verbalizing with a few, he’s not a speech phobic, so he is not stuck in the non-verbal. 

We just need buddies, and what we need to do is do small groups with those new buddies and have different opportunities with those new buddies. Finding areas of interest for your son. That’s really where he is gonnagoing to find his quote, more friends through the areas of interest you find your friends through the things you enjoy the most, but even if it’s just verbal confidence. 

And increasing it. Also, the more that he reads, like reading directions, that’s gonnagoing to help him speak with others as well. Because reading is not difficult for kids that are already somewhat verbal. It’s coming up with your thoughts, trying to process. So, minimizing the need to think and process for him. So, when teachers do ask questions, they ask more choice, direct, prompt, the right, the show, the right, the read, and really utilizing. 

The buddy process to expand to more kids is what I recommend and what’ll happen, especially if you’re doing activities outside the classroom, let’s say in clubs or even science lab and coming before class, after class, being paired and grouped with his volume will naturally increase. But to expect a regular volume in a full class of kids right now, like a large group question is unrealistic right now. 

But definitely. He could bridge down in a larger group, either write and show or using an intermediary. And sometimes the simple act of writing and reading it is really enough. And with practice through reading especially, their volume tends to increase. Isn’t that interesting? 

Yeah. I like what you were saying about how you would encourage this teenager to find his areas of interest, probably get, that would probably get him out of his head a little bit more and more like just in the moment and excited to be where he is and not thinking as much. Right. Absolutely. And also, if there’s areas he’s strong, like really, excels in and he’s good at, like, in other words, let’s say he’s strong in math. Maybe he can help another child. SoSo, he’s a big, big shot role, we call it. helping younger children with things, being more of, utilizing his skills. How’s that sounds? 

Really utilizing his skills. That gives confidence with confidence. Anxiety lowers as anxiety lowers volume will increase as well, especially in areas that he’s showing his knowledge and helping someone else. We’ve had a lot of teenagers reading to younger kids, doing projects with younger kids, doing clubs with other children, working in peer tutoring. 

you know, if your child, the teacher can say, Hey Robert, you know, why don’t you help so-and-so with his math , project or anything you can do to really help him in the areas he excels as a way to help him communicate, to guide him with peers is really another helpful thing. So not just expanding buddies, butbuddies but thinking of opportunities where he can be what we call a big shot. 

Brandon: All right. Question number four is on, school and friendships. Sort of similar to the last question. Our daughter is in ninth grade and was diagnosed with SM about two years ago. But in retrospect, we recognize now that signs have been there for much longer. She currently attends a small private school. From what I understand, she has been known to occasionally speak when question, but she’s not initiative or elaborative. I know buddies and social connections are important and when we encourage her to invite school friends over, she is disinterested. What suggestions do you have on how we can help her build friendships in and out of the classroom? 

Dr. E: W, when children are younger, parents are able to set up the world for them through set up play dates, calling the parents, setting up these opportunities. As kids get older, it’s much more difficult. It’s awkward for a teenager to have their mommy or daddy call another family to set up a get together.

It’s just not gonnagoing to happen. So, my recommendation is accept where she’s at. Don’t push it, don’t pressure her because it’s gonnagoing to cause her more stress, more anxiety, and more avoidance. And it’s gonnagoing to make her feel bad. What we wannawant to do is understand it’s very normal developmentally for adolescents, unless they really have a close relationship, not to necessarily get together outside the school. 

So, let’s set the stage for that to help her become more confident, more social. More communicative in school. We really wannawant to help pair and group her with, let’s say, three to five kids that she can be in similar classes with, especially if it’s an area of interest. So, let’s say she’s in a club or an activity and maybe three or four of those kids, or even one or two of those kids happen to be in a couple other classes. 

This is a wonderful idea to share with the teachers that, that if they can work to pair and group her with those same kids seated with, paired with, grouped with, for projects that’s gonnagoing to help her build. Friendships and connections. Also, teachers need to be aware of how to question, assuming your child does not have an underlying speech and language issue, which is in about 30 to 40% of kids, that she is able to be elaborative initiative and expressive at home where she’s comfortable assuming that. 

That’s intact. It’s very normal as kids are progressing into speech. For them to speak in quiet one or two words and not be initiative elaborative and expressive in irregular volume. So that’s what you’re working on. But in order to set the stage for that comfort needs to be. an issue that has to be set. 

So again, the pairing and grouping and buddies, teachers consciously asking questions and knowing how to bridge up and bridge down. So, if you ask a lot of yes/ no questions, your child’s gonnagoing to stay non-verbal. But if you ask a choice and she’s verbal and she answers through hearing the choice, or you ask a direct question and if she doesn’t answer and you prompt her to write it so she can read it, that’s keeping her in verbal. 

If you ask choice and she’s able to answer. Now you want to start asking more questions. What, when, where, why, how so she can explain. So, one way to do that is if she’s not doing it, when you ask a what, when, where, and how question. We wannawant to ask her to write it and then maybe read it.  

Brandon: Yeah. Also, I’m curious how going to a small public, sorry, a small private school compares for this, this teenager to going to a public school, like if she went to a big school. Do you think, you know, how, how does that change the dynamic here? Versus a small private school.

Dr. E: Yeah, that could be. Absolutely. This could be a question in itself. There’s a couple things to think about. I don’t know when this teenager app went, has been in this school. I don’t know if she’s developmentally on par if she’s been in this school since she’s in kindergarten and she’s now a teenager and she’s never developed friendships.

I’d want to ask, does she have appropriate age appropriateage-appropriate social skills? I don’t know that by what you asked me, so I would wannawant to know that. did she just enter this school this year or last year where kids have already known each other for a while? It’s a lot harder. To get into a group, to integrate into a group. 

When kids have already known each other, especially in the adolescent years, it’s, it’s definitely difficult because they’ve known each other, they’ve developed relationships, and now a child that has SM or you know, is timid to integrate into a group is difficult. So, Thisthis is where we will need to rely on teachers to help us pair group clubs activities. 

To really foster that in a large public school, it could be really difficult, especially if you’re going from an elementary to a middle school to an upper school, and now you. Your school’sschools like huge and like triple the size cuz because now you’re in high school. SoSo, it’s possible she doesn’t have any friends. 

Maybe she just started high school. Again, I don’t know the details with this case, but I’m just trying to give you all cases or a lot of scenarios that could be so entering into high school, having accommodations and interventions within a public school is, is really recommended. If she’s having difficulty socializing, she’s not reaching her potential socially, emotionally, it’s maybe affecting her academically. 

I don’t know. We need to think about a 5 0 4 or an IEP plan, and that will help her with accommodations and interventions to not only build connections socially, but also to be able to know how to question her, know how to, help her so that she can at least reach her capacity in school. So private schools don’t necessarily have an IEP or a 5 0 4, so it’s definitely, it could be smaller, which is great in nurturing. 

But it doesn’t mean the school’s going to provide accommodations and interventions. 

Brandon: All right. The fifth and final question is on, emotional regulation. My 14 year old14-year-old son had selected mutism between ages three to 10. After working extensively with a counselor, he seemingly grew out of it. However, now, sometimes my son will. Shut down emotionally and will not speak to me when he feels that I spoke to him unfairly. He will, he will snap out of his silence and start talking again with his normal ease and enthusiasm after about 10 minutes or so after these episodes related, sorry. Are these episodes related to his history with selective mutism? Are they something I need to be concerned about at this point?

Dr. E: So, these are all really good questions. One of the why’s of SM are being very highly sensitive, having maybe to the point of sensory processing challenges. So, it’s a continuum from being highly sensitive to sensory processing challenges. Often with sensory challenges. We have emotional dysregulation. It’s difficult to regulate our emotions and how we feel if he never worked on regulating his emotions. 

Just even aside from smSM, it may have been part of the SM for sure, but even if he didn’t have SM and you have someone with emotional dysregulation that they go from zero to 60 and shut down, that’s something that needs to be worked on to help them build coping skills, to be able to know what triggers are, to be able to really regulate and give them skills to regulate. 

So, what I would say is one was this worked on when he was younger. I doubt all of a sudden as a teenager, he just stopped talking suddenly. I imagine there were signs of this throughout most of his life, whether he ran outta out of the room and shut the door or he just shut down and now he’s doing it, but he’s older and it’s just changing its shape. But it’s the same sort of thing.  

Brandon: Do you think that this anger, this kind of stuff is more common for boys versus girls?

Dr. E: Not necessarily. I think boys by nature, tend to have more difficulty regulating their emotions in terms of expression. They have. I noticed in my practice over years that boys tend to have difficulty expressing their emotions and coming to terms with their emotions. Whereas girls tend to be a little better now there’s a lot of society kind of expectations on boys. Be tough, don’t express your emotions. That’s not. Necessarily the right thing to do. Please understand that. But it is true that society, at least in the past, was much more about being tougher with boys and girls were more emotional and sensitive and so forth. 

SoSo, their expression of their emotions is, Sometimessometimes something that’s brought about easier. soso, I definitely believe there’s the nature-nurture effect here. But I also want you to know that when somebody’s having difficulty regulating their emotions, no matter what age they are, helping them understand their feelings, giving them words for their feelings, really working through feelings. 

So that doesn’t happen. But also, if this isn’t really affecting his ability to function and within a few minutes he comes out of it, you can certainly say it seems like you needed some time to kind of get your thoughts together or to feel better. I mean, that’s okay. That’s not a bad thing. It’s just really, you know, not making him feel bad about it, but helping them understand. 

Because sometimes when you’re in the moment of being really upset or frustrated or misunderstood, for example, Example and become frustrated. You can’t even think straight. Right? SoSo, you do shut down. I mean, that’s a human nature. That’s human nature. So, I don’t know what the precursors are for this either. 

Brandon: Do you think this has anything to do with his selective mutism from when he was a child? Like do you think this is just like you can have emotional regulation issues without being at being mute? 

Dr. E: That’s exactly what I was trying to say is that. It may not even Bela. You could have a, somebody that doesn’t have selective mutism and they can be, you know, highly emotional or have dysregulation, but kids with SM by nature. When you look at the whys of SM definitely can be. more sensitive and have difficulty regulating their emotions. I see that. And if you think about being highly sensitive or sensory processing challenges, one of the reasons you shut down and become minimally communicative is you become overwhelmed in a setting. It causes that to happen.  

That’s a why of sm. That’s what we see. So, I definitely believe there’s a correlation here with selected mutism, but again, selective mutism is a social communication anxiety. Right? So absolutely. But can you have emotional dysregulation or just shutting down and frustrated and difficulty dealing with your anger without SM? Absolutely. 

Brandon: Do you think that this parent, do you think it’d be a good idea if this parent took a look at their child’s interests and maybe tried to like, encourage them to do something or do an activity? That would help them get some of these like feelings out, in a more controlled, setting. For example, I remember when I was a kid, I used to have, I used to get really frustrated and you guys bought me a punching bag and I, I don’t know if it even worked, but it was like a way for me to get the anger out. When I was frustrated, I’d go up and I’d punch the punching bag.

Dr. E: Yeah, so I think that’s a really good point, andand, I’m sure. That, it would help finding areas to let out your emotions and finding that area like running around doing sports, some individuals writing, drawing ways to express themselves. That’s an excellent thing to do as a parent. Also working with a therapist to help somebody learn those skills to regulate, but knowing there’s an outlet.

And one thing that wasn’t brought up here was, I don’t know the types of things the parents are asking or expecting from their child. I do notice, and I’m not saying this is the case with this question, but there’s a lot of shoulds and need to, and I don’t like that. So, a lot of parents will say, you should be doing this. 

You need to do that. Why aren’t you doing this? And what happens is you create this defensive mode in a child that causes incredible amount of frustration. And I don’t know if this child truly has emotional dysregulationdysregulation, or this child is just really frustrated by maybe how the parent is questioning them or what they’re asking them and maybe their , their mood. 

Like, I don’t know. I don’t know When I don’t know those answers, that’s what I would be asking the family if they were sitting in front of me in my office. So, there’s a lot to this question then a simple answer.