By Dr. Elisa Shipon Blum

When a child has both Selective Mutism (SM) and Childhood Apraxia of Speech (CAS), treatment must address both anxiety-driven silence and motor speech challenges. Selective Mutism is an anxiety disorder in which a child who can speak in comfortable settings is unable to speak in certain social or unfamiliar environments. CAS is a motor speech disorder characterized by difficulties in planning and coordinating the movements required for speech.

But it doesn’t end there: Many children with SM may have additional challenges—such as timidity, sensory processing issues, or learning disabilities—that also impact communication. Identifying these underlying “WHYs” is crucial. Likewise, understanding where a child is on the Social Communication Bridge (or a similar stage-based model) helps determine which strategies will be most effective at any given time.

Below is a step-by-step guide, integrating these considerations, to help you craft a supportive, holistic approach.

1. Recognize the Full Scope of “WHYs”

Selective Mutism often develops due to underlying or coexisting factors, which may include:

  • Generalized anxiety or social anxiety
  • Timid or introverted temperament
  • Speech & Language
  • Sensory sensitivities
  • Learning/processing challenges

On top of that, the child might have Childhood Apraxia of Speech (CAS) or other speech/language disorders, which further complicate verbal communication. Identifying each of these elements—the child’s complete profile of strengths and challenges—will inform both the treatment plan and any necessary school-based accommodations.

2. Collaborate with a Multidisciplinary Team

Since multiple factors can be at play, a team-based approach ensures that each domain is addressed:

  • A speech-language pathologist (SLP) experienced in both CAS and SM
  • A physician, child psychologist, or therapist specializing in anxiety and Selective Mutism
  • Teachers, special educators, and support staff who can provide accommodations in school
  • Parents and caregivers who offer support at home and during everyday outings

Keep open channels of communication among all team members to guarantee consistency across various environments.

3. Determine the Child’s Baseline using the Social Communication Bridge®

The Social Communication Bridge® (or a similar stage-based model) categorizes different levels of communication. Children may be:

  • Stage 1 (Nonverbal/Preverbal): Primarily using nonverbal means (gestures, pointing, etc.) or not communicating in certain situations.
  • Stage 2 (Transitioning to Verbal): Might whisper or speak in very short words/phrases only around trusted individuals.
  • Stage 3 (Expanding Verbal Communication): Can speak in short sentences but still limited in certain settings/with certain people. Ie, quiet, few words
  • Stage 3 (Functional Verbal Communication): Speaking more freely but may have moments of anxiety or hesitation in certain contexts. Ie, louder, more expressive speech. By pinpointing the child’s current stage, you can select strategies appropriate to their comfort level and gradually “bridge up” to more advanced communication goals.

4. Tailor Speech Therapy for CAS within an SM Framework

For Childhood Apraxia of Speech, the focus is often on motor planning through systematic, repetitive practice of speech sounds. For children who also have SM, these exercises must be introduced in ways that reduce anxiety:

  1. Start in low-pressure environments. Work initially in safe, comfortable places—home or a quiet school corner—before transitioning to less familiar environments.
  2. Use multisensory techniques. Visual prompts, tactile cues, and other supports can help with motor planning.
  3. Incorporate play and fun. Activities like interactive games help lower anxiety and make repetitive practice more engaging.
  4. Gradual verbal participation. If the child is nonverbal in certain settings (Stage 0 or 1), start with alternative communication (writing, pointing, AAC) before layering in vocal practice.

5. Address Anxiety Through Gradual Desensitization and Underlying WHYs

Since SM has roots in anxiety (and potentially other factors), part of treatment is identifying and reducing those triggers:

  1. Build rapport and trust. Spend initial sessions on nonverbal bonding activities—drawing, games, or crafts that don’t require speech.
  2. Incorporate self-regulation and coping skills. Teach deep breathing, fidget tools, or short mindfulness exercises to manage anxiety.
  3. Use preplanning and scripting. If a child struggles with certain scenarios (e.g., greeting a teacher), practice and rehearse scripts in a comfortable setting first.
  4. Allow for hesitation. Do not rush the child to respond. Give them time to formulate and execute speech.
  5. Celebrate small successes. Any verbal utterance—no matter how small—should be positively reinforced.

Note: The child’s communication stage will dictate how to implement these steps. For instance, a nonverbal child may start by using written scripts or AAC before practicing spoken words.

6. Integrate Repetitive, Predictable Activities

Structured, consistent routines help children feel secure and build confidence as well as helps to minimize the need to think/profess and hence lowers anxiety:

  • Preplan and role-play anticipated social engagements.
  • Visit the same 2–3 places (e.g., favorite restaurants or stores) to practice ‘scripted’ social communication.
  • Use 3 go-to games or activities the child knows well. Familiarity can reduce anxiety and encourage participation.
  • Practice short conversation scripts in predictable settings. Increase complexity as the child moves up the Social Communication Bridge® stages.

Repetition allows for mastery—both of speech production skills (for CAS) and social confidence (for SM).

7. Utilize Augmentative and Alternative Communication (AAC) Tools

AAC tools can reduce frustration and serve as a transitional bridge:

  • Picture Exchange Communication System (PECS): Children hand over a card to communicate wants and needs.
  • Speech-generating devices/apps: Provide verbal output without the pressure of voicing every sound.
  • Write/read strategy: The child writes down (or copies) words, then reads them aloud when ready.

As the child’s stage of communication improves, the reliance on AAC may decrease—but it remains an invaluable safety net during anxious moments or difficult motor planning tasks.

8. Tailor Strategies to Each Stage of the Social Communication Bridge®

Below are examples of how the same strategy (e.g., reading a short script) can be adapted depending on the child’s stage:

  • Stage 1 (Nonverbal): Child writes a script or chooses a communication card; adult reads it aloud. Child may simply point to pictures or nod.
  • Stage 2 (Transitional): Child with SM and CAS may use a trusted peer or parent, etc. as a Verbal Intermediary from a written script in a safe, private setting.
  • Stage 3 (Short Phrases): Child reads short, pre-written phrases or writes/reads in a private (1-1), then semi-private setting (e.g., small group), with gentle encouragement to speak louder if comfortable.
  • Stage 3 (Functional Verbal): Child transitions to spontaneously using these phrases or conversation starters in more public settings, gradually reducing reliance on the script. However, if a script and preplanning helps, this should not be discouraged. Adjusting each technique to the child’s current stage ensures success and keeps anxiety manageable.

9. Involve Parents and Caregivers

Parents and caregivers offer crucial reinforcement and insights:

  1. Identify daily scenarios to rehearse. For instance, greeting a neighbor, asking for help at the grocery store, or speaking during mealtime.
  2. Encourage choice-based questions. Start with yes/no or “Which one?” queries to build confidence, then progress to open-ended questions when the child is ready.
  3. Model calm, patient communication. Avoid pressuring the child to speak but do give them opportunities and time.
  4. Monitor changes in behavior. Look for signs of increased anxiety or frustration to adjust strategies accordingly.

10. Set Realistic, Flexible Goals

Given the variability in anxiety levels, motor planning, and other underlying WHYs, progress can be unpredictable. Goals should address:

  • Social communication (e.g., comfort with specific people or in certain places)
  • Speech production (e.g., mastering certain sounds, words, or phrases)
  • Functional application (e.g., ordering at a restaurant, speaking in front of classmates)

Update these goals regularly as the child’s communication stage changes.

11. Monitor and Refine the Plan Over Time

As the child gains skills and confidence, reevaluate and adjust:

  • Check anxiety levels in different social settings.
  • Track speech improvements to see if the CAS interventions are effective.
  • Revisit the child’s “WHYs.” Are there new or evolving factors—such as new fears, academic demands, or sensory issues—impacting progress?
  • Reassess the Social Communication Bridge® Stage.

Celebrate when the child moves to a higher stage and fine-tune strategies accordingly.

Conclusion

When treating a child with Selective Mutism and Childhood Apraxia of Speech, it is vital to look beyond the surface. Address not only the motor speech components but also the underlying WHYs—including anxiety, temperament, learning challenges, and more—and consistently gauge where the child is on the Social Communication Bridge. By customizing strategies to each stage, providing a supportive team approach, and integrating tools such as AAC, you can help the child build confidence, reduce anxiety, and develop more functional communication skills one step at a time.