 Hello and welcome to Pukie Ponders, the podcast where I explore big questions with brilliant people. Today's question is, what is selective mutism and how can we help? And I'm in conversation with Gino Hippolito. My name is Gino Hippolito, I'm a speech language therapist. I work for St George's NHS Foundation Trust and I specialise in selective mutism and I've also got a wife and two children and living in South London. Could you start off just by telling us what is selective mutism? And is that the right phrase as well because I've been questioned on this. No, it is. Well, at the moment that is what it's called based on the diagnostic statistical manuals. So that is the term. It used to be called elective mutism before and then it's just changed in 1994 in the DSM fall. So I'll first explain what selective mutism is and then how what some people might propose it should be called. So the way it's what selective mutism is, it is a considered anxiety disorder. And that was recently just acknowledged in the DSM fight. And the great thing about that is there's been a lot more research now and a lot more interesting finding out more about selective mutism since that in 2013. But it is considered a bit like a phobia of speaking or a phobia of being heard and like with any phobia when you're confronted with a threat. So the threat is being heard or where there's a situation where there's an expectation to speak. And when you're confronted with that threat, then your responses are that you fight, you fight, avoid the situation totally or you freeze. And so a lot of people will freeze and in doing so then they can't get their words out. And so just like with any kind of phobic reaction, if you are aware of the threats, your hyper vigilance, you're constantly aware of where that threat might be. And it's quite exhaustive for the individual with selective mutism. And so when you think about the situation, say in a school situation, there's constant expectation to speak in school. And so the poor child with selective mutism in a school situation is exhausted by the end of the day because there's that constant threat, constant hyper vigilance. So what some people don't like about the title selective mutism is they feel that it's because the individual with selective mutism has control over it that they select, they specifically select to speak when they want to and when they don't. And that's where the misinterpretation comes in. And sometimes it can be unhelpful, but I think the, the idea behind it is that they speak and select situations and don't in others. But a lot more people are saying that actually a better term is maybe called situational mutism, where there are specific situations where the individual with selective mutism is mute. And once I work with pediatrics, I will try and as much as possible say the individual with selective mutism just because there are adults with selective mutism as well. And for a long time, a lot of people have been talking about children with selective mutism, but actually there are adults with selective mutism as well. And that's really important to acknowledge. So it sounds like that kind of phraseology is a bit like I do a lot of work in self harm. And if we go back a few years, we used to use the term deliberate self harm. And we've lost the deliberate for kind of similar reasons that it sort of puts the onus on the individual and makes it sound like this is entirely of their choosing. So from what you're saying, then selective mutism, it's about the fact that sometimes a child will be able to speak and sometimes not. Is that right? That's right. Depending on the situation might be who is near where the person might be out. Again, it's that where there's that expectation to speak. And so and it changes, it may seem like it changes all the time, but often there is a pattern to it. However, each of those profiles that the child or individual young person experiences is different. There's a diverse population where some may not speak so much at home and it might be the opposite. They might speak outside of the home. But more often or not, we find that it's more difficult to speak outside of the home and they're feeling more comfortable when they're speaking to close relatives inside the home. And are the kind of underlying reasons for mutism often similar? Or is this a kind of a symptom of many different things? To be quite similar, in a sense, there's a predisposition like with a lot of anxiety disorders, the behavioral inhibition temperaments. And then there's often tend to be kind of family history. So there would be some form of genetic predisposition. Then there's also the environment where might where there might be a lot of pressure with communication. And so if you're behavioral inhibited, quite sensitive to things, and then all of a sudden you put in a pressure situation, then that can then trigger the selective mutism. Often we find the onset tends to happen between the ages of two and five, which is when a child transitions into nursery or school, because the communication environments, they're so different. So at home, you know, the child speaks when they want to. It's kind of child-led often. And then whereas when you're at school or nursery, often it's adult-led in terms of the adult asks you a question, you then respond when it comes to a learning environment. And also then it could be quite overwhelming for the child because there's other children there who you've got to learn to share with who are snatching your toys. And then if you're just shocked and overwhelmed by that, then that can be enough to just trigger the anxiety which then tightens their vocal folds and find it difficult to then speak in those situations. And if that's continued time and time again and reinforced, then it then becomes selective mutism. And who is affected and how prevalent is it? It's really difficult to say a lot of studies if you look in the literature, you've got clinical studies, you've got studies in the community. Generally, generally a ballpark figure is in the under eights population, it's more prevalent, which is understandable and says roughly one in 140. And that was from a study by Bergman in I think 2002. And then with the older children between seven and 12, there was another study done and roughly about one in 550. And then there was a dissertation by Sutton, who is actually an adult with selective mutism, who wrote a paper on adults with selective mutitism. And he suggested that there's roughly maybe one in 2400 in terms of prevalence for adults with selective mutism. Wow. And do we see lots of co-morbidity with other conditions? So would we diagnose selective mutism in some young people who are non-verbal autistic, for example, or is that a different thing? When it comes to non-verbal autistic, then you wouldn't call that selective mutism. But certainly there is co-morbidity with selective mutism and autism. And I think the DSM-5 can be quite confusing there because if you read the DSM-5, it may seem like you can't have selective mutism and autism at the same time. But actually, you actually can. Particularly, the main thing is you need to establish that the person can actually speak in other situations. So they have to be verbal before they're given a diagnosis of selective mutism. But common co-existing conditions is communication difficulties, so ranging between 10% to 50%, depending on the studies. And then also anxiety disorder, co-morbid anxiety disorder and social anxiety disorder, sort of specific phobias and separation anxiety, often the high prevalence anxiety conditions. Are there things that we should be kind of looking out for? Is this a kind of instance where if we can pick up sort of early warning signs, for example, that we're able to do work around prevention or not? Absolutely, no, definitely. We know that the onset for a lot of children with selective mutism tends to be the ages of 2 and 5 and can easily be picked up as a nursery in school. What's really challenging is just our view of communication and that often, and also view of children and behavior within school, that if they're quiet, then they're not kicking up a fuss. Therefore, we don't really need to sound the alarm bells here. But so often those children that might have other behavioral difficulties and communication difficulties that they might then be referred. But actually a silent child, a quiet child is actually someone in nursery or school needs to just keep an eye on. And so when it comes to selective mutism for a diagnosis, they need to have a clear pattern where they speak in some situations and do not in others. And also this pattern continues for more than a month. And if it's first month in school, then add another month to the first two months of school. Because it's quite common for children to be quiet and silenced in that first month, because it's such a big change. But we would then expect children to start to vocalize, start to interact more. But if children continue to be silent, that's when I suggest after that one month period, or if they've just started the school after two month period, refer on to whichever agency takes the lead in selective mutism, whether it's the speech and language therapist, the education psychologist, the local authority. Another thing too, there's high prevalence in the bilingual multilingual population. Four times more likely to have selective mutism and another study they saw the red flags would be if the child was bilingual multilingual, but also had an anxious predisposition that were more likely to develop selective mutism. So a lot of practitioners might be confused because of the silent period. But this is where I'd suggest if the child has an anxious predisposition to maybe then investigate further, ask the parents whether is the child speaking to them when they're outside of the home. Or do they stop and be quiet when there are people nearby? Or do they are they quite in front of other relatives to those kind of that kind of information can be really important because a bilingual child will be speaking their own language to their parent in different environments. Are there any other groups that we might see sort of interesting things in terms of communication I'm wondering about. Twins, for example, so I know that I've got two daughters the same age and they did that. What turned out to be quite a typical twin thing of not speaking to anyone except each other with their own kind of language for quite a long time and then developed completely normally and I just wondered if there's, you know, sort of anything with those kinds of examples. There are examples in the literature but also in our caseload in one sense where maybe one of the twins might have selective mutism. In terms of the prevalence I don't know the exact prevalence of that but it is yeah it makes sense because I've often heard anecdotally that yes they do have their own language to communicate or sometimes rely on the other one who might be a bit more confident perhaps verbally. I know there are times when we don't need to worry so sometimes you know someone might be listening to this and then suddenly thinking about a particular child in their care I mean are there times when we might kind of have a false alarm or is there any kind of thing we can look to in terms of reassurance. One thing to look for reassurance is if the child is starting to feel more comfortable in the environment and then starting to be more verbal in that situation. However if they plateau or what's really important as well as another thing gets missed is with selective mutism you might have high profile selective mutism where it's really clear can't that the child or young person or individual does not speak in specific situations like school. There's low profile selective mutism where they may speak or respond when they absolutely must say maybe in a class situation where the teacher is giving pressure and they might respond maybe in one word answer but they never initiate. And those children are the ones that are really high risk of just continuing on through the school years and they often then develop other comorbid anxiety disorders as well. So I think I would rather err on the side of caution and refer on and then you can always say no nothing to worry about or maybe you'll keep an eye on that kind of thing. But I as a practitioner I'd encourage people if they're not talking consistently if you're not seeing improvements if they're plateauing then at least speak to another professional about that or make a referral. I'm just keeping it real a moment because we all know how hard it is to get through referral processes. What should you know if a parent or carer and member of staff at school is concerned about a child. What does that referral need to look like what are the things that you're expecting to learn from us so that you know whether or not this is a case you need to take on. If the child is is not speaking to either adults or peers within the setting. This is from the point of view of school. And if usually for a diagnosis it would have to impact social communication and also education but I would say if one of those things are happening that will eventually affect education or that will eventually affect social communication. So I'd say just refer if I see that pattern and it continues for more than a month that I would say refer and I as a practitioner would want to accept that as a referral. Now at the same time I can't say that for all services because different services have different criteria. But I think we I think there is a need to to identify this a lot earlier for a lot of children because I'm just speaking to a lot of parents who have gone through a lot and a lot of individuals, teenagers, adults who have gone through it and it wasn't picked up earlier on. They're in Sutton study only a really small percentage got diagnosed in childhood. So if anything I as a professional would rather air on caution. But what is tricky like you said there are there are gaps in service and service delivery and that's really important and even within our profession and just to encourage those in education psychology. All those work in local authority that there needs to be a service for children selects mutism in every local authority or every NHS area, but some profession has to take the lead for that. And that's the tricky thing is because sometimes maybe speech therapists might say it's not our remit even though raw colleges speech language therapists say it is a remit to at least be involved in children with our many young people with selects mutism. But then other situations that education psychologists might say it's not our remit or sometimes cams might even say it's not our remit. So it's really important that wherever you are in your local situation that then needs the conversation with professionals to work out who's going to take charge because there are a lot of gaps right now across the UK in terms of provision for SM. And how can we help like should the adults who are supporting a child are the things that they should be doing before they even seek that help or you know what can we do that might help and and really importantly what might we do that might make things worse inadvertently. Yeah, I mean things that will start with the things that make things worse because at least that can be something we can really say we're just going to stop doing that. First we're putting pressure on the child to communicate. That's going to make it worse. Also making comments about the child that they don't speak or they can't speak those kind of things will affect the child's confidence to speak in and start. They'll start to see themselves as okay this is just who I am I just can't speak I can't do this anymore. Also when maybe take when adults take it personally I think adults can easily take it personally, whether it's a teacher or maybe a relative. If the child's not speaking to you sometimes they feel that okay they're rude or maybe they've got something against you. What's really important by understanding it's anxiety disorder. It's not it's not because of you and and to if anything get over yourself and focus on the child because once we take things personally like that then it will react. It will impact our interactions with the child and we will have whether we are aware of it or not convey negativity to the child and that's not going to help at all. If anything what I would suggest is first we'll take the pressure off speaking or that pressure for that child to speak and if anything create opportunities for the child to communicate and participate like with all the other children. I think if ending that's the first step to to to help the child enjoy themselves in that environment. So we're going to enable them to participate but without vocally participating. Yeah it doesn't have to be vocally they don't have to participate vocally. So what I'd suggest is first of all maybe even before considering speaking think of is the child actually focused in the activity. Are they attending to the activity because they might be just totally just in freeze mode and not even engaging with the actual activity. So then they practice and they think okay what can I do to make it easy for them to actually just engage and attend to the activity. And if they are attending to the activity are they are they actually participating activity are they doing something like are the other children can be just non verbally too. And then maybe the next step are they interacting the activity, even if it's non verbally, because that's what you want them to do is actually participate and interact and it doesn't have to be verbally at this stage. And then by little by little through small steps and building rapport on a one-to-one situation and then little by little allowing that to happen in the learning environment. The child will then be able to start saying maybe one word and then maybe a few words and then maybe eventually sentences within that educational setting. But it happens it can speed up a lot quicker when the younger they are so in nursery age we find that the process can be a lot quicker there. After we find after year one it can be take longer for them to move up those stages of confidence speaking. Is that because it's kind of become such a habit or their anxiety has got really high or do we know why? I think yeah both I think it's just been ingrained when I look at those two longitudinal studies and done in the 2000s. And what's interesting that their age of referrals roughly eight and a half and they accessed a psychology service and they tracked them into adulthood. And they found that roughly I think I wrote this down somewhere about 42 to 61% still had SM in adulthood because they had SM for five years before they were referred. Now this is not doom and gloom for those who are late referrals but if anything there is an emphasis where when children are referred early I was involved in a team in Kent where we did an audit of children who referred in nursery and reception and we tracked them. All we did was we offered training for parents and also teachers and then we set up a meeting where we talked about things you can do to change the environment make it easy for the child to speak. And we just tracked these children and by the age of by the end of year by the end of reception. So by the age of six 86% of the children had resolved without any other kind of work. So just like touch but earlier on can be really effective. Whereas you know once they're in year one or two or onwards or in teenage years then I mean once you're in teenage years you're dealing with likely to have comorbid conditions. But certainly in the early primary school years you do find it can take several years to then resolve after that. Are there any kind of universal sort of strategies that we can you know use within an education setting in particular that would make it less likely for like all children to develop these kinds of issues. So that taking that approach that sometimes when we look to help individuals we can end up kind of helping everyone. Yeah absolutely there's a thing which a speech therapist we one of our bread and butter strategies or forms of intervention is parent child interaction therapy or adult child interaction therapy where when you're interacting we do this with children with who have a Stammer or who might have language difficulties to help develop the language. But what it does it actually takes the pressure of communication but in doing so it actually helps develop communication. So an example of that is trying not to ask too many questions and just make comments. So if you're dealing with children and say earlier on in nursery or reception play with them build rapport do something that's fun. So they're interested they're more likely to engage and try not to ask too many questions just comment on it almost like a commentary thing and also pause to allow time for the child to respond as well. But with selective mutism there's a slight difference the way I'd work with the child with language difficulties and a child with selective mutism that situation. So a child with language difficulties I would encourage the adults to be face to face with the child so that they can see all the visual cues of talking and speaking things like that. But with a child with selective mutism I contact can be very confronting and quite overwhelming. So what I suggest is actually with the adults to be side by side or alongside when you're playing with the child so you're not making that you know I contact they're taking that pressure off you're making comments and you're doing something fun the child is more likely to make comments feel more relaxed and then start speaking that situation and then little by little you can then step it up into more of a educational activity. But that's what we call the research calls that defocus communication. And that's something which any one could do in any nursery staff or reception practitioner can do. And it's great for all children to develop their language skills. It's great for children who stammer as well because you're pausing giving them time to interact and respond. And you're doing something fun when you're having fun it's it's hard to be anxious. It's hard to to be tense. But if you're having fun you start to relax and you're more likely to speak. And I guess that really helps with building that kind of that trust and that relationship as well doesn't it. Absolutely and that's feeling a sense of acceptance of the child that there's a common theme there when reading adults experience of selective mutism and even actually when I saw there was an adult with selective mutism who spoke actually at the Royal College of Speech Therapist. There's a seminar with a clinical excellence network and she spoke about her experience of having selective mutism and she answered some questions as well, which is quite confronting or a room full of speech therapists, and you're an adult with selective mutism. And she said that was the first time and she tweeted this was the first time she spoke in 12 years in front of an audience in public. But what she said was actually I wrote these things down because they're really important. She said she felt accepted included and not pressured, and that lowered her anxiety, which made it easy for her to speak. And I noticed that your interview with Caroline a few weeks ago to there was the same kind of theme of just acceptance of the person who they are, and just enjoying that time with them. That takes the pressure down pressure off. So there's those common themes absolute those interpersonal things. It feels like a bit like the advice here to adults whether they're working with or living with a child that it's almost that we should just try and relax a bit and have fun and almost try and forget about this difficult thing and just try and get on with the day to day of enjoying a child and hoping to create a bit of a bond there. Absolutely. And that's why a lot of people when it comes to speech depth is working with young children. It seems like all we do is play. And my children asked me, well, what do you do dad and I said, I will I do a lot of play with children and talk about the different toys are playing this I want to go to your work. But that's it. That's essentially it is looking for particularly young children looking for things that's fun with the child. And using just ways where there's no pressure to speak or communicate. But having fun this often then gives the child motivation to want to speak and share and interact because children with selective mutants they do want to speak. And when they're in situation where they feel comfortable, they will speak and you will probably talk to their parents or siblings that they can talk forever. Often when they come home as well, they're just very chatty perhaps because they have been silent for the whole day. So they do want to speak is just giving them an opportunity to do that. And should we use like other methods of communication or does that kind of impound the the mutism like should we allow them to write or draw or something to show us what they mean if they find it difficult to talk or is that not a good idea. No, absolutely. I think that's great because what we want to send the message we want to send across here is communication is important any form of communication. Now, when it's a young child or younger child. Similar to that what I was mentioned before about is the child attending as a child participating as a child interacting non verbally, then you move up to any form. So, writing or using gestures things like that is a non verbal form of communication but still interaction and we want to encourage that with younger children we do want them to have the opportunity to speak. It goes with young people as well. But the more you get older with SM, then it's also important to just consider that sometimes these difficulties may not necessarily go away. And actually we got to think about maybe how to how to cope with having SM. And not only that but also as a society, how are we going to respond. Because it's impacting their access to things it's impacting their access to jobs it's impacting the access to just doing things like other adults are doing, you know, catching a train. It can be very difficult to asking for a ticket or whatever it might be there's so when it comes to adults with SM. I probably not the best to be able to convey that in fact I kind of articulated as well as those adults with SM. So what I would do is signpost you to ispeak.org it's a website developed by adults with SM. And they talk a lot about the social disability model and about just how there's things that society can do to make it easier to for them to be included for them to be accepted and for them to have access to things like that. Because when we think about it, we live in a very verbal centric society. And in a subtle way that not many people are aware of where a lot of adults with SM are experiencing prejudice. They're not having access to things like everyone else. So from social disability model we as society need to take responsibility and make some changes as well. Now I don't have all the answers to all those things, but there at least is a conversation that can be started. Absolutely. And presumably when you are supporting a child with selective mutism, you're also supporting probably quite a worried and maybe frustrated family. Yes, absolutely. I mean, yep. I mean, with any child with in that situation, I think a parent will be very worried and concerned. I know I would be. But also alongside that often, children with SM. Often there's family members who might have anxiety disorders as well, comorbid conditions. And often would find in case history that maybe one of the parents might also have anxiety. And so there is that element there. And occasionally I would have to talk to parents and just say what's really important is to be aware of our own anxiety and how we might project that to our child. And also when I talk about the child taking risks, I encourage parents and children to take risks and for the parents to model that as well. So it's what we call a have a go attitude. So it doesn't have to be in relation to speaking. It could be anything could be like a physical challenge. It could be a vocational challenge or academic challenge. But the idea is to take a risk because of the behavior inhibition, they're reluctant to take risks that children and young people just people with SM tend to be risk averse. So what we encourage is the parents and the child, but particularly the parents to model taking risks and also talking through the child about that and how they felt and how they overcame that. Because then it just sets up a great model for the child to do that. And often a lot of parents will have lots of experiences where they'll have to play or literally feel that they are taking a risk, maybe in a social situation or could even just be talking to the bus driver or talking to the shop assistant. That could feel like of taking a risk. Sounds scary actually the idea is a parent being told right you need to do this and role model it for your child and simply there we're looking at kind of supporting and scaffolding to try and make sure that the risk is taken but the outcome is not negative. Yes, that's right. So there's also ways in what we might encourage the parent. There's a strategy which Maggie Johnson and Allison which is came up with it's called the weight weight technique. And the idea is say when the parent and his child is maybe at the shop. And they're obviously the parents talk to the child that this is what's going to happen that if the shop assistant or maybe with their in public someone asked the child a question. Often it might be on what's your name or how old are you. That's often the questions that shop assistants or sometimes strangers might might say so we encourage parents to wait five seconds. Again, then creating an opportunity for the child to respond. If the child doesn't respond in the parent might turn to the child and then turn decrease the communication risk by turning into a choice question so saying also are you. Seven or are you nine. So then the child and the child is then looking at the parents so then it takes the pressure off they're not looking at the shop assistant. So you've got proximity change there so all these by doing these little strategies it takes the pressure off or decreases the pressure anyway for the child. And then the parent waits again for another five seconds. And in those situations some children might then say something and then the parent can model it back or repeat it. And then if the child doesn't respond in that situation then the parent might say oh you're nine aren't you and then move on. But the idea in that situation you actually creating two opportunities for the child to communicate. And so you're not avoiding but you're also like I said scaffolding to make it easier. And if a child was able to speak in that situation and that was kind of unusual should we be kind of celebrating and praising that or do we just kind of quietly move on maybe acknowledge it later. Yeah I wouldn't make it too much of a who are. It's interesting because in say the states they often talk about praise and but maybe it might be culture specific because I know in the states they're very big on on making things big. But in the UK we're a bit more reserved. So I what we've had conversations about this. Those who work in SM like about the difference in cultures and then how our approaches to intervention what we would say in the UK is just acknowledge it but not make it a big deal. Because sometimes if you make it a big deal it then puts the spotlight on the child and sometimes in that situation that's the last thing actually a lot of times that's the last thing the child wants. So if you move that into a classroom situation if a teacher said oh well done for talking great job. Then that's the last thing the child would want because everyone's been looking at the child spotlights on the child and they're thinking I never want to do this again. So just acknowledge it and then move on. But then they can maybe have just a word say hey that was great job well done for you know being brave and saying those things you know maybe on a one to one situation. And would you maybe be communicating that with home as well so parents can acknowledge it with their child and feel maybe reassured or. Yeah, that's right. Yeah, I say you same kind of strategies at home and also in school too. And what's the role of support staff because I do loads of work with support staff kind of our school nurses are learning support assistance all those different stuff who are often alongside our kids and often will have a really important role with any child who's working for whatever reason and I would assume but you'll correct me if I'm wrong that maybe a child might build like a really good relationship with maybe one member of support staff who might be able to really help with this. Yeah, absolutely. And in fact, particularly with the younger children. I find that the support we work through the support staff. In fact, there's with younger children. There are a lot of children who have never met me before as a therapist and I worked purely through the parent and and the teachers because they're the ones who are with the child saying they out they're the ones who are most important to the child. If the child never speaks to me ever again then there's no no problem with that from their side of things. And there are situations where I've actually never met the child in terms of we had assessment but in terms of in school setting and things like that because I've purely just been meetings with the parent and the teaching or teaching staff. And if anything they're the most important people involved when it comes to supporting children with selective mutism because they're with them day in day out. So we involve them if they're younger we just give them these strategies early on in nursery or reception. Once we move into year one onwards we tend to then have a more formal structured small steps program. So we might do shaping or sliding in and that support stuff will be really key in that. Sliding in sliding is stimulating or it's a strategy technique where you expose the child to to the anxious situation. So of an adult being near them or approaching closer to them while they're talking. And the idea is so for an example the child might be with a parent or someone who they feel comfortable with speaking to. So they might be in a room playing a game or activity or maybe they might be counting or doing some sort of activity which is fun and lighthearted. And then the new adult who that you want to introduce into the child's talking circle will then move closer and closer they might be outside of the room. Eventually once a child is continuing talking feeling comfortable they may be open the door and then maybe the next step might be then moving in just outside inside the door. Eventually maybe moving in closer to the table eventually then sitting at the table eventually maybe then participating in the activity and eventually maybe asking a question or talking in that activity. So it's a really small steps approach of moving that new person involved and eventually that person becomes a new talking partner. And when that person becomes a new talking partner then the often the parent often then moves out and it's faded out. And then from that point onwards that new talking partner helps slide in other children and other support staff in the school. So that's sliding in shaping is a similar one shaping is when maybe the parent or comfortable communication partners not involved for some reason or rather. And so what's the the adult who is doing the shaping work who might be maybe a speech therapist to start with or it could be if it's true if the speech therapist is training. The practitioner the education practitioner then the idea would be in really small step approach moving from nonverbal communication to maybe eventually sounds. It could be maybe with instruments and then sounds and blowing with like a recorder to eventually making sounds with the mouth to eventually making syllables to eventually words and phrases and sentences. So small step approach to community verbal communication. And then once that's established in terms of from a conversational point of view, then similar to sliding in then you can then slide in other children or other adults within the school setting. And how long does this kind of process take like how long would a child normally be going through this kind of therapeutic approach. It really depends again depends on how collaborative the work has been. If everyone is on board. And we recommend at least if they're doing this approach to do at least three times a week. So it can be challenging sometimes when it comes to working it out in the school day. And also finding rooms available as well. So it's hard to say hard and fast because some children they may move up really quickly. Others it does take some time but you would expect at least probably would expect some progress after several sessions. I'm not saying they're going to be speaking freely but at least this progress in terms of allowing the person to be in the room with the child hearing their voice. However, if the select mutism is really ingrained what's really important is to break the step down into really small steps. And that's where you might need a speech therapist or educational psychologist involved to problem solve and work out what that small step might look like. And do you ever get issues where like if there's a long holiday or say the period of lockdown where a child might revert to previous behaviors having kind of overcome it once. Absolutely. Yeah. That often happens. And I often reassure parents and teachers that this might happen. But often I find that children bounce back quicker. And that's a good sign when they do that because at some point in time there's going to be a transition. They're going to transition to another year group or different teachers well and so it almost starts again. So my almost. Yeah, I talked to parents and teachers to expect this to happen and to kind of normalize it. But what we do want to see is the child to then also improve probably at a slightly quicker rate than it was before. So do you often see that there's a step back when a child like transitions into a new class or like between primary and secondary that's presumably quite tricky. Yeah, it's a big transition that one. I mean, it's interesting because again, like each child is different. Some children surprise me and they might come into the new year group or maybe even go into secondary because no one else knows them and say, OK, I feel comfortable because no one knows that I don't talk, but I can talk now. So they they then start talking in secondary that might happen also in transition. But more often or not we do find there is a bit of a setback. But as long as there's things in place to support that transition, often that setback is is shortened. So things that we would suggest is maybe transition book. If it's moving across year groups, then the child to build rapport with a new teacher. We encourage schools to find out. I know some schools don't release the new teacher will find the teachers don't even know who that what they're teaching, you know, until the end of term three. But what we encourage schools to do is to identify that for the sake of this child and then identify who that new teacher is and then look for in that last term in term three to start building rapport with that teacher. We encourage schools to bring the child to that teacher to deliver errands or something like that. Or sometimes some schools they might have the new teacher go into that classroom and teach some subjects or so towards the end of year three so that they build that rapport. Some teachers are great. They might send a message over the holidays and looking forward to seeing you. Also a transition book can be really helpful in just maybe taking photos of the new classroom. The new environment or where the toilets are going to be where you know that the food hall is going to be if things have changed. So that the child just leading up to that new year can then look at those things and just to be aware. Okay, that's where I need to put things or that's where I need to do things because they what they don't like is that change and not knowing. I've worked with a child once and she found she really struggled in a transition from a reception to year one because she didn't know where to put her coat. She was anxious about she didn't know where she's going to put her coat on the coat peg. So little things like even taking a photo. This is where you put your bag when you come in. This is you get your name tag when you come in you put name on the board whatever the procedure is but so that the child will know what's happening and that can at least bring down the anxiety to make it easier. And if a teacher knows that they've got coming into their class a child who's got history of selective mutism whether it's current or kind of previous. Are there any specific things you think that they as the as the class teacher or sort of designated support staff should specifically be doing for that child and for their family. Yeah, I mean, what would be amazing this to be in an ideal world is if the teacher or the support staff can do a home visit before that new year. I know it's not always possible with schools. But when I've seen that happen and when schools have allowed the teacher to do that or the teaching system to do that is made such a difference. And sometimes that can really help build that rapport earlier on and make it easy for the child in their transition in one thing it's going to be really important we'll be talking to the parents find out what was helpful what wasn't. What does the child like so they can have in the back of mind things that the child enjoys so that you know if the child is feeling anxious that they can then think of activities the child can do to bring that anxiety down. And also ask the parents what what helps in different situations for the child. So communication is really really important is really important between home and school it's so important I find that when there's the lack of that communication often there's the progress is slower. And could be sorry gone or I also know the point is if maybe one of the two are not on board, then often we find the progress is being slower. Okay, so we kind of want to do that kind of genuine sort of child centre team around the child kind of approach. And just thinking about the home visit suggestion which yeah sounds like a wonderful thing to do but not always possible. Do you think that like doing it like this I presume is that something that would be helpful or not so much. You know what that's really interesting that's because I wouldn't have thought of that until covered 19 and what's really interesting. It's not the case for all children but some children actually find this type of interaction easier because there's a proximity there because you're just on the screen you're not there in person there on the screen. At the same time there are some children do find it difficult. Another thing also notice is that the younger children they're so exposed to social media and the parents using this that actually it's the kind of desensitised to it so it's easy for them to communicate and interact. At the same time, some do find it difficult. In the last few months when I've worked with child with select to mutism and their parent, what we tend to do is I interact with the parent we do some games or playing with these younger children. I play with some of the toys and little by little the child then might be outside of the screen but little by little as they relax and become more comfortable see that this is fun. They start become coming into the screen and then with this particular child I worked with eventually she was then interacting asking me questions or making comments about what I was doing at play so some you can use a kind of graded approach again also in that kind of interaction. It must be so great when you have a child who's been me who then does choose to interact with you that must feel brilliant. It is amazing. I don't want to have that I don't want to chase that in that being the thing I would chase for as a therapist, even though it is such a rewarding thing but I know that some. I know sometimes when that becomes the goal in my mind it can be as a therapist anyway it can be frustrating and I don't want that frustration because sometimes that's my expectation. But yes absolutely is really rewarding. Yeah. And can you tell me a bit about your research that you're doing some NIHR. Yes. That's right. I'm recently Maggie Johnson and I we wrote a chapter about some selective mutism and pragmatic language impairment and there's some papers have suggested that maybe children with selective mutism may have underlying pragmatic language impairment. In this chapter that we wrote we suggest that it's not the case for most children with SM. However, some pragmatic language impairment is it's kind of like ASD but it's without the it's more of the difficulties with the pragmatic service social use of language rather than aspects of rigidity. And so there is difficulty with social communication but it's more from the pragmatic language side of things. So what we're suggesting is that is not the case for a majority of children with SM but however like with any child they might have pragmatic language difficulties. And if you if we did have a child like that this is how we would assess the child or this is how we would provide intervention. So that's one of the things that we did on the during the fellowship but also I've been working on a systematic review as well looking at non pharmacological interventions. And what's interesting there's been a lot more research since the change in terminology and DSM five becoming anxiety disorders there's been several RCT so just writing up that paper at the moments and playing to do a method analysis there with some of the RCTs. So that's something in the pipeline. What's really interesting trend is that those the intervention that I've noticed are effective. There is that report building. There is the changing the environment or students approach in a way, but also there's always a behavioral element there as well. Did that surprise you or did it. It was actually that there was a lot of people were talking about that already and actually a lot of studies were using that but never really talking too much about it. So there was yeah that it's something which we noticed what was interesting there was a you using CBT but with online web application. And this particular study. It was just the clinician and the child. So there wasn't any teacher involved. There wasn't a parent involved parent had a bit of homework but that was it. And what was interesting the child didn't make much progress. And if anything the active control made slightly better progress. But the active control was playing computer games. Now what I might hypothesize about that is that actually with computer games there's no pressure to communicate. But you also build a rapport as well. But with this situation. I see that there is such an important role for parents and teachers to be involved. And if it's just a clinician and the child is only so far you can go in terms of generalizing the communication the speech and other situations you really do need other people on board to help that generalization to support that young child or individual in communicating other situations. Yeah, which is great to hear. And you've given us some really good and practical ideas about things that that people can do to help. And I wondered if you would mind kind of closing with I always kind of create these instant insights of the you know the minute if you only listen to one minute this is the one of maybe some just a very brief overview of the things we can helpfully do where we're worried about child. But the identification and access to services really important for clinicians parents teachers and we all have a role to play. What's really important address it and acknowledge the speech anxiety with the child so that they know that you know. And also that they know that that what you want to do is create opportunities to communicate participate and have fun and you want to take the pressure off speaking. And also whatever you do small steps is really important and do things in small steps and it doesn't have to be just in speaking. But also with any kind of goal that will think that the child wants to achieve try and do things in small steps to take that pressure off. And also collaboration is so important parents teachers clinicians all working together and also if the greater society can also make some changes as well to allow for access for adults with SM that would be great.