Thank you to Liani Austin for sharing this insightful blog post with us today. Liani is a school-based occupational therapist with two beautiful children and a heart for adoption. She is also holds the Publications portfolio on the SAISI Board. She enjoys writing in her spare time and we’re so grateful she shared this one with us. Happy reading!
SELECTIVE MUTISM
“Teacher Liani helped me to talk so I am not scared to ask Mrs B something.” These words right here. Words to feed the soul of an OT. Words that we at one stage thought would never utter this child’s mouth. Some may call it therapy, I call it magic!
Let’s call this child “Yana”. She once had a frozen mouth due to a purple heart. If you had ever watched the movie Inside Out, you would remember the scrawny purple figure called Fear.
After spending her first five and a half years at home with her loving and dedicated mother, Yana started Gr R in South-Africa. Like most children, she cried in the mornings and struggled to separate from her mother. Nothing unusual and to be expected.
Except that she did not utter a single word, or sound for that matter. No speech left her mouth in the presence of teachers for about six months at school. And she had a very kind, soft-hearted teacher. After Term One, this teacher told Yana’s mom that OT may help her as she had previously seen an anxious and over-sensitive child climb out of her shell with the help of OT. So by the fourth month of the year, Yana took my hand and off we went to figure out this frozen mouth situation.
I found that Yana (luckily) had wonderful and on par gross and fine motor skills, with no significant delays in any developmental areas in terms of her skills or perception. She was able to rely on her sensory systems which provided her with effective feedback of how her body was moving through space. No significant hyper-reactivity was present as one would likely hypothesize when looking at Yana’s clinical profile.
Conclusion 1 – Yana does not have a frozen mouth due to ineffective sensory processing or hyper-reactivity causing anxiety.
Conclusion 2 – Yana does not have a frozen mouth due to developmental milestone delays.
Conclusion 3 – Yana does not have a frozen mouth due to previous trauma or difficulties at home.
So what now? How could I as an OT help this little girl? I met with Yana’s mom and together we brainstormed all the test results and observations while her mom gave me much insight to the little girl she was at home. I explained my therapeutic approaches. And I carefully explained how a psychologist, play therapist and paediatrician could help Yana . After all this, her mother chose me. She basically placed Yana’s heart in my hands and said “Go ahead, I trust you”.
*Disclaimer – As occupational therapists we pride ourselves in being valuable members of multi-disciplinary teams, ethically guided by the HPCSA. Therefore, it is always best to refer to a paediatrician or psychologist when a little one with suspected anxiety or selective mutism enters our rooms.
Seeing as there were insufficient evidence for a diagnosis of Sensory Processing Disorder, my OT gut went with a DIR Floortime® approach. A playful, fun, child-led therapy where the therapist joins the child on whichever level they may be, makes friends for life and then walks out of their bubble to face life.
In short, DIR® stands for Developmental, Individualized, Relationship-Based approach and was developed by Dr Stanley Greenspan and Serena Wider. The model emphasizes that a child develops in relation with another, most often the primary caregiver. “Floortime” essentially means joining the child where they are in terms of their current development, not necessarily according to expected age norms, right there on the floor. Previously missed growth opportunities are playfully revisited in order for the child to move forward. Have a look at http://icdl.com/ for a wealth of further information.
Coincidentally, DIR® shares a few similarities with ASI® in that it is also play-based, child-led and adult-facilitated. For any passionate ASI® OT, this is certainly a reliable tool in their toolbox. In short, ASI® intervention is an evidence-based approach and is designed to improve sensory perceptual abilities, self-regulation, motor skills, and praxis. In doing so, it supports the child’s ability to show improved behaviour, learning, and social participation. Intervention is provided in a specialized therapy room with sensory equipment that provides tactile, visual, proprioceptive and vestibular opportunities in a structured manner.
If ASI® is the screwdriver, DIR® is the hammer. Each tool has its own unique traits, and applications, but is respected as an independent tool that one cannot construct without, whether it is constructing a house or the inner works of a child whose innate development has not yet unfolded.
When following a DIR® approach, one aspect to bear in mind, is a child’s sensory challenges and strengths. Music to an ASI® therapist’s ears.
For me, personally, I naturally grab my hammer (aka DIR®) when a young child enters my world. And I gently grip that hammer even tighter when it is child who is described as “difficult” or “all over the place” or “aggressive”. While using ASI® to treat the absolute sensory devastation beneath, DIR® helps me to dance with the child, to enter his universe, become his star and in the end, climb into that space rocket together to reach for the moon.
I saw Yana responded well to movement and calming resistive input so we climbed, slid down and had fun on a swing. Initially all with a deathly silence from Yana. I matched her silence with one word “sentences”, and we spoke non-verbally. No pressure! And after 20 minutes Yana started uttering sounds and a few words and then suddenly as if she had spoken all along, told me in a crystal-clear voice; “I’ll come and visit you for a whole school day next time!”. A few more sessions ensued.
I sneakily observed Yana on the playground and saw she had made a friend with a very sweet girl in her class. She spoke freely to this girl as long as she thought no adult was around. I asked the friend’s mom permission and roped her into a therapy session with me and Yana. What fun! Yana showed her friend the ropes and giggled out loud. And then victory! Yana suddenly started speaking and told a whole story. She was now the Yana at school that she was at home.
While Yana now spoke in OT and with most friends, it took some time for her to speak to her teacher, but towards the end of the year she was able to communicate in full sentences, hence her telling her mom that she wasn’t scared of speaking to her new Grade One teacher the following year!
Yana was not formally diagnosed with selective mutism in the end, but showed most symptoms. Selective mutism must be diagnosed by a medical doctor, usually a paediatrician, paediatric neurologist or psychiatrist. Therapists and psychologists often form part of the team that assists the doctor in order to come to a final diagnosis.
Another child who I saw for therapy, who was indeed diagnosed with selective mutism by a developmental paediatrician at the age of four years old, remained silent at his loving pre-school for almost two years. Yep, almost 500 days of consecutive silence at school. He whispered to me during our very first session and the teachers couldn’t believe their ears! They really thought he was mute and that his parents were lying when they said he spoke in full sentences at home. This doctor first sent him to an OT who helped him to rule out autism with the help of a diagnostic test.
Selective mutism really is in the name. The child selects in which settings to be mute. This means that they will communicate fully and without difficulty with select people and in certain settings (mostly at home), but will remain completely silent in others. There is a strong link between anxiety and selective mutism, which is seen as an anxiety disorder. Some children will have such fear, that they will also avoid eye contact and all non-verbal communication causing great debilitation. Many children with selective mutism will have a blank and serious facial expression in social settings. Selective mutism is not due to trauma, whereas in trauma mutism the child speaks in no setting at all.
I hope this story helped you to have a better understanding of selective mutism and how occupational therapy may play a part in the treatment approach.