Unlocking the Mystery of Selective Mutism with Dr. Aimee Kotrba

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[00:01:40] Kate Grandbois: I'm so excited for today's topic. This is going to be so interesting today.

We have the great pleasure of welcoming Dr. Aimee Kotrba to talk to us about selective mutism. Welcome Aimee!

[00:01:52] Aimee Kotrba: Thank you. I'm so excited to be here and join you.

[00:01:56] Aimee Wonkka: , 

You are here to discuss selective mutism before we get started. Can you please [00:02:00] tell us a little bit about yourself?

[00:02:02] Aimee Kotrba: Yeah, absolutely. I'm a psychologist, a child psychologist. I own a practice in Michigan called thriving minds. And we specialize in seeing kids with selective mutism. I, when I was in graduate school, I'd never even heard of selective mutism.

It never came up in any of the trainings that I did. And then right after I got out of school I started working in a clinic and a little boy with selective mutism came in the doors. And he was a really severe case, but I loved working with him and his family. And just got really involved in lit reviews and learning about selective mutism and training on selective mutism.

And it sort of snowballed into where I am today where I get to work with all kinds of kids across the country with selective mutism. 

[00:02:54] Kate Grandbois: This is going to be so interesting. So I, we learned about Aimee, Aimee. I'm not sure what your experience [00:03:00] was with learning about selective mutism from, but from the speech pathology perspective, I heard about it in graduate school, but recieved zero training on it. As a matter of fact, I think I may have been told that it was not something that I could address. Aimee was your experience. 

[00:03:15] Aimee Wonkka: I think I was told something similar. I remember learning about it. I remember learning that it was a good time to refer to a different professional. So I'm super excited to have this conversation today and learn more about selective mutism and about the role of the speech language pathologist with respect to selective mutism

[00:03:35] Kate Grandbois: It's going to be so good. Great. I can't wait. Okay. So before we can get into the fun stuff, the powers that be required, that I read our learning objectives aloud as well as our disclosures. Sometimes people ask me to skip this part. I can't ASHA makes me read it. So bear with us while we get through this as quickly as possible.

 Learning objective, number one, describe the evaluative and diagnostic process for selective mutism. Learning objective, number two, identify at least one [00:04:00] strategy or action that caregivers, educators, and communication partners can do to support children with selective mutism learning. Objective number three, list the overall components of an intervention plan and learning. Objective number four, identify appropriate social and academic expectations for students with selective mutism. 

Disclosures Dr.Aimee Kotrba financial disclosures. Aimee is the founder of confident kids camp and the owner of thriving minds. She has authored two books. The first of which is titled selective mutism and assessment and intervention guide for therapists, educators, and parents.

The second of which is called overcoming selective mutism, a field guide for parents. She's also the instructor for an upcoming workshop titled unlocking the mystery of selective mutism offered through thrive, offered through thriving minds. umAimee's nonfinancial Aimee's 

[00:04:49] Aimee Kotrba: Aimee coach buzz, nonfinancial 

[00:04:50] Kate Grandbois: disclosures.

Aimee does not have any non-financial relationships. Kate that's me, my financial disclosures. I'm the owner and founder of grand watt therapy [00:05:00] and consulting LLC. And co-founder of SLP nerd cast my nonfinancial disclosures. I'm a member of ashes, SIG 12, and serve on the AAC advisory group for Massachusetts advocates for children.

I'm also a member of the Berkshire association for behavior analysis and therapy, Mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest group. 

[00:05:21] Aimee Wonkka: Aimee that's me. My initial disclosures are that I am an employee of a public school system of grandpa therapy and consulting and co-founder of SLP nerd cast.

And my non-financial disclosures are that I'm a member of Asher and SIG 12, and I serve on the AEC advisory group for Massachusetts advocates for children. Okay. We did it. We got through the boring bits onto the good stuff. umDr. Quarter, why don't you start us off by giving us just some general information?

Like - what is selective mutism?

 Yeah. It's so interesting. I feel like, again, a lot of people don't really understand maybe because of the [00:06:00] name. I think it's funny because I'll meet people and I'll tell them about, you know, well, I specialize in selective mutism and they're like, oh, that's when kids are choosing not to talk.

Right. It's probably due to some sort of trauma. And I'm like, no, no, not at all. So selective mutism is considered one of the anxiety disorders. It used to be sort of this like other disorders of infancy and childhood, like off on its own little island of lost toys somewhere. But in the most recent DSM, they finally put it where I think it belongs, which is the other anxiety disorders.

So I think it's nice to think of it kind of like, umany sort of specific phobia. umso for instance, if you think of specific phobias, you might think of things like fear of Heights, fear of animals, fear of blood. Selective mutism is really the fear of speaking in public settings. And it can even sort of generalize [00:07:00] to just general communication.

So even things like non-verbals nodding, shaking their head, shrugging, pointing to things, making choices, even written communication can be difficult for some kids. We know it's not due to a primary or at least diagnostically. It's not due to a primary language disorder, but it's a really co-occurant with language disorders.

Hence one of the reasons why I think SLPs are incredibly valuable. In the intervention piece, you know, depending on what study you look at, it seems like more than 50% of kids with selective mutism have some sort of co-occurring language delay just broadly. It's relatively rare. You know, it's only about 1% of kids in, in school settings, but I think either we're getting better at diagnosing it.

I hope that that's what's going on or [00:08:00] rates are increasing because we're sort of seeing this creeping up of the prevalence of selective mutism. 

you know, I think rates of anxiety are increasing across the board nationwide. 

so I don't know if this is just sort of like one of those things it's, it's increasing along with everything else, but

 we do see a little bit of increase in selective mutism.

So it's certainly something that SLPs are gonna come across and they're in, you know, in their day to day of working in schools, working in private organizations or private clinics and in hospitals as well. Well, 

[00:08:30] Kate Grandbois: you, you answered my next question, which was obviously going to be why, what is the role of the SLP in, in, in terms of intervention and diagnostics evaluation?

And it sounds like there is a role, there is room for us at the table here, which is totally contraindicated, but Aimee and I were told in graduate school, which by the way was a long time ago. So

[00:08:56] Aimee Kotrba: yeah, no, I think so. I think SLPs are incredibly [00:09:00] valuable as a part of the team, partly because of the co-occurrence of the language delay. Like I don't know how to assist in language development. And so I need somebody on my team who can help with that piece. But to be honest, even in the kids who don't present with a language delay, I think SLPs play this great role because they know they sort of know the trajectory of speech.

They know how to help elicit speech in like slow steps. 

maybe you could think of it similar to like stuttering, perhaps like there's this development of increasing speech when you're treating stuttering. 

the similar to what we're asking kids to do in selective mutism, which is sort of like practice small steps towards increased speech.

And you guys are the experts on speech. So it's super helpful to have an SLP as part of the team. 

[00:09:55] Kate Grandbois: And before we get too down a rabbit hole, because now I have a thousand more [00:10:00] questions I want to ask. I'm thinking about the reality of the environments that we work in. So I know that you mentioned that it's relatively rare, less than one, 1% or less than 1% of the population in a school setting and the role of the SLP in terms of identifying or triaging for a student who may get referred to them for a blanket communication disorder, or, you know, any other, any other reason, and the potential lack of resources available within that school team to effectively support the student.

At least in the school environment. I know you're in private practice and there are probably going to be external resources, but I've got to assume that that's, that's a real 

[00:10:42] Aimee Kotrba: problem. Yeah, and I think it's tough. And, you know, 

I would say that this SLP is not usually the first person in the school setting who recognizes that there's an issue to be very honest, even though a lot of these kids will demonstrate symptoms [00:11:00] kind of from birth.

Like when we look at the trajectory of these kids development, oftentimes parents are saying things like they were difficult to sooth when they were babies. 

they were scared, you know, there was more like stranger danger and separation anxiety than we would typically see in development. They didn't speak in public settings, but, but none of these things.

Really concerning, right? You don't expect a three-year-old to be ordering in a restaurant. And none of these things are really concerning until the kids start in school. And then the teachers are having a really hard time evaluating them. So oftentimes teachers are sort of like the first eyes, seeing these kids, recognizing that something is going on.

Sometimes there's a concern that these kids are autistic. Cause they're not speaking. 

sometimes there's a concern that they're oppositional, like they're just choosing not to speak. 

but then at that point, sometimes the kid gets know referred to special education, at least for an evaluation. And that's oftentimes when the SLP becomes part of the picture, [00:12:00] but you're right.

I mean, it's tough with SLPs are pulled in multiple directions and this might not be the kind of case that falls in the lap of an SLP naturalistically. It might be the kind of case that an SLP might even have to sort of, 

be assertive to try to get on the case, knowing that they would be a valuable member.

[00:12:22] Aimee Wonkka: Can you talk to us a little bit? Just, I feel like this is a nice segue into our first learning objective. What does that assessment look like? Who does it, what types of like, is there a standardized assessment for selective mutism? What, what is, what does that process look like? Yeah, 

[00:12:41] Aimee Kotrba: so I would say unfortunately, unlike some other things where there's a very standard procedure of do this, give this questionnaire, do the standardized test and you will know magically, you will have your answer.

You know, evaluating for selective mutism is a little bit more nuanced. 

having said that it's [00:13:00] not terribly hard to diagnose because when it all boils down to it, if a kid talks at home and they don't really talk in school, I mean, you at least have your antennas up right. For something going on. But what I typically see.

In terms of like in the school, in the clinic setting, how are we evaluating for this one is we're trying to find out more about how the child uses communication. Right? So do they speak, who do they speak to? In the school setting, you know, there's a lot of quirky, interesting things about kids with SM where sometimes they'll speak to adults, but not kids or vice versa.

Sometimes they'll talk to women, but not men. Sometimes they'll not speak at all, but they're very sort of like non-verbally communicative sometimes they're totally frozen, but finding out more about their methods of communication in the school is, is really. Helpful, not [00:14:00] only from a diagnostic perspective, but when we start talking about intervention, it's going to sort of tell us, like, where are we starting with this kid?

What are we working on? You know, are we starting with a whisper? Are we starting with the kid who doesn't talk at all at school? Are we starting with a kid who will answer a question if you're like point blank asking them in a private area, but they're never going to be the kind of kid who would initiate to you or, or willingly willingly talk to you.

Right. So I would say the first step is just asking the teacher, asking the parents, try doing an observation in the classroom, trying to find out more about. This kid's communication behavior. And then above and beyond that, you know, there are some questionnaires that are valuable and helpful. There's a new one out actually this last year, it's called the Frankfurt scale of selective mutism.

it's available for free online. So if you just search Frankfort scale of selective mutism it's age [00:15:00] normed, and has a lot of questions about the child's speaking behavior in public scenarios. So like, Did they talk to the pediatrician? Do they order at a restaurant

 at home, you know, do they talk to extended family?

Do they talk to babysitters? Do they talk to parents in public settings? And then at school, do they talk to peers? Do they talk to teachers? Do they speak in front of groups? And I think combining those things sort of information observation about the child's communication behavior plus the questionnaire piece.

and then I, I really find it valuable. If you can get a video of the child at home speaking comfortably, I think it's a really eyeopening, right? Like this is the, the difference between the kid at home and the kid at school. I think if you can get those three pieces and what you see as a kid who either doesn't speak or doesn't speak very much in the school setting and does at home, you can sort of feel comfortable that that's [00:16:00] probably selective mutism.

[00:16:03] Aimee Wonkka: Well, you answered a question that I had, which was, is there sort of a continuum of maybe severity is not the right word, but different kind of profiles that you'll see with students. 

and I guess one thing that I'm wondering is it's, it sounds like from what you're saying, it's really more about looking for those patterns of communication behavior and kind of those patterns tied specifically to the communication environments and tasks.

Is that, is that fair to say? 

[00:16:31] Aimee Kotrba: Yeah. Yeah. I think the environment would be including like the people who the child might be communicating with. And then I usually say demands, but tests. So speech demands, speech tasks. Yeah. How do they communicate? Given different kinds of demands and kids was selective.

Mutism are so fascinating because maybe this isn't fair, but I say they're kind of like rigid and rule-bound because you might have a kid with selective mutism who [00:17:00] in school does not speak at all. Almost looks kind of frozen, like a statue. They don't speak to peers, they don't speak to adults. And then they walk off the school grounds.

And I mean, literally like they cross the boundary. Truly crossed the boundary. They step outside of the school and they're just like, blah, blah, blah, blah, blah. Just talkative talking to mom, talking loud all the way home in the car. And I think that

 I think that people can get frustrated by that because they're saying like, well, the kid is totally capable of talking.

I saw them talking as they walked outside with them. They're totally capable of it. Or sometimes kids will talk to peers, but not adults. Right. And so teachers will say, they're talking to their friends and then they stop talking when I come over. And I think it's because they're oppositional when the truth is, is that there's just interesting, kind of rigid.

Rule-bound quirks about kids with selective mutism. 

and it's not, it's not in that [00:18:00] positionality. It's it's anxiety about certain, like you said, environments, people in demands. 

[00:18:06] Kate Grandbois: I, I mean, this is so interesting. And I'm thinking about the role of the SLP. Let's say there's a situation where there is a profile of a student who's been identified as having selective mutism and has also been identified as possibly having a co-occurring communication disorder or language disorder.

how do you evaluate that student? If they, you know, - how do they do that? How does the speech pathologist do that?

[00:18:40] Aimee Kotrba: It's so hard. It's so hard. So, okay. What I will say is that there are kids with selective mutism that if you were to pull them into your office, give them some adequate time to warm up and get used to you and then ask them specific questions.

There are a lot of kids with selective mutism who would answer. Yes.[00:19:00] having said that there are a lot of kids that would, right. And then you're trying to do this sort of standardized evaluation for communication delay, with a kid who doesn't talk to you. 

and so what I say, and I know that this isn't like, I know that this isn't as standardized as people would like it to be, but I think that you can get a feel for the communication delay via watching videos of the child, speaking at home in a comfortable setting. So asking parents to bring in as many videos as possible. Sometimes I will ask parents to do some of the communication evaluation, like tests, with the kid at home. Now, they're not going to be scoring them. And obviously they're not incredibly reliable or valid evaluators, but you can get a little bit of a feel of the way that the kid would answer if they were completely comfortable. And you can sort of hear some of the disfluencies or communication delays. but it's not an exact science because yeah, you've got this like [00:20:00] anxiety all tied up in it as well. 

[00:20:02] Kate Grandbois: And I also have to, I mean, as a, as a dually certified behavior analyst, I also feel like being mislabeled as oppositional or having a behavioral.

I mean, that's, that's, that's rough. And I have to assume that there is a significant amount of counseling and educating that needs to happen across the school team or across the school environment to address the social, emotional and anxiety related piece and not slap a label. And just because that that's got to compound the problem.

That's absolutely. that's something definitely to be aware of. Do you have, how do you recommend that people go about embracing that counseling and educational component? 

[00:20:44] Aimee Kotrba: Well, I think I come from it from the perspective of just describing to them the way that the sort of cycle of selective mutism works.

So because no one can see me right now and try to talk you through this. But basically what happens is these kids, [00:21:00] these kids already, we know have some genetic components of anxiety, usually anxiety runs in the family, right? And then they have some neurological differences. When we do research on kids with selective mutism, we find that there are McDilla is highly over-reactive and takes a very long time to habituate.

And so that part of their brain that's like the, the guard dog, I guess you could say that tells them that they're in danger, tells them that they're in danger too much, too quickly. And for too long, And so these kids are coming into a school setting, a public setting with this sort of like overactive Aimeegdala, a genetic predisposition towards anxiety.

And they're put into situations where they're asked to speak or engage or communicate. And I mean, that happens like a hundred times a day for, for a typical kid, right? Like another kid talks to them or the teacher asks a question or just happens [00:22:00] repeatedly in school. And when they are in this situation, they get anxious and they do it.

We all do when we get anxious, which is a void, right? Like if you can think of something that you felt really nervous about, I guarantee that your first response was, how do I get myself out of this? Do I not do that thing 1000%?

they avoid. But interestingly, we, as adults tend to step in and help them avoid, right. Because we don't, I mean, they're like cute little kids. They tend to be really sweet. And so we sort of step in and help the avoidance to occur. And then the kid learns, I was right. That was too hard. I can't do that thing.

And the adult learns, well, we shouldn't ask him questions and we shouldn't put them on the spot. And, you know, and the cycle continues where the child is more likely to avoid. The adult is more likely to [00:23:00] rescue them. And so what happens in a school setting then is that people see this avoidance from the child.

And they swing one of two ways. They swing either to, oh my gosh, that poor little like shattered glass. We can't ever ask him a question. We don't want to do anything. That's hard or swing the other way of like this. Kid's just oppositional. And you know, I just won't give them their lunch until they tell me what they want for lunch.

[00:23:29] Kate Grandbois: Well, that person needs. So if you're listening and you know, someone who's doing this, please correct them immediately. That's just terrible. Yeah, 

[00:23:36] Aimee Kotrba: exactly. So I think the beginning is just trying to educate people on that. Why this avoidance is occurring. And I think that that makes it understandable, right?

Like I totally want to avoid things that I'm afraid of. I can't always, but I totally would love to. And the avoidance is out of fear. It's not out of manipulation or oppositionality, it's a hundred percent out of [00:24:00] anxiety about the situation. Well, 

[00:24:03] Kate Grandbois: and as you're, as you're telling this story and describing it this way, I mean, how much compassion do we have for a tiny little person, a small human being who doesn't have self regulation skills who doesn't necessarily have the ability to think about their own thoughts or, you know, embrace a lot of the strategies that we adults use to manage our anxiety and, you know, self-talk and all those kinds of things.

How much compassion do you need to have to create safe spaces? For a little person to feel more comfortable and to learn. I mean, we're talking a lot about this as, as the school setting. 

but also through any therapeutic setting where you're learning new skills or your, you know, improving upon a certain level of skill, you have to have a safe space to do that or not if it's going to happen.

And so I. That's that's just a lot. 

[00:24:57] Aimee Kotrba: Yeah, it is. And, and, you know, when I, [00:25:00] when I talk about sort of like the first steps of intervention and what parents and schools can do to help the very first step, like you said, is just being empathetic, that these kids are struggling. And oftentimes these kids are going home and telling their parents, I love my teacher.

I love my therapist. I want to talk to them. I'm to talk to them tomorrow. And then they just literally can't get the words out the next day. So, um, yeah, having empathy and then just developing relationships with these kids is, is really powerful in sort of like the first steps toward helping kids feel more confident to speak.

[00:25:37] Aimee Wonkka: I do want to zoom back for just a second

 because I feel like. There are also times where speech pathologists might be the person saying, I think that this is what's going on. 

and I just wanted you to talk a little bit about, because it's so connected with this anxiety piece. 

should we also be referring to a psychologist to make sure that that's what's [00:26:00] going on and also to have somebody on the team who can speak to all of these communication partners about that anxiety piece?

Probably a little bit better than a speech pathologist might be able to 

[00:26:10] Aimee Kotrba: just based on our training. Yeah. Yeah. And I think, I think that that's a great point. And when I think of having a team

 selective mutism, maybe more than a lot of others

 mental health disorders that I work with really requires a team.

Like I C I, as a mental health professional can not do this myself. The teacher cannot do this themselves. The parents can do this themselves. So to me, the best case scenario for a team would be a mental health professional who can sort of speak to the anxiety piece, a speech pathologist who can assist with the communication piece.

Not again, just the communication disorder that might be there, but just generally, how do we help shape communication for this kid? And the teacher would be fantastic and the school, and then the parent, I feel like [00:27:00] if we have those people on our team, that's like best case scenario for this kid, because they're really getting sort of a, a well-rounded approach and intervention for selective mutism.

[00:27:12] Kate Grandbois: Okay. So let's, let's fast forward a little bit and imagine a perfect scenario where this has been identified. You've got the teams import, you've got a compassion and a learning environment. That's rich with empathy and a team that's well-educated and counseled on, on what is going to go into this? What do you do?

What does the, what does the intervention look like? 

[00:27:38] Aimee Kotrba: Yeah, so the intervention, and this is where I was saying before we started videotaping, but I love selective mutism and I love selective mutism treatment and intervention. And I could go down a rabbit hole for six hours with you talking about like tips and strategies intervention.

So this is where I have a hard time keeping I'm going to try so [00:28:00] broad strokes

 this like other kinds of anxiety disorders

 research shows is the benefit and the sort of like the gold standard evidence-based intervention is behavioral intervention. So again, broad strokes, if you haven't

 a fear of, or a phobia of any what needs to happen, you have to sort of face that fear in little steps.

Right. Or you could think of it from more of a learning perspective. You can think of it. Like if you're learning any, anything, any sort of skill you're learning how to read, you're learning how to do math. You're learning how to play soccer. You start with the small steps, but eventually over time, you build up to the more complex steps.

Right? And so that's exactly how it works with kids with selective mutism. We start them trying to do things that are more kind of where they're at currently in a communication sense. And we're asking them to do increasingly challenging [00:29:00] facing their fears, increasingly challenging communication over time.

So I'll give you a for instance of one thing that parents will tell me all the time that I'm like, and you as a speech pathologist will probably understand what I'm saying here. Parents will say things like, well, I have a kid who doesn't talk at school. And so I said to them

 I'll buy you a pony. You will just go in and say hi to your teacher tomorrow morning in the classroom.

And they didn't do it. I can't understand why offer them a pony and a trip to Disney. And I can't understand. And I try to explain to parents. Coming in at the beginning of the day with no warm up time with a huge group of people milling around and then initiating, right, like initiating is harder than responding and initiating something to the teacher.

It's going to be really challenging. So we as professionals have to start setting these appropriate steps of communication where maybe at first the [00:30:00] response is just consistent, non-verbal responding. And then we're starting to look for maybe a one-word answer, but we're doing that with forced choice questions because forced choice questions are going to be easier than open-ended questions.

Right. If I said

 what did you bring for lunch today? A sandwich or salad. That's a lot easier for a kid to answer. Then what did you do over, you know, vacation this summer? That's such a huge question. Any kid for any kid to answer? So we sort of started. And build up. 

[00:30:34] Kate Grandbois: I have a comment and a question. So my comment was you used a word before, which I think is a really great word for all speech pathologists to know which is shaping.

So the concept of providing reinforcement for successive approximations of a behavior that you want to see. So the exam, I love the example you gave about, why didn't you just say hi and I take you to Disney world, right? So that's not a, that's not a [00:31:00] successive approximation. That's not a baby step.

You're jumping all, you're jumping off within the water. We got to dip the toe in first. Right? So I, if you

 if you're listening and you want to learn more about shaping, it's a great

 we do it in speech therapy all the time without knowing the scientific word for it, I think. But it's a, it's a really wonderful way to sort of look at your treatment targets.

That was my comment. My question. Is, and I'm not sure this is going to take us down a rabbit hole, or maybe it's a really terrible question. And you can tell me that it was terrible question, Aimee and I both work as

 AAC specialists. And so as you're talking, I can't help, but think about the use of visual supports as you're creating these successive approximations or these small baby steps came to my mind when you said closed ended question

 or increasing nonverbal communication as a, as a small step.

So do you see the use of choice boards or

 other other support, other visual supports [00:32:00] to facilitate more communication in, in this type of intervention? 

[00:32:05] Aimee Kotrba: Yeah, it's a great question and really hard to answer because it sort of depends on where the kid is at. So again, if I think of this in sort of a stepwise process where generally we're always trying to sort of encourage a kid to do something that's a little out of their comfort zone, a little out of their comfort zone, a little out of their comfort zone, then using something like a seize or choice boards might be great for a kid who doesn't communicate at all in the school.

But if you have a kid who is communicating a little bit in the school, giving too many non-verbal options might actually. Stagnate that, that stepwise process. Right. So I love it as a step in getting more communication, but it has to be thought of as a step that will eventually be the expectation will be raised to actual verbal communication, because we I've, I've worked with some teenagers who were given

 like [00:33:00] iPads or computers eventually to communicate.

And they were able to type everything that they wanted. Right. They were able to do well in school. They were able to type to peers. Now that's great in terms of communication, but is it really like where we want to go? Is that really vocationally appropriate, you know, socially appropriate in the real world?

No. And so it's hard sometimes to sort of pull those things away eventually and, and expect increasing verbal communication, but it can be definitely be used as a step

[00:33:34] Kate Grandbois: interesting. I 

[00:33:35] Aimee Wonkka: mean, I dunno, it makes me think I had any, I don't know anybody who's listened to right now. I'm like super duper afraid of airplanes. And if I could take a 

[00:33:43] Kate Grandbois: train duper 

[00:33:44] Aimee Wonkka: afraid of airplanes, right?

Like if I could take a train everywhere, I would never fly in an airplane. I just want to do it. 

[00:33:51] Kate Grandbois: I'm also afraid of airplanes and take drugs to fly. So I'm not ashamed of it. I'm not throwing a stone, stone etching, Aimee, 

[00:33:56] Aimee Kotrba: but 

[00:33:56] Aimee Wonkka: no, I think, I think it's just like, I think that that's, that's an [00:34:00] interesting analog that I was thinking about in my mind.

Like, like sometimes, and we talk in AAC and this may or may not be true

 for selective mutism. Like sometimes there's an accommodation that needs to be in place and that's the way that you can access your world. And that's that. It's like the glasses, you know, I wear glasses or contacts or I can't see, like, that's my opinion.

No amount of ponies is going to change that. 

so yeah, I think, I think, again, that's another place where having a team is super important because as the speech pathologist, I don't want to be the person responsible for making that choice because I might think in my mind, this is a great idea and it's a great way that I can help this student to access their school day without having the perspective of the psychologist or the mental health professional, who is able to say, oh yeah, but have you thought about XYZ?

So I think just one more plug for collaborative team 

[00:34:52] Aimee Kotrba: work. Yeah, absolutely. Yeah. And I think, you know, I think a different perspective that maybe I have as the [00:35:00] mental health professional that people perhaps in the school, or maybe SLPs don't have is one of my supervisors once told me that if in a session you have not made a child uncomfortable, you have wasted their time in yours.

And that's a really hard right for me to think about because I am compassionate. I love kids love working with kids. I'm super compassionate and empathetic to what they're dealing with, but it's like an educator, right? If I'm like consistently and just expecting what they can do right now, I'm not helping them to grow.

And so as a team, how do we continue to help this kid to grow? But at a pace that the kid can participate in, feel confident in make gains. And there's always that like balance and that helps with the team. The team piece helps with it. 

[00:35:48] Kate Grandbois: I, I w as you were talking, I was just going to say, for me, that goes back to creating a safe space for growth, because, you know, there is that slippery slope where you want to push them to the edge of their comfort zone, [00:36:00] but you don't want to become punishing.

You don't want to go into that rule of, well, you're done. I don't want to talk to you anymore because you're a meanie pants and you make me feel uncomfortable. 

so there really is that sweet spot and that all comes down to rapport and safety and, and empathy, and just creating that environment where someone can be vulnerable, can feel fear and, and move through it.

And that is, that is so important. That's like the 

[00:36:27] Aimee Wonkka: number one. So, so this is big, right? Because we don't want to, we D we don't want to stop pushing art students or clients. We don't want them to reach that plateau where we've said like, okay, here, here you go. But like, how, how do we help? How do schools or parents speech pathologists, how do we make sure that we're helping, you know, kind of with that zone of proximal development, if you will, or like comfort zone, you know, and making sure we are [00:37:00] finding that sweet spot.

And are there other things, you know, that you would advise that people do kind of as strategies, like, should we be helping with some like relaxation strategies or other things, I guess just tell us more, please, please tell us more 

[00:37:14] Kate Grandbois: things. It just keep talking. This is so. 

[00:37:17] Aimee Kotrba: Okay. More things. Here's some more things.

Uh, so yeah, in general, I think the first step is sort of trying to decide, okay, where is the child currently? What are some strategies we can use to try to help them take the next steps? Now here's where I could go down the rabbit hole. And I'm gonna try not to, but encourage you to maybe read my book, do some more research on selective mutism.

there is shaping, right? So we're asking the kid to increasingly

 communicate with us through successive approximations. There's something called fading. 

it's called stimulus. Fading is the behavioral

 name for it. But the idea that a new person fades slowly into the existing speech that a kid already has.[00:38:00] 

So it's different from normal interactions. And here's how

 so typically in a normal interaction kid, mom, or at the store, a stranger comes up and says, oh honey, you look at you. You're so cute. I love your shirt. How old are you? And it's very quick. Right? And then the kid has sort of taken off guard and they avoid, they hide behind parents, parents talk for them and so forth.

What's different about stimulus feeding is it allows a child through slow little steps to get comfortable with somebody, overhearing them, talk, and then interacting with them verbally. And so the way that you do this and it's, I will tell you right now, it might sound kind of silly, or it might sound like that's not going to work.

So, well, it works so, but you have mom and kid in a room by themselves. So maybe in the school, maybe they're on the playground. COVID I know is making it hard for moms to come into school. Mom and kid are on the playground. Mom and kid are in the office and they're talking, they're playing a [00:39:00] game that might elicit some speech.

So guess who UNO headbands. 

there's all kinds of fun games here. Again, SLPs, you guys know the games, the OLIS that speech right. Kid and mom are talking that mom's eliciting speech and the new person just slowly enters into that interaction. So at first they just come into the room and they're like in the back doing something busy on their computer, you know, writing some notes, cleaning up.

I had become very good at pretending like I'm busy when I'm really not busy or busying ourselves in the back. And then eventually kind of coming a little closer and sort of starting to pay attention to the child. And then starting to reflect what the kid is saying. So if you're following me in terms of like step wise, exposing the kid to

 different levels of

 their speech, it's like, I'm not paying any attention, but now I'm in the room, I'm paying some attention.

Cause [00:40:00] I'm reflecting you. Right. So you know that I'm hearing what you're saying. I heard what you said. I heard what you said. I heard what you said. I'm just reflecting what you're saying. The kid says to mom

 does your person have blue eyes? And I say blue eyes. What a fantastic question. All it is. All it is, is me saying, I heard what you said.

I heard what you said. I heard what you said. Then 

[00:40:20] Aimee Wonkka: eventually 

[00:40:20] Aimee Kotrba: I'm kind of up closer to the kid and parent, and then I'm starting to pepper in some questions myself. And so in a, in a kind of sneaky way

 I'll start to lean over to mom's guests who board and I'll start answering the kids' questions. So kid is really asking them like, does your person and blue eyes, and I'll say blue eyes.

What a fantastic question. They do have blue eyes. Thanks for asking me now the kid wasn't asking me, but it's again, it's sort of the step towards. Your TA I'm hearing you talk, you're talking to me, we're having a [00:41:00] conversation and then I can start asking some small questions, then start asking the guests who questions.

And I've like, kind of taken the board away from mom now at this point. And so I'm slowly fading into this existing speech and transitioning the speech to myself slowly. And mom has now kind of faded out. She stops paying as much attention. She goes to the other side of the room, and eventually now I'm the elicit or speech.

And the kid talks to me and not just mom. So that's like an amazing tool that works with a lot of kids with selective mutism. That 

[00:41:39] Aimee Wonkka: was a really good description. And I got an awesome picture in my mind of what that probably looks like. I guess a question I had was. 

[00:41:49] Aimee Kotrba: Is 

[00:41:50] Aimee Wonkka: it different from kid to kid? Like how long does that take?

Does that all happen in like one session? Does that happen over time? Does it depend? 

[00:41:59] Aimee Kotrba: Oh, [00:42:00] Aimee, I'm such an expert. It happens in 10 minutes every time. No, I'm just kidding. I totally depends. So I have kids who I can feed into their speech pretty quickly. And when I say pretty quickly, I mean, probably within 30 minutes or so, and then I have kids who it would take me.

Six one hour sessions to truly fade into their speech and allow them to maintain speech because they're so anxious. And so when I entered the room, they stopped talking or they stopped talking very much and I can't take the next step. And then eventually their speech increases because they kind of get used to me being in there.

And then I start reflecting and they stopped talking or they stopped talking as much, or they start whispering in mom's ear. And I have to sort of wait that out and continue to reflect, but not take the next step. So it does take time. What I will say is that a lot of kids get used to this idea of stimulus speeding.

They find comfort in it because it's predictable and it's sort of slow and [00:43:00] rapport building just generally in its nature. And so over time, maybe I'm the first one fading in to this interaction, but now I'm going to fade in the teacher. Now I'm going to fade in some peers. Now I'm going to fade in the art teacher.

and every time it gets faster because kids, they just start to get it, they just start to get it. And what once took five hours for me takes one hour with the teacher and 20 minutes with the students and then like five minutes with the art teacher. Quick, quick, quick. 

so it, it depends on the kid and it depends on how many times they've done it, to be honest.

So 

[00:43:41] Kate Grandbois: aside from stimulus fading, what are some of the other, I mean, just thinking about the lack of resources that are really out there, because this is such a rare presentation. 

you know, there are li I'm, I'm making the assumption that there are not a lot of in-house resources for selective mutism. I had schools across the country.[00:44:00] 

so someone who is listening, who is interested in exploring these kinds of things, what other. 

easily achievable or easily attainable skills or

 things can teachers and team members do to sort of help when they've identified a student with selective media. 

[00:44:17] Aimee Kotrba: Yeah, one very easy thing that people can do.

that helps a lot and it doesn't work with every kid, but it helps a lot is just starting to ask close ended questions or forced choice questions, however you want to call it. 

and then giving the child a latency in which to respond. Now, this can be socially awkward sometimes, but when they, when they look at research on how long people give for somebody to respond, once they ask a question, it's about two seconds.

I ask you a question and if you don't respond in two seconds, I feel super awkward and I move on or I ask a different question, stop talking to you because it's really weird. 

[00:45:00] we try to ask a forced choice question and then gives a child are what we usually say is at least five seconds, but maybe longer to respond because a lot of times these kids have communication delays, and they're trying to think of like the correct way to say it.

What does she want to hear? How do I pronounce that? What's the right answer. Uh, and so it takes them a while to get the response out. The other piece though, is that it helps to give that delay because what it says to the kid is like, no, I really mean to follow up with this question. I'm willing to wait for you.

I really mean it. When I ask, I'm not just going to sort of flippantly move on. And so asking a question is close ended or forced choice and then waiting five seconds. And then if the child has an answer asking again, and again, that's like kind of socially awkward, but I'm asking the same question again.

Maybe. Slightly easier. So here's a for [00:46:00] instance

 let's say that

 I'm, I'm talking to the kid about what they had for lunch, right? That was the example I gave earlier. And I said, what did you have for lunch today, a sandwich or a salad. And the kid doesn't answer. I wait that super uncomfortable. At least five seconds.

I probably actually avert my eyes at this point because a lot of really concentrated eye contact can make kids with selective mutism really uncomfortable and maybe even prohibit them from responding. So I might kind of look down. Look someplace else. If the child doesn't answer, I ask again, and maybe I need to change the way that I ask because kids was selective mutism, probably aren't going to correct you if you were wrong.

So maybe I have to say, oh, did you have a sandwich, a salad or something different? Cause like, maybe I'm wrong. Right? They're not going to be like, actually I had a brownie for lunch. So I re-ask the question. And I wait at least five seconds. Just that alone increases the [00:47:00] likelihood that kids with selective mutism will respond to my question.

And then of course, I also have to be sort of cognizant of like, are there a lot of other people around that the kid might feel anxious about responding in front of, right. I might want to pull them aside and have them kind of privately answer me. I would want to be somebody who has a good relationship with the child.

So I want to be kind of aware of those factors as well. That 

[00:47:23] Kate Grandbois: makes so much sense. 

and I am thinking more about some of, I know we're talking a lot about schools and what the expectations are for students in school. And how many do, as you said earlier, demands, there are demands, subtle demands placed on kids all day, sit on your carpet square, raise your hand.

Don't poke Johnny in the arm. You know, it just

 not to mention here's your math worksheet. You have seven minutes to do it. And then the Bell's going to rain and there's pressure everywhere. So how do [00:48:00] these, how can we make accommodations for these kids across the board? Not only socially and in our, you know, structured therapy that we've identified in this fictitious school with tons of resources in our well-trained team, what other accommodations can we make for them across the school?

[00:48:19] Aimee Kotrba: Yeah. And I think accommodations are a really important piece, you know, to me, I feel like whenever I'm working with a kid with selective mutism, it's sort of a two-pronged approach. There's the intervention piece, right? Like let's, as a team, come up with some ideas of things that we can do to help a kid feel encouraged to take the next steps, to be brave, that might include a reward system.

you know, it might include

 behavioral practices. It might include needing a special education plan so that the SLP can pull them out of the classroom or push into the classroom. But the other piece to that you're right, is accommodations because a lot of these kids, there's a high expectation to speak and [00:49:00] be engaged in school and so forth.

So how can we come up with a plan for the things that the kid's not ready for yet? Right. So that might include things like

 sitting next to a communication partner in the classroom I'm sitting next to, or in a group with somebody that they already talked to or feel comfortable with. 

it might include things like scheduled bathroom breaks because kids are not usually going to ask to go to the bathroom.

Right. Johnny to have a potty accident because he couldn't come up and tell you, then you'd go to the bathroom. It might include things like coming in and meeting their teacher prior to the school year starting so that they feel comfortable with that person. And maybe can even get verbal with them before the school year even begins.

it might mean things like

 preferential seating up by the teacher, because what I wouldn't want is, you know, little Johnny starting to try to use this brave voice, but we usually call it

 eventually in the school year, but he's sitting in the back of the classroom. And so like 30 little heads swivel around whenever he says anything.

So sitting up next to the teacher where [00:50:00] maybe she would be able to overhear him speaking more quietly

 and 30 heads are not going to turn and look at him. 

we have to have some sort of accommodation for presentations or show Intel or

 participation points for older kids. Like how do we, how do we accommodate that now?

Accommodation, as you know, doesn't mean like it's just excused. You just never have to do a presentation for the rest of your life, but how do we help the child be successful where they're at and sort of grow. A presentation might be that the child videotapes themselves at home doing the presentation and just the teacher watches.

And then maybe the teacher watches with the child they're watching with them. So the kid kind of gets the idea of like, well, the teacher heard me talk and then the teacher watches with two friends that the child gets to pick. And that, and so we're sort of like increasing the challenge level, but, but still accommodating that we know that like the kid's not gonna be able to do a presentation tomorrow.

That's not realistic. So how do we help [00:51:00] them take those steps? 

[00:51:02] Kate Grandbois: Do you find that kids with selective mutism are at a higher risk for falling behind or getting flagged with special education, academic, special education needs? When in fact that's not the case, it's just been an unsupportive environment or the right accommodations haven't been made.

So in other words, just in that example, the teacher doesn't provide corrective feedback on the presentation or doesn't, you know, assign it. The, it gives an excuse or doesn't provide the learning opportunity because there's just this assumption that they can't do it. 

[00:51:34] Aimee Kotrba: Yeah, definitely. Yeah. We do see kids falling, but we see kids falling behind academically.

part of that is that there's so much like group work

 teaching that happens within classrooms now that if a kid's not participating in the group project, the group work

 then they're not really learning. They're not really learning those skills. 

kids, because they can't ask questions to the teacher, oftentimes we'll fall behind.

So let's say [00:52:00] mathematics, right? If you don't understand something and you don't ask the teacher, you don't clarify. And the teacher can't really evaluate how much you understand math builds on itself. And so eventually you're lost a year or two later. You're completely lost. So we see kids falling behind academically.

We see kids falling behind socially. 

we tucked so much, like, I'm sure you do about early intervention, early intervention, because as kids get older with selective mutism, they begin to sort of identify as the kid that doesn't talk. Everyone else identifies them as the kid that doesn't talk. Right. And everyone's going to make a big deal out of it when they a talk.

and socially they start falling behind because like in kindergarten, if you don't talk to your best friend, okay, that's reasonable. You guys are still playing in swinging together, but like intense. You don't have a best friend that you don't talk to. And so eventually these kids start falling behind socially.

And then just in terms of mental health, if they don't get good treatment, we tend to see increases [00:53:00] in depression. We tend to see increases in just general anxiety. Overall, their world just kind of get smaller and smaller because what they learn over time is if I avoid something, it feels good, at least in the moment, right.

I avoided that. I'm not going to do those hard things. I can't can't do those hard things. And so then not only does it become an issue of not speaking now, it becomes an issue of not being on social media, not texting, not hanging out with friends, not going to doctor's appointments, not driving, not getting a job.

Right. And so it almost compounds itself. And so having that early intervention. Incredibly important. 

hence why I love to do these talks and educate people on selective mutism so that we can work as a team to, to try to deal with this as kids are younger, rather than, you know, when they're teenagers and it's really, really hard.

[00:53:55] Kate Grandbois: I'm wondering if you could tell us a little bit about

 [00:54:00] some more of those expectations, so, or I guess, let me reframe that. I'm wondering if you could tell us a little bit about what documentation you might recommend. So, you know, if a family, or if a speech pathologist is listening and wants to begin advocating for the family or making those referrals.

We've discussed a lot of different accommodations and my understanding, and you can tell me if I'm wrong is that we still have academic expectations that are appropriate, and we still have social expectations that are appropriate. And we're using all of these strategies like stimulus, fading, and

 shaping, but what can

 how can we advocate for these families to make sure they have the documentation to make sure that those accommodations are being implemented properly?

Because these are, this is a very unique situation where we have the, you know, reasonable, social and academic expectations with a whole lot of accommodations, which is sort of a unique situation. [00:55:00] 

[00:55:01] Aimee Kotrba: Yeah. And, and I find that a lot of the kids that I work with end up needing some kind of special education plan.

and it's incredibly helpful if the SLP is again, part of that team. 

and so kids will usually

 have no problem really getting a 5 0 4 plan because it's a diagnosis that can be made by a medical doctor and sort of necessitates accommodate accommodations within the classroom setting. 

a lot of the kids that I work with need IEP in order to access the SLP or the social worker school psychologist, or whomever is the mental health professional in the school.

And the most typical designation that I see with IEP is for kids with selective mutism is either emotional disturbance or emotional impairment, which my spin is. I'm not as crazy about that one. 

Maybe that opens the door

[00:55:52] Aimee Kotrba: speech and language impairment. If there is evidence of a communication disorder, some, some SLPs that I've 

[00:55:58] Aimee Wonkka: talked 

[00:55:58] Aimee Kotrba: to have actually been like, [00:56:00] well, I, I was able to

 make the argument for speech and language impairment because of social pragmatics, because the kids weren't using.

Speech in a socially pragmatic way, right? They weren't asking questions. They weren't starting conversations. They weren't interacting with their peers conversationally. And so I was able to sort of make that argument that that was a delay that they were experiencing and then otherwise health impaired or OHI

 because it is considered a chronic health condition.

Anxiety is a chronic health condition that impacts the child's alertness. So kind of like the flip flop of ADHD, kids who have anxiety are hyper alert to what they're fearful of and therefore are less alert to the other things going on in the classroom. Like if you can imagine Aimee, you said that you're terrified of, of, you know, airplanes.

I mean, imagine being on an airplane and then trying to learn, no, it's not 

[00:56:55] Aimee Wonkka: happening, right. It's definitely not happening. I'm just counting down until we get 

[00:56:59] Aimee Kotrba: to land. [00:57:00] So, but that's what these kids are experiencing. And so you being, you would be hyper alert to the, all of the fear stimuli on the plane, all the sounds that people 

[00:57:10] Aimee Wonkka: that captain.

Oh 

[00:57:11] Aimee Kotrba: yeah, yeah. Does that mean that we're crashing? Does that mean, oh yeah, 

[00:57:18] Kate Grandbois: I heard, I heard a bump. We're going down. We're going down.

[00:57:23] Aimee Wonkka: I can't imagine how exhausting, like having experienced, you know, a very close approximation of what you just described every time I fly. 

it's exhausting, that's exhausting. That's like an exhausting experience to be that hyper alert. And to imagine how hard that must be for a child, if that's their entire school day or, or even if that stretches beyond that, that's like when you go to the grocery store, it's just, you know, it's, it's gotta be just very draining, a very draining experience.

[00:57:59] Aimee Kotrba: A lot of [00:58:00] parents will say, you know, my child comes home and they fall apart and they're a hot mess the rest of the night, or they're exhausted. And I don't know why. And it is because of that chronic, we know the impact of chronic over arousal on the brain and on the body. And that's what these kids are experiencing.

So to some degree, I got a lot of respect for these kids because they're, they are usually managing, they're keeping it together. They're learning, they are learning in school. I mean, they're doing better than I might do to address 

[00:58:31] Aimee Wonkka: that piece though. Are there, I guess, back to those strategies, are there any.

Universal strategies that might be helpful to kind of deal with that piece. And is that something that would usually be addressed, I guess, by the mental health professional in the school setting or, or if a child is receiving, you know, outpatient services, like kind of to communicate that piece too, just maybe building, I don't know if it's a thing where you build in breaks or you build [00:59:00] in opportunities for just a moment of relaxation.

I don't know if that's even possible for some of these 

[00:59:05] Aimee Kotrba: kiddos. I 

[00:59:08] Aimee Wonkka: mean, certainly teaching 

[00:59:09] Aimee Kotrba: relaxation strategies can be really useful for these kids and giving them breaks during the day can be really useful for these kids. But to be honest with you, a lot of it is the, the school setting or the, or the parents and the family and the private therapist, starting to understand appropriate expectations for this kid.

That lots of times what happens prior to understanding that this is selective mutism, is that our expectations are so high. And we're peppering this kid with questions that they can't answer yet, and we're not allowing them to be successful. And so a lot in a lot of ways, it's like, okay, now we know that this is the level at which the kid feels comfortable communicating.

So we're going to do it here and we're going to do it one step above. And that's it. We're not going to ask them to present [01:00:00] anymore in that, in the way that we're asking the rest of the class, because we know it's too hard, right. And that's what causes this increase in anxiety. So for a lot of kids, as we all become more educated in what to expect and how to prompt a child, we're allowing the kid to be more successful.

And we're not over asking there. There's not like the lunch monitor. Who's like, well, if you don't order, then I'm not going to give you your lunch today, which actually has happened to separate with my kiddos. 

we're not over asking anymore and that just brings their anxiety level down too. So I think it's a mix of both.

[01:00:31] Aimee Wonkka: And I'd imagine that you'd see, once everybody scales their expectations to a level that's appropriate and doable for the child, that's also a nice chance. Although it's a stretch for the child to feel confident about, oh, I did this thing and it was hard and I did. 

[01:00:46] Aimee Kotrba: Absolutely. The kids build. I think kids build momentum and they feel so good about being successful because most of these kids want very much to speak.

They want very much to speak, but what they found [01:01:00] is repeated failure. And so being able to be successful and having people be impressed by them and happy for them, maybe earning some rewards is in itself really internally motivating and makes them feel good and confident. Yeah, 

[01:01:16] Kate Grandbois: this is so, so interesting.

I, I feel like I could talk to you for a whole other hour, but since our time is pretty much coming to a close, I wonder if you have any parting pieces of advice for anyone listening, who either is interested in exploring selective mutism a little bit more, or is faced with a student who has selective mutism for the first time.

[01:01:39] Aimee Kotrba: Yeah, I guess my parting wisdom would be, get involved and get educated and do something. I think a lot of people see kids with selective mutism and they, they either don't know how to help or they maybe feel like it's not the role of an SLP is not part of the team for kid with selective mutism. 

but the truth is, is that the interventions that we [01:02:00] use are very effective

 and you can change a kid's life.

I mean, there's, there's nothing better in my personal opinion than seeing a kid who never talked through kindergarten, first grade, but finally got a plan into place and a team on board. And then they talk and they have friends and they are, you've like opened up their lives in this way that you don't get the opportunity too much anymore.

And the parents cry and it's so sweet. So get involved, get educated

 It's so I, I love working with this population, 

[01:02:34] Kate Grandbois: such a pleasure having you. This has been so tremendously informative. 

Some of the resources that we listed today, we will put hyperlinks and they will be available for you in the show notes. 

you can also find additional resources on the episode page, Dr. . Kotrba you so much for joining us. This was so great. 

[01:02:54] Aimee Kotrba: Oh, good. It's my pleasure. Thank you for having me.