Selective Mutism: Practice And Intervention Strategies For .
Selective Mutism: Practice and InterventionStrategies for ChildrenShu-Lan Hung, Michael S. Spencer, and Rani DronamrajuThe onset of selective mutism (SM) is usually between the ages of three and five years,when the children first go to preschool. However, these children are most conimonlyreferred for treatment between the ages of six and 11, when they are entering the elementary school system. Early detection and eady intervention is suggested for effective SMtreatment and to prevent long-lasting complications, such as socialization and leamingproblems. This article presents a brief literature review of SM; intervention approachesthat have been used; and one SM case study that includes intervention strategies, experiences, and lessons leamed firom working with a child with SM. The authors' goal was toprovide school social workers and teachen with a better understanding of the features ofchildren with SM to enable early detection and early intervention in preschool and earlygrades in elementary school.KEY WORDS; early childhood mental health; early intervention; Head Start; school social worker; selective mutismSelective mutism (SM) is a condition inwhich children who normally speak wellstop speaking in specific social situations,usually when they start attending school, especially preschool (American Psychiatric Association[APA], 2000). Many young children with SMremain undiagnosed for several yean, until theyenter the elementary school system. Becausespeech is an important part of communication,being unable to speak may negatively affect achild's social and emodonal development. It limitsopportunities for social interacrions, delays appropriate language skills, and restricts schoolactivities and social involvement with other students (Giddan, Ross, Sechler, & Becker, 1997;Krysanski, 2003). Intervention as early as in preschool or the early elementary grades may beimportant to helping these chüdren overcometheir problems, and it could also prevent secondary problems with socialization and leamingin the later school years (Stone, Kratochwül,Sladezcek, & Sedin, 2002; Wright, Miller,Cook, & Littmann, 1985). The purpose of thisarticle is to help school social workers andteachers gain a better understanding of the features of this disorder and to provide informationnecessary for early detection and intervenrion.We present a brief review of the literature onSM, identify various approaches to intervention.doi: 10.1093/cs/cdsOOee 2012 National Association of Sociai Wori ersfoUow with a case study using behavioral intervenrion, and present a summary of importantsteps to take and a list of resources.DEFINITION AND ETIOLOGY OF SMSM is defined in the Diagnostic artd Statistical Manualof Mental Disorders (4th ed., text rev.) (DSMIV-TR) (APA, 2000) as a disorder in which a childdoes not speak in specific social situations in whichspeech is expected (for example, school, with playmates) but speaks normally in other situations. Thesymptoms must last for at least one month, excluding the first month of school because many children may be shy and afraid to speak in theclassroom during that period. The German physician Adolph Kussmaul first reported this disorderin the late 19th century, and, in 1934, it wasnamed "elecrive mutism" by Moritz Tramer, aSwiss child psychiatrist (Dow, Sonies, Scheib,Moss, & Leonard, 1995). The disorder was first included in the third edition of the DSM (APA,1980), and in the fourth edition (APA, 1994), theterm "elecrive mutism" was modified to "SM" toindicate that these children do not speak only in"select" situations.Features associated with SM have been described in a variety of ways, including excessiveshyness, fear of social embarrassment, social isolation, withdrawal, clinging behavior, compulsive222
traits, negativism, temper tantrums, controlling,and oppositional behavior (Hungerford, Edwards,& Iantosca, 2003; Krysanski, 2003). The etiologyof SM is varied. Researchers have suggested thatearly developmental risk factors—such as maladaptive family dynamics; unresolved internalconflicts; genetics; and histories of immigration,hospitalization, or trauma—may be causes of thecondition (Cohan, Chavira, & Stein, 2006; Ford,Sladeczek, Carlson, & KratochwiU, 1998; Gordon,2001; Kristensen, 2001; Remschmidt, Poller,Herpertz-Dahlmann, Hennighausen, & Gutenbrunner, 2001; Viana, Beidel, & Rabian, 2009).The presenting symptoms of SM, especially considering the lack of interaction with people, aresimilar to those of autistic disorders and someother developmental disorden and delays. Therefore, diagnostic investigations for SM should focuson anxious psychopathology and cognitivefunction as well as other comorbidities to preventmisdiagnosis (Kristensen, 2000; Krysanski, 2003;Viana et al., 2009).The onset of SM is usually between the ages ofthree and five years, occurring on entry into aschool setting (Cunningham, McHolm, Boyle, &Patel, 2004; Kristensen, 2000). The duration ofSM may be from a few months to several years,and researchen have found that the longer itsduration, the more resistant it can be to intervention (Bergman, Piacentini, & McCracken, 2002;Kehle, Madaus, Baratta, & Bray, 1998).The prevalence of SM in a school-based samplefrom a large U.S. district has been estimated as 0.71percent (Bergman et al., 2002). Research conductedin Israel found that the SM rate among immigrantsis as high as 2.2 percent (Elizur & Perednik, 2003).It has been assumed that the frequency of SM isunderestimated because the problem may not berecognized as children with SM do not usuallydisturb others or attract people's attention (Bergmanet al., 2002; Elizur & Perednik, 2003; Kumpulainen,Rasanen, Raaska, & Somppi, 1998). Because SMmay be unfamiliar to many people who areworking with children (Kumpulainen et al., 1998),its characteristic behaviors may be thought to be theresult of shyness and may not be seen as particularlyproblematic. A common misconception about SMis that a child with the condition wül outgrow it.This keeps SM underreported.In addition, because most children with SM aretypically not speaking in school but frequendyspeaking at home, some parents may be hostileand blame the school for their chud's disorder(Kumpulainen et al., 1998). School personnel aresometimes hesitant to provide assistance for achild with SM behaviors because of the parentalrefusals of help. These conditions make intervention for children with SM complex and difficultto carry out.APPROACHES TO INTERVENTIONIntervention approaches that have been used withSM include behavioral, psychodynamic interventions, medication, and multimodal treatments.Behavioral approaches emphasize modificationof the environment and incorporation of techniques such as contingency management, stimulusfading, systematic desensitization, positive reinforcement, audio/video self-modeling, and cognitive—behavioral interventions (Blum et al., 1998;Carlson, Kratochwul, & Johnston, 1994; Rye &Ullman, 1999; Stone et al., 2002). In the events ofthe case study that follows, we applied the behavioral techniques of systematic desensitization, stimulus fading, and shaping. Systematic desensitization,also caUed "graduated exposure therapy," is aprocess in which an individual learns to cope withand overcome fear in small steps, which thenallows him or her to take greater steps to selfreliance. In SM treatment, this technique helps tomitigate or extinguish the stress and fear responsesto those specific situations that are more anxietyprovoking. In stimulus fading, also called the"sMding-in technique," the SM individuals arebrought into a controlled environment withsomeone with whom they are comfortable andwith whom they can communicate, and thenmore people are added, one at a time. Becausethe mute situation usually occurs at school andspeaking behavior is usually normal at home, aparent is usually the one who functions as the safebase, and classmates and the teacher are thepeople who are gradually introduced to generalizethe child's vocalization. Shaping is a process inwhich a child is slowly encouraged to first communicate nonverbally, then make certain sounds,then whisper, and finally speak a word or sentence. The phrase "vocalization ladder" has beenused as a metaphor to represent the shapingprocess for working with children with SM(McHolm, Cunningham, & Vanier, 2005; Oon,2010). Behavioral intervention has been recognizedHUNG, SPENCER, AND DRONAMRAJU / Selective Mutism: Practice and Intervention Strategies for Children223
as the most effective approach for treating SMspecial education, family participation, or school(Cohan et al., 2006; Viana et al., 2009).based intervention and medication (when necessary) (Blum et al., 1998; Brigham & Cole, 1997;Psychodynamic approaches emphasize identifiCarlson et al., 1999; Cohan et al., 2006; Joseph,cation and resolurion of the child with SM's intra1999; Moldan, 2005). Researchers have stressedpsychic conflicts. The intervention process usuallythe importance of efforts—like teachers, parents,involves activities such as art and play therapy toand specialists—in the intervention process forfacilitate communication, which enables the childchildren with SM, because these children need toto express feehngs nonverbaUy (Manassis et al.,resume their speaking behaviors across various set2003; Radford, 1977; Stone et al., 2002). Thetings (Auster, Feeney-Ketder, & KratochwiU, 2006;focus in a family-system perspective is on changCohan et al., 2006; Oon, 2010). Many researchersing disadvantageous family dynamics; however,have suggested that combinations of approachesthis may result in the child maintaining his or hermay be beneficial for children, depending on theirmute behavior (Oon, 2010; Tatem & Delcampo,varying situations (Brigham & Cole, 1997; Cohan1995).et al., 2006; Gordon, 2001; Moldan, 2005; Russell,Medication has been used for children withRaj, &John, 1998).SM, taking into account the severity, duradon,and resistance to psychosocial intervention ofthe condition (Carlson, KratochwiU, & Johnston,CASE STUDY: RENEE1999; Kaakeh & Stumpf, 2008; Lafferty & ConThis case study involves a preschool child firom anstantino, 1998; Stone et al., 2002). However,inner-city, predominantly African American Headmedication should not be the only interventionStart center in Detroit. It illustrates the features ofused to treat SM—it should be combined withSM and provides examples of treatment processespsychosocial intervention. Currently, there are nothat adopt a multimodal approach, using behaviodrugs approved by the U.S. Food and Drug Adral intervention, play therapy, and school andministration (FDA) for use in children with SM.family involvement. This case also illustrates thatAntidepressants—in the form of selective serotoearly intervenrion can be effective in treating SM.nin reuptake inhibiton (SSRIs)—are prescribed inThe therapy sessions were conducted once athe treatment of people with anxiety disorders,week, mainly in the classroom and an adjacentincluding children with SM. Fluoxetine is thereading room, with some time also spent in otherdrug that has been studied most often, and its effiparts of the school environment. The interventioncacy as a treatment for SM has been demonstratedteam included the therapist, two supervisors, the(Black, Uhde, & Tancer, 1992; Dummit, Klein,parents, and the teachers.Tancer, Asche, &c Martin, 1996; Kaakeh &Stumpf, 2008; Süveira, Jainer, &c Bates, 2004). Background Information and EarlyHowever, in 2004, the FDA issued warningsFindingsbased on reports that the use of SSRIs had causedRenee, a four-year-old girl, had been in Headsuicidal thinking in children and adolescents withStart for two and a half months. One of Renee'smajor depression (Sharkey & McNicholas, 2008).teachen found that she consistently had a blankThese warnings have affected and caused morelook and was not speaking at school but did atconcerns in medication use for mental illness inhome. Because of previous experience with athe United States. When medication is introducedstudent with SM, the teacher recognized these befor SM treatment with children, it is necessary tohaviors and reported Renee to the mental healthclosely monitor the type of drug chosen and thespecialist. Classroom observations and assessmentsdosage and to alert parents to possible side effectswere initiated, and concerns were discussed withand teach them how to manage adverse eventsthe family.(Sharkey & McNicholas, 2008).Renee's mother reported that she was herThe multimodal approach, applying more than youngest child, with three older siblings. Reneeone intervention, is also frequently used to treatwas raised by her parents and had no history ofSM. Most multimodal treatments involve formsserious mental or physical health problems. Thisof psychodynamic and behavioral interventions,was her first time attending school. Her motheralong with occupational therapy, dance therapy.was shocked by the teachers' report about Renee224Children & SchoolsVOLUME 34, NUMBER 4OCTOBER2012
not talking, because she was a very talkative andhappy chOd at home, despite appeadng shy onsome occasions. Renee's father thought that therewas no need for any intervention and believedshe would grow out of it. However, her motherinsisted that if the school believed that the intervention was necessary and appropriate, she wouldrather have the help for Renee. When Renee'smother asked Renee why she did not talk atschool, Renee answered that she did not knowwhy but just could not talk.The therapist's observations confirmed Renee'steachen' reports, which showed that when teachen greeted Renee or asked her questions, shelooked frozen and blank. The teachen behevedthat she did not hke people to talk to her becauseit made her unconrfortable. Consequently, theygradually reinforced her behavior by avoiding interactions with her.Initial Play Therapy SessionsThe therapist's role in the classroom was somewhat like that of a teacher, not only doinghands-on activities with the children aroundRenee, but also focusing on observing and interacting with Renee and encouraging interactionsbetween her and her peers. The fint time thetherapist came to the classroom, Renee lookedfrozen and did not respond to anyone. She stoodsilently in a fixed position for a period of severalminutes, watching the other children and thetherapist. Her body was as immobile as her voicewas mute. However, the therapist observed thatwhen Renee saw others laughing, she appeared tohave a very small smue, but it quickly disappeared.This observation helped the therapist to knowthat Renee did pay attention to people and herenvironment and that she was not as frozen as sheappeared.Right after the first classroom observation,Renee and the therapist had a chance to have 15minutes of individual play time in the readingroom, which was connected to the main classroom by an open door. The therapist invitedRenee to the room and offered a hand for her tohold. Without speaking, Renee raised her handto hold the therapist's, showing acceptance, andwalked with the therapist to the room. The therapist introduced herself to Renee and told her thatshe was a therapist and she hked to play with httlechildren to help them do things they founddifficult to do. The therapist also told Renee thatthey were going to engage in whatever good andsafe activities Renee hked when they were together and that Renee was welcome to tell orshow her what she liked or did not like in anyway, at any time. Renee seemed to be very comfortable in the room. In the warm-up activity, thetherapist asked if Renee wanted to draw something and offered her paper and crayons; Reneetook the materials without hesitating, sat down,and started drawing. Instead of talking to Reneedirectly, the therapist used a rabbit puppet to talkto her. Surprisingly, Renee answered the therapist's question about what she was drawing. Sheraised her head, looked at the therapist—not thepuppet—smued, and answered "A circle!" in aclear and confident voice. Then she kept drawingsome lines, without answeting any other questions. Later, she played puppets with the therapist,without talking, but laughed with the therapist,which was quite different from how she acted inthe classroom. When the session ended, Reneewent back to the main classroom and resumed herblank look and unresponsive behavior. Her gaitlooked much heavier and slower than it had beenin the reading room. Even though Renee spokejust one sentence and remained mute on returningto the classroom, it was considered very rewardingby the intervention team to have had her firstspoken sentence during the first individual session.At the beginning of each session, somewarm-up activities, along with desensitization andshaping techniques, were used to prompt Renee'sspeaking behavior. The warm-up activities included playing puppets and games, drawing pictures,reading books, and playing musical instruinents.Activities Renee Uked or had spoken of—forexample, activities like the puppet play during inprevious sessions—were repeated to trigger herspeaking. During these activities, the therapisttried to manage Renee's stress and conrfort levelsand also put into words what she might be thinking or trying to say so as to induce her to speak.Activities that Renee liked and had spokenabout, like reading a book or playing a game,were repeated in subsequent sessions, with the apphcation of desensitization and shaping techniquesto encourage her to speak more regarding thoseitems. New toys, books, and games were added toextend her wUlingness to speak about things withwhich she had less experience.HUNG, SPENCER, AND DRONAMRAJU / Selective Mutism: Practice and Intervention Strategies for Children225
In addition, activities exploring the school environment were used to expose Renee to new situations. The therapist would ask Renee first if shewould hke to take a walk, and Renee was allowedto hold the therapist's hand anytime she wantedto during the walk. The therapist also gendyplaced her hands on Renee's shoulders or offereda hand to Renee if she sensed that Renee mightbe not comfortable in a new situation. The therapist would talk with Renee most of the timeabout what the therapist saw and felt during thewalks—for example, touching an object andtelling Renee how she felt when touching it. Thetherapist also asked Renee if she would like to tryto touch and feel the object. Whenever they metanyone, the therapist would offer a friendly greeting; Renee did not have to say anything, just holdthe therapist's hand so as to feel more comfortable. As Renee's mother mentioned that Reneewas very interested in dancing, the therapist alsoobserved that Renee was very afraid of approaching the stage of the school. Using Renee's stronginterest in dance to diminish her fear of the stage,the therapist started introducing some environment exploration activities during the sessions. Atfirst, Renee was encouraged to just observe thetherapist's way of exploring the stage—forexample, watching her go up on a stage to walk,dance, and sing. Then, rather than watching thetherapist, Renee would be encouraged by thetherapist to get on the stage with the therapistand, later, to stand on the stage on her own toplay with or touch things freely. AU the situationsencountered during the walks together could potentially help Renee reduce her stress level andbuud her confidence in the school environment.During the therapy sessions, the therapist encouraged all attempts at communication by Reneewithout forcing them to happen. Renee had triedusing head nodding, hand shaking, facial expressions, and drawing to communicate with the therapist. The therapist's role was to buud a safebridge and help Renee to cross the bridge toexplore something new or difficult, allowing herto cross back when needed.During these weekly sessions, Renee spoke tothe therapist; however, she stopped speakingwhen anyone else came into the reading room.Gradually, some progress was made. When otherchildren or Renee's teachen came into the room,she did not stop speaking but still only spoke to226the therapist. To help Renee get to the transitionstage of talking with teachers and other childrenwhen they came to the reading room, new intervention strategies \vere discussed and implemented.School Involvement and FamilyParticipationBoth school personnel's involvement and thefamily's participation were important in the generalization of Renee's speaking behavior. Thetherapist, teacher, and family documented Renee'sprogress, including observations and strategiesused. In addition to the progress reports, Renee'steachers and her family were encouraged to havebrief talks at school drop-off and pick-up times.These conversations were held in a friendly andinformative way, either in private or in the presence of Renee, depending on the informationshared. In addition, Renee's mother agreed tocome to her classroom as a volunteer to helpRenee have a better sense of security at school.Renee's mother also took her for walks in theschool building to gradually familiarize her withthe people and the environment.Increasing Frequencies of Interactionand Speaking with People at SchoolAfter Renee had said a few sentences, selectedchildren who were friendly to her were added tothe peer-group play sessions to help her make thetransition to talking with other people. Reneeagreed to invite Lori, a girl who was a year olderand very advanced in language expression, to joinRenee and the therapist as a group for the playtherapy session. Gradually, Renee was able tospeak with Lod. The role of the therapist gradually faded as Renee was helped to regulate her experience by speaking with a peer. In the nexttherapy session, Renee was encouraged to invitetwo friends to play in the reading room, and at thefollowing session, more children were engaged toplay and speak with Renee. During this period oftime, Renee stül only spoke once a week with thechildren playing with her in the room and in thetherapist's presence.Shordy after three group sessions, Renee'steachers reported that she spoke for the very firsttime in the classroom without the therapistpresent. The whole class was surprised and celebrated at that moment. When Renee saw herclassmates' reaction, she seemed overwhelmed.Ghildren & SchoolsVOLUME 34, NUMBER 4OCTOBER2012
Renee's teachers reported that she returned to herblank look for the rest of the day. The next day,one the teachers saw Renee crying sadly in theafternoon, which had never happened before.The teacher asked Renee if anyone had hurt heror if she missed her mother or if there wasanother reason. Renee shook her head. When theteacher asked Renee if she wanted to talk, Reneecried even louder. The teacher assumed thatRenee might be sad because she wanted to talkbut could not do it, making her frustrated. Reneeretained her blank look and did not speak for therest of the week.In discussion, the intervention team realizedthat Renee might have experienced the sameemotions that many children with SM have experienced: When their speaking behavior fintappears in public, children with SM inadvertentlyattract a great deal of attention to themselves, andtheir stress level increases. This may make themfeel overwhelmed and dissuade them from tryingto speak again. Intervention strategies to helpRenee deal with the negative experience werediscussed to prevent further damage to the generalization of speech. These strategies includedpraising Renee's accomplishments privately andavoiding celebrarion by a big group to prevent herfrom becoming overwhelmed and, thus, increasing her stress level. The therapist also planned towork with Renee to release her stress regardingthis negative experience in their followingsessions.At the following play therapy session, Reneeseemed to be sad and had very little desire tospeak. The therapist told Renee that she understood that the experience of speaking in the classroom and her classmates' reaction might havemade her feel scared. The therapist also toldRenee that the teachers had promised that if shespoke again in the classroom, her classmateswould not react in the same way. Renee frownedand looked sad. A great effort had to be made tohave her speak to the therapist and then to thechildren in the group session. As Renee's speakingbehavior recovered shghdy during the play sessions, she agreed to invite the teacher whoworked most closely with her and her family to asession. When the teacher first came in, Reneedid try but was not able to speak out. The teacher's presence apparendy created a barrier for her.The therapist decided to introduce systematicdesensitization and stimulus fading techniques tomanage the situation. It was arranged to have theteacher gradually move in closer when Renee andthe therapist were reading or talking. That way,Renee would be able to manage her comfortlevel when speaking in the teacher's presence.The therapist signaled the teacher about whenand where to sit to get closer to Renee. The therapist tried to motivate Renee to speak using apicture book and games with which she was veryfamiliar. After Renee started reading the bookaloud to the therapist with her teacher next to her,the stimulus fading technique was used, graduallytransferring the therapist's role to the teacher.RESULTSFor the next week, Renee's teachers reported thatshe talked with some of her classmates and occasionally answered the attendance check in theclassroom, but she only talked to the teacher inthe reading room when there were no other children or teachers around. Renee's mother reportedthat Renee did not show much change at home,although she seemed to Hke to talk more aboutschool.There were seven sessions, but intervention wasterminated at the end of the semester, just asRenee's speech was gradually appearing at school.In foUow-up reports, Renee's teachers noted thatshe started speaking a few sentences at the beginning of the new semester and that, after twomonths, her frequency of speech was indistinguishable from that of other children.RECOMMENDATIONSThe following is a summary of strategies and experiences gained from working with this case:1. Form an intervention team involving keyworkers, such as a therapist, a teacher, andfamily members.2. Explain the features of SM and the intervention approaches available to the intervenrion team; buOd up cooperative andcollaborative relarionships within the team;encourage and support the team to get involved positively in the intervenrion process.3. Develop a home- and school-based intervention plan with the teachers, the family,and the child (if he or she is able to participate). Ask the family to create a list of theHUNG, SPENGER, AND DRONAMRAJU / Selective Mutism: Practice and Intervention Strategies for Children227
4.5.6.7.8.9.228situations and places where the child doesand does not talk. Ask the parents aboutthe child's strengths, hkes, and dislikes andabout things to avoid. Integrate this information into activities to create a best-fit intervention plan.AUow the child to become familiar with thetherapist with minimum stress at or beforethe first individual session. For example, inthe case study, Renee first observed the interactions between the therapist and herclassmates in a natural classroom setting.Arrange for the therapist to interact andtalk with the child in a place where thechild normally speaks, such as the child'shome, to help the child initiate verbalbehavior with the therapist. This may helpthe child to start feeling less pressure tolink his or her speaking behavior with thetherapist's appearance.Increase the child's sense of continuitybetween home and school. For example,the family may record the child reading astory at home to play back at school, orthey could encourage the chud to talkabout school at home, without pressure, ifhe or she is ready to.Do not allow anyone, especially team orfamily members, to assign blame for thechud's mutism as this may increase thechild's stress and worsen the condition.Examine environmental factors to determine possible barrien preventing the childfrom speaking. Try to reduce barrien andcreate a more comfortable atmosphere toestablish better environmental conditions.For example, have a family member withwhom the child is comfortable help thechild explore the school environment bytalking about and introducing the schoolenvironment, by participating in schoolactivities, and by talking with teachers andchildren in the classroom. In addition,family members can create opportunities forverbalization in select places where the chudfeels less stress and then gradually extendthat to other situations.Never force the chud to speak, but gradually encourage all attempts at communication such as head nodding, hand shaking,facial expressions, and writing or drawing.10.11.12.13.14.Encourage the chud to try whispering ashe or she becomes comfortable with thesenonverbal communications. Always allowthe chud to choose his or her mode ofcommunication.Minimize pressure, and emphasize trust toenable the child to buud confidence in hisor her attempts at verbal communication andmove toward resuming his or her speakingbehavior in desired places.Analyze and manage all the factors thatcontribute to changes in the child's verbaland verbal-related behavior during all processes, especially the factors contributing tohis or her stress versus comfort levels. Besensitive to what activities or materials thechild is most interested in and is morewilling to speak about. Clarify in what situations—such as in specific rooms orplaces, playing certain games, or readingparticular books—the child is more willingto exhibit speaking behavior. Use thesefaetón as the basis to create a friendlier environment to induce speaking behavior.Introduce behavioral techniques appropriately to gradually generalize the child'sverbal behavior: Use systematic desensitization to help the chud become familiar withnew intervention situations an
Selective Mutism: Practice and Intervention Strategies for Children Shu-Lan Hung, Michael S. Spencer, and Rani Dronamraju The onset of selective mutism (SM) is usually between the ages of three and five years, when the children first go
followed by a review of intervention methods and research at each tier. Based on the theoretical and research literature base, we conclude that early intervention may result in the prevention and amelioration of many occurrences of selective mutism. KEYWORDS: Selective Mutism, Childhood Anxiety Disorders, Social Phobia, Prevention, Treatment
Within these pages, you’ll find useful information, tips and strategies, and other assorted resources to help you best support children diagnosed with Selective Mutism. As an educator, you are in a uniquely well-suited position to observe symptoms of SM that occur in school settings and to help your students.
Anxiety, wariness and hypersensitivity Family history of shyness or selective mutism Family history of other psychiatric illness, especially anxiety Precipitating: Separation, loss or trauma Frequent moves or migration School or nursery admission Self-awareness of speech impairment Teasing and other negative reactions
Reluctant Speaking and Selective Mutism Resource Pack For those working within an early years or school setting This resou
Selective mutism (SM) is an anxiety disorder that prevents children speaking in certain social situations, such as school lessons or in public. However, they're able to speak freely to close family and friends when nobody else is listening – for example, when they're atFile Size: 300KB
from selective mutism. While children develop selective mutism for a variety of reasons, in most children with the condition, it is thought to be a severe form of social anxiety disorder. But because it can arise for other reasons, technically it is not considered an anxiety disorder. Children s
Subsea Intervention Type 1 (Class A) - Light (riserless) Intervention Type 2 (Class B) - Medium Intervention Type 3 (Class C) -Heavy Intervention Well and manifold installation Maintenance -scale squeeze -chemical injection Increasing demand for mature fields Image Ref - Subsea Well Intervention Vessel and Systems
No. Per API 650 Section 3.2.4, the tank is limited to one in. of water vacuum (roughly 25 mm). If the tank must be designed for 50 mm water vacuum, then this is a special design which is not covered by API 650. 3.2.4 9th - May 1993 Should the vacuum relief system set pressure be 25 mm of water if the required design vacuum condition is 50 mm of water? API 650 does not cover the required .
