School of Speech Ep 26 (edit)
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[00:00:00] Announcer: Welcome to the School of Speech podcast presented by SpeechTherapyPD. com. School of Speech is designed specifically for the school based SLP to come together to discuss current topics, tackle difficult situations, and share our insights. Our goal is to bolster confidence, celebrate our triumphs, and foster a community that's Dedicated to the excellence in the school setting. 

[00:01:30] Carolyn Dolby: Hello and welcome everyone. I'm Carolyn Dolby. I am SpeechTherapyPD. com's podcast host for School of Speech. School of Speech is designed for the school based SLP so we can all come together. We're going to explore current trends, share our insights, and really champion our expertise.

[00:01:51] Our goal is to bolster confidence, celebrate our triumphs and foster a community dedicated to the excellence in the school setting. So I am so thrilled for today's episode. It is titled effective techniques supporting children with selective mutism. We have Emily Laracy She is here to help us explore what our role as school based, school based SLPs are, what our role is supporting these students.

[00:02:20] She's going to dispel some myths, we're going to discover some facts, while providing essential assessment tips, evidence based treatment strategies, really, all the things that we need to really help our students find their voice. Well, I want everyone to settle in for a great episode. We do have a little bit of housekeeping.

[00:02:40] Before we get started each of our episodes are 60 minutes and will be offered for 0. 1 ASHA CEUs. All right, let's get through some of our disclosures. Emily receives royalties from the book, Treating Selective Mutism as a Speech Language Pathologist. She is also receiving an honorarium for her expertise in today's interview.

[00:03:04] Non financial Emily is the secretary for the Selective Mutism Association Board of Directors. We've got an excellent speaker today on this. For me, I receive a salary as the district level specialized support clinician for Portland Public Schools. I'm also compensated for my graduate courses that I teach for the University of Houston, and I'm also a consultant for school districts across the nation supporting their program development and safety.

[00:03:28] And I do receive compensation from speech therapy, pd. com for hosting school of speech. My dream non financial. I volunteer for feeding manners and I'm a member of special interest groups, 13, 14 and 16 that's about me. I know we want to know all the things there is to know. to know about Emily.

[00:03:47] She is a school based speech therapist. Her primary interests are in the influences of psychological factors such as anxiety on Children's speech and language development. Emily currently serves as a speech pathology representative and secretary of the Selective Mutism Association Board of Directors.

[00:04:07] She has presented on selective mutism at National State and local conferences, she has participated as a team member in the treatment of dozens of children with selective mutism and other comorbid diagnoses. She's been recognized for her work with selective mutism and other speech language disorders as the recipient of the American Speech Language and Hearing Association's Distinguished Early Career Professional Certificate.

[00:04:36] The Pennsylvania Speech Language and Hearing Association's Rising Star. She's also the winner of the Star Award and the East Stroudsburg University Young Alumni Award. She is again the author of the book, Treating Selective Mutism as a Speech Language Pathologist. Welcome, Emily. 

[00:04:53] Emily Laracy: Thank you so much. I'm so excited to be here with you guys tonight and talk about just my favorite topic, so... happy to be here.

[00:05:01] Carolyn Dolby: I love that you're here. . I think what would help us help me, for sure, if we could start by, do you mind maybe defining selective mutism and let's start there.

[00:05:13] Emily Laracy: Sure, absolutely. So, I think a lot of people know that there's an anxiety component to selective mutism. So when we're talking about selective mutism, we are talking about an anxiety based disorder that results in an inability to speak in certain situations, despite having appropriate or normal or typical speech in other situations.

[00:05:31] So usually for most kids, that looks like they're able to talk at home or with comfortable people like their parents or their immediate family members, but in either community settings, or particularly the school setting, they really struggle to speak or are not speaking at all. 1 of the key words in that kind of definition or conceptualization of SM is really that word inability to speak rather than refusal to speak or choice not to speak.

[00:05:57] And, you know, when we talk about, you know, we talked about. Talking about some myths tonight that kind of surround SM, which I think are prevalent kind of in our society and even within our field of speech is Oftentimes, there's this assumption that these kids are choosing not to speak or they're refusing to speak.

[00:06:13] I've heard people talk about it in terms of, well, they're trying to control the situation or it's a behavior or it's a child trying to be manipulative or a child who's defiant. And really, we just find that that's not the case. Overwhelmingly, so we find that these kids are when they're able to express themselves comfortably when they're talking to their parents, when they're writing things down, they're saying, I really want to talk.

[00:06:34] I really want to be able to tell people what I'm thinking and talk to my friends and talk to my teachers and have conversations, but they say things like, it feels like my words get stuck. It feels like my throat closes up. It feels like I want to say the words, but my brain just can't get them out. My mouth just can't get them out.

[00:06:50] And so it's really more this experience of such overwhelming anxiety that it inhibits the child's ability to speak in certain situations. And so when we're looking at what's our role as an SLP, and we can get more into this, it's really kind of working collaboratively with another staff member who's able to work on that overall anxiety piece, like a school psychologist or a school counselor.

[00:07:14] But then also our role is really helping kids to work on that communication piece and making sure that they're using. Functional speech at school the way we would with any of our other students. 

[00:07:25] Carolyn Dolby: Well, I think what really Just right off the bat, you hit us heavy, and I love this because I think semantics matters.

[00:07:35] We're wordsmiths, and so as speech pathologists, we understand how powerful words are. And the fact that you define selective mutism is not being a choice or refusing or the behavior of not wanting to speak. But in fact, the inability. And having us all reframe our thought when we're talking about that, especially with all the education that we do just on a daily basis with the staff members.

[00:08:02] That right there. That is that's. Amazing. And that kind of just right off the bat, you've, you've blown my mind with just, just simple definition that really shows the true nature of it the inability, I love it. So I, I don't have a lot of experience with selective mutism. So I really, I would like to really know, could you kind of go through maybe some of the signs and symptoms so we can kind of see what we need to be looking out for red flags and things like that?

[00:08:33] Emily Laracy: Sure. I think it can look, it can look very different, but there's also a lot of kind of similarities that that. tend to run through a lot of these cases. So typically for a lot of kids with SM, what we see are a lot of shutting down at school. So if you think about, you've probably heard of like the fight or flight response.

[00:08:51] We tend to see these kids engaging in more of a freeze response. So they don't tend to be the kids that kind of externalize behaviors and they're not like running away or tipping over chairs or things like that when they're anxious or escalated or upset. These are the kids that are withdrawing and freezing and shutting down when they're anxious, when they're put on the spot, or when they're even perceiving that they're being put on the spot even if others don't perceive it that way.

[00:09:13] So this can look like a child who is not raising their hand is having accidents because they're not able to ask for help. To use the bathroom is not able to convey if they're hurt or if they're sick. So, you know, I've had parents tell me stories of a child who had, you know, significant stomach pain a child who fell at recess and broke his wrist, a child who had a possible concussion because he fell off the playground and those kids were in significant pain and not able to communicate that to anyone at school.

[00:09:38] So they just went through their day in such pain and then finally were able to explain it. When they got home with their parents and kind of maybe less obvious ways. This is a child who might be playing parallel to other kids, but it's not engaging in any kind of conversation with them. It can sometimes look like a child who's very non verbally engaged and almost very extroverted, but just not using verbalizations.

[00:10:01] So sometimes it might be that kid who looks like they're playing at recess because they're running around with everybody else. But if you would really do an observation and focus on that child, they're not inviting others to play, they're not asking to join a group. If someone asks them a question, they might kind of shut down and not look at the person and not be able to answer.

[00:10:18] They're certainly not engaging in conversations at lunchtime, at recess, on the bus, at free playtimes. They're not able to answer questions from the teacher. In some cases, they're not able to engage in any kind of like oral tests. So at the school that I work at our kindergarten through second graders do a series of assessments where they have to read words out loud.

[00:10:37] A lot of reading fluency tests require you to read out loud so the teacher can look at your accuracy. And these kids often aren't able to do that. can sometimes be mistaken for academic deficits and being looked at as, oh, well, this is a child who must not know his ABCs, must not be able to read, must not know these words or these sounds or these letters or these sight words.

[00:10:56] And so they're getting marked as getting zeros on some of these assessments when really, they probably know a lot of the material. They're just not able to say it at school. 

[00:11:05] Carolyn Dolby: Wow. Are there different, like, levels of selective mutism. 

[00:11:10] Emily Laracy: So if you, if you look at the DSM and kind of the diagnostic criteria, it doesn't define like a more severe or less severe type.

[00:11:18] A lot of people in the SM world are starting to use the terminology like high profile versus low profile SM to kind of talk about levels of severity because there certainly is a spectrum in terms of you could have a child who's not saying any words at all to anyone in any situation other than their house.

[00:11:35] Which would be a pretty severe presentation. Some of those kids that are, are that severe also have a pretty strong social anxiety component. And so they may even be very behaviorally inhibited. So they're not giving a thumbs up or a thumbs down. They're not nodding or shaking their head. They're even having trouble kind They're not doing like the brain breaks or the freeze dance or the things that the rest of the class is doing, even when there's no speech demands being placed on them, they're still struggling with that social anxiety piece, too.

[00:12:03] So, we often see that with those more like high profile presentations versus the more low profile. There may be a little bit more flexibility in terms of maybe they're able to talk to a couple of peers, but not all their peers. Or maybe they're able to talk to one adult, but no peers, or maybe they're able to talk.

[00:12:19] In their homeroom classroom, but not in any of the rest of the parts of the school, like the music room, or the library, or the cafeteria, or maybe when they go out in public, they're able to talk to their family members in new environments, but they can't talk to, like, the clerk at the grocery store, or they can't order something at Starbucks or things like that.

[00:12:38] Carolyn Dolby: Wow. Okay. Thank you. So, I guess that brings us back, because I think we're, I think we are all wanting to know, what is our role? What is our role when it comes to selective mutism? I know before we got started, we were talking about, I didn't, I don't have, I didn't have it in grad school. It's not something I'm well versed in.

[00:12:59] So I, I think that would help us all and all our listeners. What is our role? 

[00:13:04] Emily Laracy: Yeah, so actually, if you go on to Asha's website and you look at kind of our scope of practice, which is a lengthy, lengthy document, lengthy website that has quite a lot of things in it but if you look at the Selective Mutism page specifically, Asha actually outlines 12 different ways that SLPs can and should be involved in working with individuals with SM.

[00:13:22] And some of the big ones to highlight are we can be part of the assessment team. We can be part of the diagnostic team. I, ASHA is not super clear on whether we can diagnose SM as an SLP independently alone kind of working without a team, generally best practices to work with a team of people so that you as the SLP are looking at all the language kind of components that go into SM and may either be Exacerbate the SM or contribute to maintaining the SM.

[00:13:51] Part of being able to diagnose SM. If you're looking at again, the DSM criteria is being able to rule out other speech or language or developmental disorders that may better explain the lack of speech. So, things like autism, where we may have a child who has the same kind of amount of speech across different environments, and we don't see that big change verse in home versus school or home versus community presentations.

[00:14:16] I once had a case with a student who, it was during COVID, so we all had masks on, and the teacher came to me and was like, you know, I have this student, he's new to our school, he hasn't said a word to me the entire year. When I ask him a question, he kind of avoids eye contact, like, you know, is this that thing you always do?

[00:14:31] And you know, we, I screened the student, I met with the student, and it turned out he had a fluency disorder and was having Really severe blocks, and we weren't able to see a lot of that because the mask that was on that was, you know, covering most of his little face. And so what looked like SM when we did some further analysis was like, oh, no, this is a straight up fluency disorder.

[00:14:51] And when we treated the fluency disorder, all of those SM like symptoms went away, and he was able to communicate and not avoid it anymore and all of those things. our role in being able to rule out other things. Another one that pops up a lot is just expressive language in general. So how do we know, is this a child who just has kind of a, a generalized expressive language delay or disorder?

[00:15:12] Or is this a child who is more situationally dependent in what they're able to say? And again, with an expressive language delay, you'd expect to see the same thing across settings. You'd expect to see them to have The same level of impairment with their teacher, with their friends, with their siblings, with their parents versus the SM, where you see those very marked differences between audience between kind of communication partners between settings and things like that.

[00:15:35] So, 1, big area is being part of the assessment process, contributing to that diagnosis and being able to say, like, yes, I see characteristics of SM that are not explained by their language skills or kind of the other things that we're assessing here. No, I don't see S. M. You know, I think it's better explained by this diagnosis instead of fluency disorder, autism spectrum disorder, things like that.

[00:16:00] So the assessment diagnostic process is, is important, but also Asha says that we can be part of doing direct treatment for these students. And I think that's another myth. That I find that I have to dispel a lot of times when I'm in conversation with SLPs about this is there's this kind of belief in our field of this is an anxiety disorder.

[00:16:19] So this should be treated by psych and we shouldn't touch this. And while it's true that, yes, you should be working collaboratively with whoever it is in your setting or your school who works on anxiety. I've seen that be a social worker. I've seen that be a school counselor, a school psychologist. A B.

[00:16:34] C. B. A. In some cases who was working on social skills with kids. So yes, you should definitely be working collaboratively with that person, and they can be addressing that anxiety piece, the coping skills piece, getting to the root of that, helping kids deal with and manage feelings of anxiety. And you as the SLP can at the same time be working directly with the student to increase their communication.

[00:16:57] So thinking about how can we help kids talk to more people? How can we help them talk in more places and during more activities? So people, places, and activities tend to be three things that we look at when we're thinking about what we can do. Where where do kids need to work? Where do we need to focus our goals in our time?

[00:17:12] So doing that direct treatment to help kids with that and then certainly kind of the things we do with all of our students advocating for our students collaborating with other team members consulting with other team members making referrals if we see other you know concerns and things like that. 

[00:17:26] Carolyn Dolby: We, we have a question from the audience and then I, I think I also have a question too, but one of the, the question Amy just asked is how often does SM co occur with autism?

[00:17:37] Or because you said we're ruling out something that better, that would better explain the situation. So do, do they co occur or is it usually one or the other? 

[00:17:47] Emily Laracy: Yeah, great question. I'm not aware of a specific number of, like, this percent of the time that they, they co occur, and I think some of that is because we're still learning more about autism and its various presentations and learning more about SM and its various presentations, but it can occur.

[00:18:01] I have worked with psychologists who will diagnose both as comorbid disorders. And again, I think sometimes you really have to think about, like, what's, what's the biggest issue for this child right now? I've worked with some kids who have kind of what we used to call Asperger's, where they're fairly high functioning in terms of their level of language skills and social skills and things like that.

[00:18:20] They still have kind of some things that they're working on and some things that they struggle with, but in those cases, it wasn't necessarily the autism that was causing them so much struggle. It was the SM that was causing them so much struggle. And then in other cases, I've worked with kids who just had.

[00:18:34] Who had an autism diagnosis and parents were saying, well, could this be SM 2 and we were really seeing like, at this point, it's the child's kind of global language and developmental delays that are getting in their way, so to speak that are causing them the most struggle. And so we want to address those things before worrying too much about the anxiety piece, because we're not seeing that be as much of a factor at this point.

[00:18:57] So they can certainly co occur to varying degrees. I think different ones can pop up at different. Phases of life depending on kind of the child's specific profile of their strengths and needs. And then just as you're planning your treatment, kind of thinking about what's, what's the biggest thing we need to work on right now to make this child's life easier and to help them have more functional interactions.

[00:19:17] Carolyn Dolby: So, getting back on the assessment pieces, I'm, I know we're all. Wondering, okay, how do you. They have to be eligible for our services. So, what would they be? What would their disability be under speech with expressive language? What if their expressive language. In at the home is within functional limits.

[00:19:41] We, how could we wouldn't how could we say that that's a, you know, a disorder when it when they're using their expressive language in other areas? 

[00:19:50] Emily Laracy: Sure. So for I think a lot of our audience tonight is school based clinicians, and I'm primarily a school based clinician too. So kind of speaking to that lens.

[00:19:59] I tend to tell people to think of this in terms of a social language disorder or a pragmatic language disorder. And so really when you start thinking about it under that lens in terms of, you know, You know, what pragmatic functions is this child using? Are they requesting things? Are they making comments about things?

[00:20:14] Are they able to deny things and reject things and say no to things? Are they able to negotiate? Are they able to compromise and stand up for themselves and be assertive and make friends and engage in play and humor and all of those kinds of things that we expect a typically developing child to do at school?

[00:20:30] You know, looking at all of those kind of functions of language and saying, okay, Is is my child with S. M. or suspected S. M. Are they doing these things? And if they're doing them, are they doing them consistently? And like I said, are they doing them across people across places and across activities? And so even if they have those skills at home, if they're not able to use those skills at school, that still falls under our role as being able to support kids at school.

[00:20:55] And I think it's really important for students to engage with the school in the school environment to make sure they can use all of the skills that they need and have all the skills that they need to engage in academic activities, engage in social activities and engage in kind of social, emotional types of, you know, friendships and relationships and things like that 

[00:21:10] Carolyn Dolby: are and Miriam, one of our listeners going back, keeping us on assessment was wondering, is it detectable in toddlers?

[00:21:18] How early can you diagnose? 

[00:21:22] Emily Laracy: I've worked with teams who have diagnosed students as young as two and a half years old. So I think there, there can definitely be some really clear patterns. Often we see this pop up when kids are first in some kind of childcare or school setting where they're away from their parents.

[00:21:37] Right? So if you've got a child who's kind of home with their parents all the time, maybe they've got a stay at home parent. They're not in any kind of child care or preschool situation or things like that. We may not see it pop up until they start kindergarten and then all of a sudden they're in a new setting without their safe person there to talk to.

[00:21:53] And now all of a sudden it's apparent like, wow, this child cannot communicate with other adults or peers. But in children who kind of do have those exposures early on or in those different settings early on, you can see a pretty significant difference in how these kids are Playing and how they're making eye contact and how they're using or not using nonverbal communication and how they're using or not using verbal communication.

[00:22:15] And so, again, just really looking for those differences across settings. I've seen it diagnosed as early as, like, 2. 5. 

[00:22:21] Carolyn Dolby: Wow. Okay. Thank you. Thank you. So two and a half. So early, early detection, right? Yeah. Early intervention's best. Keeping on with assessing cause I, I still we're wanting to, I like the, when you said, sorry, I'm tripping on my own words right now, ruling out some another diagnosis that would better better describe it, but also really looking at language and I thought expressive language, but I liked how you really, it's thought provoking to Really think about the social use of language.

[00:22:53] Yes, they have language, but are they using it like you said with people, places and. Across activities. 

[00:23:01] Emily Laracy: Yeah, so I think things like when we're talking about assessment, doing things like multiple observations, so observing this child in lots of different settings with lots of different people, how do they do?

[00:23:10] One on one versus in a small group versus in a large group. How do they do with peers versus adults? How do they do in structured versus unstructured activities, but also using rating scales that parents teachers and or yourself if you're interacting with the child could fill out there's, you know, potentially even reading skills that you could have older kids fill out if they're able to, to engage in that kind of help with that and looking at things like, How are they using these skills functionally?

[00:23:36] So if you're familiar with the self five assessment, which is kind of a common one that most people are aware of it has the pragmatics profile, which is a checklist of 50 different social language skills that kids need to use to be successful in school. And so it goes through things like, can they use greetings and farewells to greet people?

[00:23:54] Can they interrupt appropriately? Can they get someone's attention appropriately? Can they. Use nonverbal facial expressions or gestures to communicate information and so just having the parent fill that out and the teacher fill that out and being able to look at are these similar ratings or are these very different across these settings can be a really powerful tool and saying like, okay.

[00:24:14] This child does not have these skills in this setting, and that's why they qualify for our support and our therapy services. 

[00:24:21] Carolyn Dolby: And would you, would you, how many students with SM that present with us selective mutism are speech only? Are we 

[00:24:30] Emily Laracy: Most of the students I've had on my caseload have been speech only or have at least started as speech only students.

[00:24:36] So I do often classify them under the speech or language impairment under IDEA. I have also seen it classified under other health impairment, OHI. If they have a diagnosis of either social anxiety or selective mutism, some schools will do it that way. In very rare cases, I've seen some schools classify it under the emotionally disturbed, the ED category.

[00:24:56] Oh, wow. And, and they, they justify that. And if you look at the criteria for kind of what constitutes that diagnosis, some of the criteria are things like making and sustaining age appropriate friendships, being appropriately assertive, having, you know, feelings or thoughts that are not appropriate to the situation, which anxiety could be described that way, depending on kind of how you classify it.

[00:25:20] So I have seen a few schools do it that way, but I wouldn't say that's the norm. I would see I would say most often I see it under speech or language impairment or other health impairment. 

[00:25:30] Carolyn Dolby: I was wondering because I know that we as speech pathologists, you know, being the. One in case manager, that's hard, especially when it really needs to be collaborative.

[00:25:41] We need more than just us with a student like this. I would I would expect. We do have a question in the Q and a, but it's. I and thank you for asking this about for those that have. Okay. So the question is for those that have a pragmatic deficit at school and have bare minimum progress over the year, but they have age appropriate pragmatics in the home setting.

[00:26:06] What can we do? I feel like this question really is going to lead us to what I was going to ask about, like, treatment wise. But I think this is great because this is a case study for our question asker the child shows signs of inability to speak at school and in class and their team doesn't know what to do.

[00:26:24] How would you support them? And thank you for asking that question. That was great. 

[00:26:28] Emily Laracy: Yeah, that's a great question. And I think that's often, you know, probably the second biggest question is like, what, you know, what are we supposed to do? And how are we supposed to help? Which I think is a great question because it shows, you know, you've got these students, you've identified these students, you see that there's a need there for support.

[00:26:41] You see your role as the SLP there is being able to support them. You're just looking for the tools to do it. And thankfully, there's more and more tools available each year that can kind of support some of that. So I would say that the biggest source or resource that I would put everybody to is the Selected Mutism Association.

[00:26:58] You know, as a disclosure, I am on the board. But it has, it's SelectedMutism. org. You can also Google it. It has many, many free resources that are helpful for clinicians but also for family members who might be looking for more information. So things like the Educator's Toolkit is a free guide that we released a couple years ago that can be helpful for talking about school teams and kind of orienting everybody about it.

[00:27:20] What is this? What's going on here? Where does it come from? You know, what do we know about what causes it? And what are some strategies we can use to help the student? 1 of the, the most, most thoroughly research strategies or most evidence based ones that we have right now is called parent child interaction therapy.

[00:27:38] Adapted for selected mutism. So it's a long name. P. C. I. T. S. M. is what we call it. So you'll find lots of literature about that. And really what this uses is 2 types of skills. So it's divided into child directed interaction skills or CDI skills and verbally directed interaction skills or VDI skills.

[00:27:55] And so the premise of these skills is that you start by building rapport with the child and not putting any speech demands on them. So the first time you're meeting with them, or the first 10 minutes of your 30 minute session, you know, however, you're kind of divvying up your time, you're not asking them any questions.

[00:28:10] And that's a big component of this skill. No questions at all, which seems kind of opposite to those of us who are used to asking tons and tons of questions and eliciting a ton of language. But really, the mindset is to back off on the speech demands and really help the child's anxiety to lower and help them to feel more comfortable as you build that positive rapport.

[00:28:29] All right. So instead of questions, you're using a lot of comments, you're using a lot of behavioral descriptions talking about what the child's doing, what you're doing, praising anything and everything that you can to kind of show this child that they're being successful. So great job coming in the room with me.

[00:28:43] I love how you sat down in the chair at the table with me. You know, we're going to play this memory game today. You don't have to talk today. We're just going to play this game together. I'm going to talk. If you feel like talking, you can, but you don't have to. So being really transparent in an age appropriate way about what your expectations are and playing a game or doing an activity or a preferred activity that has no speech demands.

[00:29:03] And for some kids, you can do this once or twice, and then they're ready to kind of shift into the more verbal skills. Other kids, it may take them longer to warm up. And so a lot of it depends on on your student on the comorbidities on their age on on how long they've. You know, people who have not been able to speak how kind of prevalent this is across people, how comfortable they are in a one on one situation.

[00:29:22] So there's, there's lots of variables, but essentially after you use these kind of skills of providing lots of labeled praise using lots of commenting, using lots of behavioral descriptions, you shift into using the VDI or the verbally directed interaction skills. And that's really the process of just being really intentional about how you ask questions.

[00:29:40] And so we often tell people, don't use any yes, no questions. Which again can be kind of a surprise because most of us think, okay, if we've got a child who's struggling to talk, we can ask them a yes, no question. That's an easier type of question. They can nod or shake their hand, head or point to something or give a thumbs up or a thumbs down and great.

[00:29:57] We've just found a way to communicate with them. And while in the short term, that seems like a great solution because you've, you've gotten the answer to your question, essentially, in the long term, we find that it's not helpful for kids because it just reinforces the not talking. So it just kind of gives them a nonverbal way to respond and continues to reinforce, like, oh, okay, well, they asked me this question and I'm not able to answer it.

[00:30:20] But if I keep giving my thumbs up or my thumbs down, I can kind of get through this interaction and get back to my day and not have to. To do the scary talking thing and so instead what we find is really helpful is to use a mix of forced choice questions, which are like multiple choice questions. So instead of saying, like, is your favorite ice cream chocolate, you can change it to a multiple choice question and say, is your favorite kind of ice cream chocolate, vanilla or something else.

[00:30:45] And just by changing the format of that question from a yes, no to a forced choice, you're much, much, much more likely to get a verbal response because it just doesn't lend itself as well to a nod or a shaking of a head because you can't really nod or shake your head to answer that appropriately. You almost have to answer it verbally.

[00:31:01] So using those. Those forced choice questions very thoughtfully can be very helpful. And then shifting to more open ended questions like, what's your favorite kind of ice cream? Or what did you do this weekend? Or what game should we play today? And kind of again, layering that with those earlier CDI skills.

[00:31:16] So layering on all that positive praise, layering on those additional comments and behavioral descriptions. So it's not just a non stop barrage of questions, but maybe you ask a question, they answer you. Great job answering my question. Okay, let's get back to our game. I'm going to flip this one over. Oh, good job looking.

[00:31:33] Okay, you're going to flip your card over. Nice job with that. Hmm. What did you pick up there? So you're kind of mixing in these rapport building skills with also these, these Verbal eliciting skills, and then I will say another technique that's super helpful is what we call a fade in. And this, you know, can can be done a lot of different ways, depending on your setting and your resources and, you know, how available the child's family members are.

[00:31:58] But essentially, what you do is, if the child's able to talk to one of their family members, like, say, a parent, you have the child and the parent come in, say, to your speech room, and you have them start in there doing an activity without you in the room, and you talk to the parent ahead of time and say, your job is to keep your child talking throughout this whole interaction.

[00:32:16] So you might teach them about forced choice questions and open ended questions and. How to kind of elicit that in a thoughtful way. And so the parent starts by playing with the child. They warm up, the parent asks the child some questions, get the, gets them verbal there at school, and then you maybe walk past the door.

[00:32:32] So the child gets used to the idea that like, okay, there's someone else around here. And the parent keeps talking and keeps the child talking. And then maybe you come in and you sit in the very edge of the doorway and you don't look at them, you don't talk to them. You bring your clipboard, you bring your computer, you look totally unengaged.

[00:32:46] You just do your work, and the parent keeps the child talking. And then you slowly, incrementally fade your way into the interaction. So then maybe you move a little bit closer, a little bit closer. Then you sit at your desk nearby. Then maybe you sit at the table with them. Still kind of not looking super interested, but just kind of getting the child used to your closer and closer presence.

[00:33:06] The parent's keeping the child talking throughout all of this. And then you get to a point where. Maybe the parent asks a question, the child answers the parent, and then you, as the observer, start to make some comments like, Oh, that looks like such a fun game you're playing. Wow, I really love Zingo.

[00:33:20] You're really doing a good job. You're totally kicking mom's butt on this one. And then, again, the parent keeps the child talking, and as long as the child keeps talking through each of these steps, you can kind of keep working your way into the interaction. If at any point the child stops talking, like they freeze, or they shut down, or this is too much, you might have moved a step too quickly for them.

[00:33:39] So you would just kind of back up a little bit. Let them kind of rewarm up again, let them kind of get back to where they need to be, and then kind of start easing your way back in. But eventually, as you ease your way into this interaction, you as the new person start asking the questions, and the parent slows their questions, and then the parent starts to kind of fade themself out.

[00:33:57] So once the child's answering you comfortably, the parent might take a step back, and then maybe the parent goes and sits at your desk. And then maybe the parent goes and sits by the door and then maybe the parent says like, Oh, you know what? I'm going to run to the bathroom. You guys keep playing zingo.

[00:34:08] I'll be back in a minute. And they leave the room for a few minutes and then come back. And ideally, if you're out this process, if it's done kind of carefully and incrementally, you've kind of passed the talking baton on from the child was first able to talk to their comfortable person, the parent, they kept up that talk as you kind of, integrated yourself into that interaction, and now they're able to talk to you comfortably too, because it was done so seamlessly, and the parents able to fade themselves out.

[00:34:31] And usually what we see, sometimes it can take, you know, one or two times of doing this, but usually what we see is once that speech is there, it tends to stick with that person. And so now, hopefully, the next time you go to pull that child, they'll be able to talk to you one on one. They still might need some warm up time, some of that kind of no speech demands, commenting, behavioral descriptions type of time.

[00:34:51] But as you start to ask them questions on your own, hopefully they'll still be able to answer you. And so now you're a familiar person who can talk to them, and now you can pass this baton on to somebody else. So now maybe you fade in their homeroom teacher, and do kind of the same process. And this time you and the child start off playing, and the teacher fades herself in very slowly, and then you fade yourself out.

[00:35:10] And then you can do this with peers, and with other adults, and kind of slowly increase the people that you're talking to, or the places that you're talking in. 

[00:35:19] Carolyn Dolby: I like that calling fade in the fade, in fade out, which is great. And I like the idea of using a parent. That's not always possible in the school setting, to be quite honest.

[00:35:28] Having the parent be able to come to school and do something like that. I, so hopefully using that and the school setting might be, if they do talk with, let's say they do talk with peers, but they won't talk with. The adults to use that that's a great technique to fade in with what whoever their conversational partner is that you can get on the school setting.

[00:35:51] We have had a couple of questions come in. We have someone they have a. Student that will often not respond to those forced choice questions. And if you reverted back to the yes, no, is that bad? Because we don't want to yes. No. But I guess if we're trying, I guess she's asking, where would we start if.

[00:36:12] If they're not responding to those open ended questions, do we go, but I think. Would we then go back to setting the report and having non speech demands? 

[00:36:21] Emily Laracy: So, yeah, there's a couple ways you could kind of approach that. So one thing I would say is, yes, I would backtrack a little bit and try not having any speech demands for maybe a session or two and see if that Helps to kind of establish that rapport and kind of that lowering of the anxiety and then maybe try some of those questions again.

[00:36:39] 2, I would try a fade in and to your point. Yes. Sometimes parents can't come in. Sometimes their work schedule is crazy. Sometimes, you know, during covid parents weren't allowed in our building for like 2 straight years. You know, sometimes there's barriers and and we're not able to do that. I've already done variations of fate ends where I had a parent on FaceTime on my phone.

[00:36:56] And so we were able to do that. They were able to call in from work and we kind of did kind of a modified fade in that way. I've done it with the child siblings if they're in the same school and they're able to talk to their sibling and I've kind of, you know, coach the sibling a little bit on what I would need from them.

[00:37:09] Like you said, if there's peers or, you know, an adult that the child's comfortable with, and they are able to talk to you can start with that person. Certainly. So there's some ways to kind of be flexible with those fade ins, but those can be really helpful. If they're not, if going from rapport building to forced choice questions is too big of a jump for them.

[00:37:25] Sometimes a fade in in there helps bridge that gap. Another strategy that's out there. It's called the ritual sound approach. And basically what that is, and this, this will feel very speechy and very familiar to SLVs. But basically what that is, is this idea of like, you, you play a game and you shape the child's responses from airflow to individual sounds up to an individual word and then eventually into like whole sentence answers.

[00:37:50] And so it can look like something as simple as like, if you have some feathers, so I borrowed feathers from my art teacher if you have some feathers and you and the child each have a feather and you say something like, okay, I'm going to make my feather move and you make the focus on the feather moving, not on the child talking.

[00:38:05] I'm going to make my feather move. So first I'm going to go, and then I want you to do the same thing. So watch how I make my feather move. And then you hold it up, and maybe you do the H sound, like, H, H. And you blow on the feather, and that makes it move. Wow, look how fast my feather moved! I wonder if you can make yours move so fast.

[00:38:19] So go ahead, you do the same thing. Go ahead and make your feather move. So first you have the child practice a couple different airflow types of things. And then once they can do that, you can try a couple of voiceless phonemes. And once they can do that, you can work a couple of vowel sounds, or a couple of voiced phonemes in there.

[00:38:33] And eventually you can shape, I usually do nonsense words first, so I might do like, I'm trying to think of one, like, See if you can make your feather move that way. Do it the same way I did. And then you can shape that into a whole word, mip, which is a nonsense word. And then you could shape that into a specific word.

[00:38:49] So maybe if you happen to know the child's favorite color is pink, maybe you shape the word pink get them to make their feather move by saying the word pink. And then you say, okay, now I'm going to ask you, what's your favorite color? And I want you to make your feather move by saying pink. Okay. So let's do that.

[00:39:03] What's your favorite color? What's your favorite color? And they do pink and make their feather move. Great job making your feather move. Like, and so that can be really helpful. I've had a couple of kids who, as you said, couldn't make that jump to forced choice questions and they really needed those intermediate kind of air flow, voiceless sounds, voiced sounds, individual words.

[00:39:23] I will say though, that. That doesn't tend to be the norm of all the kids that I've worked with. Not very many have needed broken down to that level of specificity, but it's a great tool to kind of have in your toolbox. If you have a kid where you can't do a fade in for some reason, or you need kind of another strategy. 

[00:39:39] Carolyn Dolby: That is great.

[00:39:40] The, you called that the ritual sound approach. And I like that because I think all of us were like, I was. Quickly writing that down, thinking, okay, we start with just airflow sounds like the giving no, again, no language pressure. It's just, it's just play and moving to a voiceless, right? Easy airflow feel not.

[00:40:03] And then I love that shaping. Yeah, that's what we do. We love that. 

[00:40:07] Emily Laracy: Yeah, sLPs because they're like, Oh, I can do that. No problem. I'm great at shaping sounds. I'm great at kind of knowing the hierarchy of sound. So that that's a nice one for us to use. 

[00:40:17] Carolyn Dolby: It's, I think the bottom line is the, we're really taking the pressure off, like, it's just play.

[00:40:25] We're just, we're breathing. We have to breathe, you know, using our breath to get us to start phonating. I love that. Fantastic. Got some more questions coming in. My student is not yet speaking with me or in the classroom. At this point, his teacher frequently uses yes, no questions to figure out his wants and needs in the classroom and to get his participation and assess his learning in the school day.

[00:40:50] She's really asking, should I advise her to move to forced choice in that environment, even though he's unlikely to respond to those questions at this point? 

[00:41:00] Emily Laracy: Great question. And I think, I think your previous question was getting at this a little bit too of like, should I go back to yes, no questions.

[00:41:06] One thing we didn't talk about yet is what we call the negative reinforcement cycle of SM. So essentially what we know about SM is that kids get pretty good at not talking, they get pretty good at figuring out how to not do this thing that is so scary to them and so hard for them and so challenging for them.

[00:41:23] And so we see that in. The head nods and shaking the thumbs up and the thumbs down the hiding behind mom, the turning away from the situation, the walking away from the situation, the not making eye contact. We see those types of avoidance behaviors. And what we know is. If we kind of allow those avoidance behaviors to happen and answer for the child, so maybe we ask the child a question.

[00:41:47] They look down at the ground. They kind of shrug their shoulders a little bit. We say, oh, you don't know. Okay, well, I'll ask somebody else. You know, Johnny, what do you think the answer is? What we've just done then is in the short term, we've solved our problem, right? Because we've, we've kind of had the child participate, which was our goal as the teacher, or we've kind of gotten our question answered.

[00:42:03] And we moved past that awkward moment. And, and, you know, the teacher feels like, okay, I got something out of them, you know, like, okay, good. We've, we've handled that situation. But in the long term, we've just kind of reinforced and the child has either consciously or unconsciously learned. Okay, well, when I look away and shrug my shoulders, they'll move on to somebody else, and I don't have to do this really hard, scary thing.

[00:42:24] And so over time, imagine how many times your kids are getting prompted to talk throughout the day. I mean, I've got students that by the time they walk from the front door to their classroom, they're being asked four or five questions. They're being greeted by four or five different staff members. You know, like, this is probably hundreds or even thousand times a day that they're being prompted to talk.

[00:42:41] And so that's hundreds or even thousand times a day. That this avoidance cycle is getting reinforced and becoming their default response of just okay. I'll look away and shrug and then I don't have to answer. I'll look away and shrug and then she'll move on to somebody else. And so our job as the interventionists in this setting is to really create an alternate pathway.

[00:43:00] So, instead of having all these instances of negative reinforcement where you know. And so when we're talking about this scary thing is being taken away from kids when they avoid it, we find appropriately challenging ways to help them be successful and so really thinking about I am getting to your question.

[00:43:16] This is just a long way of answering it. No, I love it. Keep going really thinking about what's an appropriate challenge for where this child is right now? So, as some of you have said, if you've got kids who are not talking to anyone in any setting, they're not going to just start answering a question just because the teacher words it tomorrow.

[00:43:30] They're not going to make that jump yet and they're not ready for that yet. So, rather than it. Putting them in those situations where we're reinforcing the not talking, I would say stop asking that child questions for right now, because it's better to not reinforce the avoidance than to reinforce the avoidance, if that makes sense.

[00:43:46] It's better to kind of take a step back take a break from that expectation for right now, because if we reinforce the avoidance more, we've just got all the more work to do to break that cycle and kind of create a new pathway there. So if you've got a teacher who really wants this child to participate, You know, they're not able to answer a question in front of their whole entire classroom right now.

[00:44:05] Okay, that's not the expectation for this child. Maybe you do go back to non verbals with them for a little bit. You know, maybe they are just giving thumbs up or thumbs down, you know. Emily, do you agree or disagree with Sarah? Go ahead and show me with your thumb. She gives a thumbs up or a thumbs down.

[00:44:18] Maybe they're using some kind of card on their desk. You know, something to show that like, yes, I need help. Or yes, I, I understand or no, I need help or something like that. Because it's always this balancing act of what's an appropriate challenge for them. And how are they getting their basic needs met throughout the day?

[00:44:33] Right? And so, you know, we want to make sure that if you've got a child is not talking to their teacher or in their classroom at all. They still need to be able to ask for help. They still need to be able to ask to go to the bathroom. They still need to be able to ask to go to the nurse. And so we're not going to say absolutely never use a nonverbal or never use a yes.

[00:44:49] No question. You know, if you've got a child who fell and the teacher needs to know if he needs to go to the nurse, you might have to ask a yes. No question in that moment because it's a safety issue. So even though these are kind of general principles. Early on in these early stages of treatment, we might be making some exceptions because we're saying we need to get their basic needs met.

[00:45:06] So maybe for now, the way they're requesting going to the bathroom is by handing a card to the teacher before they go. That being said in therapy, we're also working up towards being able to talk to the teacher and being able to verbally request going to the bathroom. So we don't want to get stuck in the non verbals.

[00:45:22] We don't want to get stuck in the thumbs up and down. We don't want to get stuck in the yes, no questions and just accept those from now on as an appropriate response. We still want to build those more appropriate responses. But for now, we may need to use them in instances of health or safety or kind of, you know, getting basic information from the child.

[00:45:39] Does that answer your question? 

[00:45:41] Carolyn Dolby: Yeah, I am so glad you said that, because I, for a minute there, I was having, I was having some trouble because, right, those basic needs. So, I just want to make sure I have. This is why they need us this way speech paths are really needed to be part of this team is because we do need to find a communicative modality for them to get those basic needs met in the greater in those greater settings, but then.

[00:46:08] In therapy, that's where we are working on. I like we're doing the fade in or the if we're going back to the ritual sound approach, a question that came in and I'm sorry, I wanted to come back to that because it's a real good question. We've got someone that is doing that the ritual sound approach where the child is willing to imitate sounds.

[00:46:32] They're even willing to imitate words, even sentences, but will not. Engage verbally. Otherwise, how do how do you shape it into conversation? 

[00:46:46] Emily Laracy: So there's a couple ways you can do that. If if the child's able to write and they may not be able to do that yet, but if they're able to write either just kind of agent developmentally wise or from an SM expressive kind of way, a lot of our kids are more comfortable writing than they are talking.

[00:47:00] So if they're able to write, I would suggest that for a little while You have, you ask the child a question, you have them write down their response, and then first you read the written response out loud to get them used to the fact that they've contributed an idea and you're now verbalizing it for them, and then fade into having the child read that response out loud.

[00:47:16] So maybe it looks like something like, so, say ice cream again. You're talking about what's your favorite kind of ice cream, the child writes down mint chocolate chip, you pick up the paper and you say, mint chocolate chip, oh your favorite's mint chocolate chip, thanks for telling me mint chocolate chip.

[00:47:28] And then the next time you do it, you say, okay, this time, I'm going to say mint chocolate and you're going to say chip, so you're going to finish it. So what's your favorite kind of ice cream? Mint chocolate, and then you wait and the child fills in chip. You can do that without writing too, so you can do things like kind of fill in the blank types of responses.

[00:47:44] You can also do things where maybe you start with you and the child saying something at the same time, and then you kind of practice that over time until maybe you're whispering the child saying it at full volume, or you're mouthing it and the child's saying it at full volume. Sometimes. That kind of mask of saying it with another person can make them feel more comfortable and less in the spotlight.

[00:48:03] And so that can, can help with some of those things. Like I said, those fill in the blank types of things. So maybe you're practicing if you're practicing answering a question and the question is going to be, did you play inside or outside this weekend? I'm going to say in, you say side. So I'll ask the question, did you play inside or outside this weekend?

[00:48:20] I played in. And the child says side and then the next time they say inside and then the next time you say I played and they say inside with my brother, you know, so you're kind of increasing the amount that they're offering each time. Anytime that the child can plan what they're going to say, or preselect what they're going to say, that's going to make those responses easier than trying to think of them kind of off the cuff like that.

[00:48:42] And anytime you can kind of provide those set choices instead of them having to think of their own novel response, that usually makes it easier because they're not having to. Share their own opinion necessarily or generate their own idea. They're kind of starting by just picking something and then maybe you move that more towards more open ended things where they are starting to do more volunteering of their own thoughts.

[00:49:04] Carolyn Dolby: Yeah, thank you for that. I think I missed a question and I think you kind of just answered it. We had someone ask about she has or they they built wonderful and a ton of rapport and this is high school and they enjoy being with the clinician. However They will just stare. No moving past that.

[00:49:24] And so I'm thinking what you said about using written language, especially at the high school level, is incorporating that. I think that answered that question. Thank you. 

[00:49:33] Emily Laracy: Yeah, and I would also say just kind of general tip for like, tweens and teens, getting their buy in is so critical. And so especially as we get to those older ages, those 9, teenage kids really being transparent about what you're doing and what your role is.

[00:49:47] So it tends to be less play based at that age and tends to be a little bit more like, okay, like, I know talking is really hard for you. I know this is really challenging. I know I'm asking you to do the hardest thing. This is the hardest part of your day. I'm probably your least favorite class and that's okay.

[00:50:02] And it's my job to help you get the skills you need to, you know, Have a job someday to have a relationship someday if you choose to, to make friends someday to be in a club if you want to, to be in the band, if you want to. Those types of things. So getting buy-in from them and written, written activities is a great way to do this.

[00:50:20] You can also just kind of make up your own surveys. I've made several different things where I listed a bunch of jobs or goals or extracurricular activities and had kids rate, you know, what were their top. Or had them fill out kind of all about me types of pages that were age appropriate where they talked about what are their interests?

[00:50:37] What do they see themselves doing? What do they like to do on the weekends or after school? What do they want to do when they graduate high school? What do they want to do in college or as a job or things? You know, what? What dreams and aspirations do they have? And once you know, what kind of some of their interests are.

[00:50:51] You can start to tailor things to it and say like, okay, if you want to be a jewelry designer and own your own jewelry shop, that's an amazing goal. And you're going to need to be able to talk to customers. So let's think about ways, things that we can practice that will make it easier to talk to customers, or that will make it easier to make small talk or, you know, let's role play some exchanges.

[00:51:10] You might have, if you're working at a job or you're working in a cash register and you have to tell people how much money it is, or that they need to scan their credit card or something like that. So finding ways to make it. Motivating and meaningful for them is really critical. And also, I'll say sometimes teens aren't ready to work to jump to the verbalization work, but they might, they might struggle with things like writing emails or writing texts, and those can be nice kind of intermediate ways to start working on some of those.

[00:51:37] them thinking of their own thoughts, them expressing themselves, help them text their friends, help them come up with a plan of how we're going to text our friends. And maybe it starts with you write out the text first or, and you plan the text and they write, they type it out and send it, or maybe you two work on it together, or maybe they write a draft, or there's lots of ways you can kind of practice that.

[00:51:56] And that may be a good way of kind of easing into something because again, remember these kids may have spent. 10 to 15 years of their life, not talking to people. And so this is something that they've lived with as long as they can remember. It's not going to be fixed as quickly as it will if you start intervention with a 3, a 4, year old.

[00:52:16] Carolyn Dolby: Right. I would, I would suspect the longer that it has been going on, the harder it is to remediate and to help. I, a question I'm having is, like, what kind of goal would we You know, we have to have goals if we're going to be providing services, right? So what kind of goals are we looking at? 

[00:52:35] Emily Laracy: Yeah. So again, coming back to that framework of people, places and things.

[00:52:38] So as you're writing, you know, in my school, we have to write smart goals. I'm sure most people have to write smart goals, or at least very concrete, measurable goals. So writing goals, you know, That might look something like in a small group setting, the student will answer open ended questions from a teacher in 4 out of 5 opportunities, you know, across 3 consecutive days or something like that, or during unstructured playtime, such as recess or, you know, free time or study hall, the student will ask for help in 3 opportunities across a 30 minute period.

[00:53:11] Or something like when in a large group of peers of, you know, 6 or more peers, the student will answer questions from peers, you know, with 80 percent accuracy, or in 4 out of 5 opportunities or something like that. So there's lots of ways you can kind of word it, but As we're thinking about goals, I think something that can be tricky is kind of thinking about, okay, I wrote this beautiful goal, they mastered this beautiful goal, and now what do we do next?

[00:53:34] Because I know we're not done, but how do I know where to go from there? And so what I usually tell people is only change one variable at a time. So if you're working on the skill of answering questions, and your goal was they'll answer questions from their teacher in a one on one situation, Keep some of keep most of those things the same and only change 1 component of that.

[00:53:53] So, if they can answer questions from their teacher in a 1 on 1 setting now, make it answering questions from their teacher in a small group setting. So, you've kept most of those components the same. You've just changed kind of the setting or the. the situation that they're in. If you're working on them being able to ask questions, maybe they first work on asking questions to their teacher, that tends to be the most functional first.

[00:54:15] And once they can ask questions to their teacher in their classroom, now can they ask questions to their other teachers? So can they ask questions to their library teacher, their music teacher, to the building substitute? To the office staff to the nurse to things like that. So you've kept that goal of asking questions and a one on one situation the same, but you've changed who it is that they're asking those questions to.

[00:54:36] So always kind of thinking about, like, what's what's 1 variable. I can change here to kind of increase the difficulty of this without it being a major shift. That's going to cause them to really struggle 

[00:54:46] Carolyn Dolby: and keeping in the when we're thinking about goals, or what is your opinion on goals being directly

[00:54:52] Speech in with the speech pathologist 1st and only or collaborative working collaborative across the settings. What would your recommendations be? 

[00:55:02] Emily Laracy: So, collaboration is always ideal, and I think sometimes there's there's barriers to that that we have to be aware of, but certainly the, the. The ideal situation would be that everyone on the team knows exactly what the student's working on and can kind of help support that, which may look like taking a step back, right?

[00:55:19] So I've had conversations already with, you know, my entire school staff where I said, this student is not yet able to answer questions from everybody. They are just working on answering questions from me and from their classroom teacher. So I know you all really, really, really want to help. And I so appreciate that.

[00:55:35] And it's not helpful when five of you say, Hey, Good morning so and so. How was your day? How was your weekend? What are you doing today? What special do you have today? Are you excited for class today? Who's your teacher? That's not helpful because she can't answer those questions yet. What's more helpful is if you just make a comment when you see her.

[00:55:50] Hey so and so, so good to see you. Hey Emily, I hope you had a good weekend. Hey Emily, so glad you're at school today. Something that doesn't require a response. And I'll let you know when we're ready to practice. I know you'll all be great when we're ready to practice with more people, but we're not there yet.

[00:56:03] So sometimes it looks like kind of being clear to the rest of the team of like, how they can help and kind of who the focus is right now, and who might need to take a little bit of a step back. So it's not too much all at once. I've had some really great collaborative efforts where once the student could talk to me and could talk to their teacher, we really shifted to doing almost more push in therapy.

[00:56:25] Where I was working in the classroom and kind of facilitating speech between different peers or between different paraprofessionals that were in and out of the classroom. And so there was a lot of kind of co teaching and collaboration that went on as students have gotten older. I've had them had goals that were more set to the regular ed setting instead of always in pull out services.

[00:56:44] So things like, you know, they'll ask questions to 4 different teachers throughout their day. Or they'll answer questions in four different classrooms throughout the day, and they might have had a clipboard that they take around with them. And either the student keeps track, they check things off every time they answer a question, or the various teachers do, and they check things off.

[00:56:59] So there's definitely, it's definitely important to have that collaboration so that everybody knows this is where the student is, and this is what the expectation is for them right now. And also as those things change that we're continuing to update the team and say like, okay, now she is ready for you to ask her questions.

[00:57:13] And that would actually be super helpful. So please ask forced choice questions, or please ask open ended questions. 

[00:57:19] Carolyn Dolby: I think that that is so, that it's a shift for us. Cause we always, as speech paths, we want everyone communicating. We want everybody to have this language rich environment. And of course, questions, questions galore.

[00:57:32] But I think starting with educating the staff. Especially on what a speech demand is versus making comments. Interacting is great, but really, because everyone wants to help and they think they're helping but having to really educate the entire staff of what they, everybody is on board. It is a team.

[00:57:52] I love that. Well, now, you know, really, well, how do we know when to end? How do we know dismissal of speech services? 

[00:58:02] Emily Laracy: Yeah, I, I think that's a great question. I think that's one that I'm always kind of thinking about with all of my students is like, you know, at what point are we ready to kind of release them back onto their own?

[00:58:11] And I think it's that same question, right? So in Pennsylvania, where I am, we always have to think about what's the educational impact. Is it impacting them academically? Is it impacting them socially? And if we can collect evidence that Through observations, through grading scales, through input from the child themself, through input from teachers that they're able to engage in all those age appropriate social skills that they need and academic tasks that they're expected to do.

[00:58:34] Then I think we can really back off of our services. I've seen a lot of cases where a piece of state on his consult for maybe a year or 2, especially if it's a transition year. So, for us. Fifth grade is the end of elementary school. Sixth grade is the beginning of middle school. So fifth to sixth grade is a huge transition.

[00:58:52] And you go from having one teacher all day to having several teachers in one day, and you go to switching classes, and you go to being with lots more students, and it's a big transition year. So I would advocate for not ending services right before a giant transition, staying on as consult, or just kind of making sure that transition goes smoothly, making sure they make that jump to a new setting, a new school year, a new teacher, that kind of thing.

[00:59:13] Smoothly and successfully, and then kind of looking at backing off of services. You know, and it may be something that kind of pops up again. I know an individual who had SM as a child was on medication, got therapy for it was doing amazing, got through middle school without any therapy was doing amazing, got to high school and then just a mix of.

[00:59:35] High school and peer pressure and being a teenager and hormones and all of those things. It came roaring back for him, and he had to get back on meds and get back into therapy, and he needed some more support again. So, kind of just keeping an eye out on these kids are making sure somebody's kind of got this child on their radar so that if it does pop up again later in a new situation, or if something changes for them, we can kind of just be aware of that situation and jump back in if we need to.

[01:00:00] Carolyn Dolby: Right. Wow. So you're saying, yeah, it's not a 100 percent fix possibly that you're saying that it could come back again because the anxiety is the behind it. So we're not, wow. Wow. Thank you. Oh, thank you, Ellen. She said you have no idea how helpful this session has been. Thank you. Well, thanks for, yeah.

[01:00:22] Thank you for joining us. We are getting towards the end. And I hate that because this has been so thrilling and I know I couldn't wait for this episode because I, I, I was saying before we got started how I just have a new one on my caseload this week. And so this has been amazing for me. So many, so many wonderful resources and the strategies really.

[01:00:47] I love that. I kind of tried to write those in about, not starting with not having a speech demand and and the, the difference between just having those comments and rapport versus a demand and then not doing those. Yes. No. And doing this forced choice. Then we go to the fade in. I love that idea.

[01:01:09] Ritual sound approach that that 1, I think resonated with all of us. Like, okay, I can. Yeah, I got that. And then seriously, the negative reinforcement. Being that when you are giving them that out. That we're not helping them. You know, I think that that is powerful for us. And then finding the alternative pathways was helpful, especially with those older students when we can incorporate writing typing, texting and all those kind of things.

[01:01:39] Fantastic. Is there anything else that I missed or, or, you know, the other question I was going to say, where can we get more resources for this? Because I think a lot of us, there's like, we would love a. Yeah. You know, a step by step where to go. What's the next step? Lay that on us. 

[01:01:55] Emily Laracy: Yeah. So great.

[01:01:56] That's exactly what I was just going to say. It was just to kind of end with some suggestions. Like I said, the Selective Mutism Association, there are free webinars available. There's a caregiver's toolkit, which is great to give to parents who are looking for more information. There's an educator's toolkit, which is great to share with school teams.

[01:02:11] We recently created an educator's web course, and so there's different tracks there for either elementary or secondary teachers to kind of do a self paced course to learn about SM and how they can support kids with SM. So that's available on the website. So definitely check out, you know, selective mutism dot org.

[01:02:26] I would also say another great resource is called the SM University. If you just Google SM University, it'll come up and. That is a free online training program to learn those skills, those evidence based child directed and verbally directed interactions. There's videos. There's quizzes. There's descriptions.

[01:02:43] It's a great way to kind of learn those skills. So that's great for us as clinicians, but also again to share with parents with teachers who might be willing to learn. So that's a wonderful free resource. Not to self promote, but my book treating SM as an SLP is available and I tried to design that book to be kind of like you said, like, oh, I just got this kid on my caseload.

[01:03:04] I'm not sure where to start. I'm not sure what to do. What do I need to know? Where do I get started? And so it kind of goes into a lot more depth of the topics we hit tonight and the ones we didn't get to. So that's available. So I would say those are some really great resources. And then, you know, just kind of a final closing thought is we're in a really good position to work with these kids because we understand scaffolding and that's what these kids need more than anything else is they need incremental goals and steps forward and they need it to be carefully scaffolded so that they can be successful and have all those successful repetitions to kind of become their new response pathway.

[01:03:37] And so, We get scaffolding maybe better than anyone else in the school building. And so we really have the mindset to work with these kids. And it can be one of the most rewarding populations to work with. I know it's not maybe a high incidence disorder at this point. I know a lot of people said they might've had one or two or they previously did.

[01:03:55] But they can be so rewarding to the point where earlier this school year, a teacher came to talk to me and said that a student who's on my caseload and is about ready to be dismissed who had had SM was leading her table in singing Taylor Swift at parent pickup. Quite loudly and quite obnoxiously from what I hear.

[01:04:11] So we had to have a little conversation about that. We had to have a conversation about you can't do cartwheels in the hallway. And so, you know, just being able to see the shift from this was a child who came in that was so severe she could not even give a thumbs up if you asked her a question. She was having accidents because she couldn't go.

[01:04:25] She couldn't request to go to the bathroom. She couldn't even slide a card across the table to her teacher. And now is at the point where she's like, Conducting Taylor Swift concerts in the cafeteria. Like it's just, it's amazing to see the progress that these kids make once we have the right interventions in place.

[01:04:39] So, don't give up if you're feeling stuck. There's lots of resources out there. You have a ton of skills to be able to help these kids. So I hope tonight just kind of gave you some ideas and gave you kind of some tools to be able to use with this population. 

[01:04:51] Carolyn Dolby: Well, Emily, thank you so much. This has been so informative.

[01:04:55] I know everybody that's listening is. We're able to take back so much with what you've taught us. And did you was it SM University? I want to make sure I got okay. SM University is right. Okay. Well, we are at the end of our night. Thank you so much. Everyone for joining us. Well, I want to thank Emily.

[01:05:14] Thank you so much. This is fantastic. Thank you. Everyone that's listening. And I look forward to seeing everybody again. Thank you. Bye guys. 

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