building brave muscles27c2s3mdcxk2qzutg1z8oa91-wpengine.netdna-ssl.com/... · 11/13/2013 ·...

Building Brave Muscles: The Specific Behavioral Skills that

Target Increasing Bravery

Laura Kirmayer, MSW, MA CMI Post Doctoral Fellow

November 13, 2013

Outline for our Time Together

•  Brief Review of Selec/ve Mu/sm 101 •  Treatment Plan

•  Skills Training and Prac/ce •  Brief Introduc/on to Climbing the Ladder: Targeted Prac/ce

•  Ques/ons and Discussion

What is Selective Mutism?

* Persistent failure to speak in specific social situations when speaking is expected (e.g. school, extra-curricular activities, play dates) but speaks fluently in other situations (e.g. home)

•  Fluid speech in other situations (often at home and in familiar places)

•  Causes Impairment

•  Duration for at least 1 month and not the 1st month of school

DSM- V

“Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”

Changed to “Anxiety Disorders”

(Otherwise Criteria is largely unchanged)

Debunk The Myths Elective Mutism

Selective Mutism = Social Phobia Trauma Related Child will “out grow” the behavior Shy Autism Cognitive Deficits Language/Communication Disorders

Nature and Nurture

Current conceptualization of SM

Child is prompted to talk or engage

Child gets (too)

anxious

Child avoids

Adult rescues*

Child’s and adult’s anxiety are lowered*

Nega>ve reinforcement

Behavioral Conceptualiza>on

Why do children continue not to speak?

Selective Mutism is a Learned Response

Long Series of Negatively Reinforced Interactions

Becomes Automatic

Rapid Fire on a Daily Basis

The Contamination Effect

Treatment Goals •  Develop the child’s capacity to manage anxiety

related to speaking so that child is able to overcome its impact (Building Brave Muscles!)

•  Increase number of people, settings, and situations in which child speaks responsively and spontaneously

•  Diminish anxiety

Psychoeducation This includes the child, parents, teachers and even friends and friends parents, store clerks and doormen! Treatment is transparent and collaborative, we need everyone on board! Really important to debunk the myths that may interfere with how we approach the child and the anxiety

Distress Tolerance

Natural instinct is to help a child in distress.

A Talking Map is our starting place in Treatment

Create one together as we walk through next slides…

People, Places, and Activities •  Unique varia/ons from child to child

•  Treatment needs to be individualized to these varia/ons –  Same goal and same approach, but different star/ng points and different size steps

PEOPLE Haves

•  Parents •  Siblings

Have-Nots •  Peers •  Relatives •  Neighbors •  Family Friends •  Teachers •  *Strangers

PLACES •  Safety zones •  Sensitivity to surroundings can result in really dramatic

differences even within a setting •  Frequently observable shifts in presentation depending

on degree of comfort •  These boundaries tend to be rigid

ACTIVITIES •  Activities they feel confident or comfortable engaging •  Less self-conscious activities •  Less structured activities •  Activities that involve physical activity and produce

laughter…

How We begin…

Avoid contamination effect

NO QUESTIONS PLEASE!

Remove the expectation to speak and build a comfort level

Gradually and systematically

Sensitize child to our presence and to verbalize in our presence through the use of

two core skill sets

Familiar with PCIT or TCIT?

Parent-Child Interaction Therapy Or

Teacher-Child Interaction Therapy

SM Behavioral Skill Modules

•  Child Directed Interaction (CDI) –  Reward/ Reinforcement

•  Verbalization Directed Interaction (VDI) –  Exposure/ Approach Task

•  Fade-in –  Passing the ‘talking baton’ –  Generalization

•  Targeted Exposures

Child Directed Interaction

CDI

PRIDE Skills •  Praise - Labeled Praise (LP) •  Reflect (RF) •  Imitate •  Describe- Behavior Descriptions (BD) •  Enjoyment

****AVOID

• Questions, commands, and criticism- sarcasm

The POWER of the skills •  LP:

–  increase behavior you are praising –  increases self esteem

•  BD: –  lets child lead –  shows interest –  models good speech and vocabulary –  Attention skills –  Organizational skills

The POWER of the Skills (2) •  RF:

–  Child leads conversation –  Models verbalization and listening –  *Increases verbal communication –  Demonstrates acceptance and understanding IMITATE and ENJOYMENT

AVOID MINDREADING!!!

Pull for the Narrative through Behavior Descriptions!

ANY Verbalization…

REFLECT and LABELED PRAISE IT!

(trifecta: Sticker!)

Behavioral reinforcement Targeting TALKING

Brave Talking earns Brave Bucks

= Prizes

*debunk myths about extrinsic motivators and use of reinforcement

Skill Drill •  5 minutes

–  10 behavioral descriptions –  10 labeled praise –  reflect ALL verbalizations (if any) –  0 questions –  0 commands –  0 negative talk

Verbalization Directed Intervention

VDI

Verbalization Directed Interactions

Defini>on VDI is a specific set of “Do” skills that builds on the SM-‐CDI “Do” skills, adding specific prompts to verbalize and providing valid opportuni/es for the child to respond. Why we do it To op/mize opportuni/es for a child to provide a verbal response and minimize opportuni/es that inadvertently discourage verbal responding. TO BUILD BRAVE MUSCLES!! When we use it AWer the child has had an opportunity to warm up with SM-‐CDI. Even when you deem that a child is ready for VDI, *s/ll uses LP, RF, and BD in your skills repertoire, combining CDI and VDI.

Types of Verbalizations •  Sounds and Noises

•  Responsive –  Following a prompt (question or command)

•  Spontaneous –  Self initiated

•  Socially ‘Expected’ –  Hello, Good-bye, excuse me, please and thank you

Following a warm-up… •  Whenever he/she spontaneously verbalizes: REFLECT

and LABEL PRAISE (bonus…sticker!)

•  OR

•  Plan for a prompted verbalization…

•  **When should we use CDI? When should we use CDI and VDI together?

Effective VDI Sequence

3 types of questions

Yes/ No Forced Choice Open Ended

Direct Command for Verbalization

DCV

Forced Choice or Open Ended Ques/on /or

Direct Verbal Command or Prompt for Verbaliza/on


Wait 5 seconds

The longest 5 seconds ever…

DISTRESS TOLERANCE



Verbal Response No Response Nonverbal Response




Verbal Response

Reflec/on and Labeled Praise

No Response

Wait 5 seconds Reformat or Repeat

Ques/on

Nonverbal Response

Acknowledge Gesture and Neutral Probe for

Verbal

No response/ nonverbal

Wait 5 seconds and “Plan B”

Verbal Response

Reflec/on and Labeled Praise


Accommodating versus

Enabling

•  A child verbalizes during morning mee/ng in a barely audible whisper. Her counselor reflects the verbaliza/on so that the others in the group can hear exactly what she said.

•  This is accommoda/on if the child has not yet consistently verbalized during morning mee/ng and/or is working on the goal of verbalizing in front of peers.

•  This is enabling if the child has already incorporated this behavior into her repertoire and is working on volume as her target behavior.

•  A child is prompted to verbalize during morning mee/ng and says, “I don’t want to.” The counselor says, “Great job telling me that you don’t want to.”

•  This is accommoda/on if the child has not yet demonstrated an ability to say “I don’t want to,” or “I don’t know,” in which case she has reached a goal with this verbaliza/on.

•  This is enabling if “I don’t want to,” is func/oning as an avoidance behavior and she needs prac/ce just deciding among op/ons, which is a common comorbid problem for children with SM.

•  A child is interviewing a peer for her Brave Buddies Workbook. The counselor points to the next ques/on, but the child does not read it. The counselor leans in to the child and whispers the ques/on in her ear.

•  This is accommoda/on if the child did not ask the ques/on due to difficulty reading from her workbook.

•  This is enabling if the child did not have a skills deficit in reading.

Accommodating Versus Enabling

Do’s and Don’ts

Do’s •  DO Label Praise for Talking

–  Example of Labeled Praise: Thank you so much for telling me you want crackers for snack.

–  Example of Labeled Praise: I love how you told me that you’re done with your worksheet.

–  Ra>onale: As opposed to an unlabeled praise (“Good job!”), a labeled praise reinforces and shapes a very specific behavior (talking), thus increasing the likelihood of more talking in the future. Note: Cater Labeled Praise to the age and personality of the child. The enthusiasm and energy of a cheerleader may not be necessary or age appropriate. Find a style of praise that fits for the child. Some children may ini?ally exhibit or even express discomfort with praise. This DOES NOT mean you should stop using praise, alterna?vely gradually build the child’s tolerance for praise by repeated and con?nued use adjus?ng frequency, volume and enthusiasm.

•  DO Reflect Verbaliza>ons

–  Example of a Reflec>on: You told me you need to go to the bathroom. –  Example of a Reflec>on: “Seven! You told me the answer is seven.” –  Ra>onale: Reflec/ons demonstrate that the individual is listening and ahending to the

child’s verbaliza/on, which also lets the child know that he or she was heard. Addi/onally, Reflec/ons maintain a high rate of verbaliza/ons between individuals and models an excellent use of language and listening skills.

Do’s •  DO be a Play-‐by-‐Play Announcer (Behavioral Descrip>ons)

–  Example Behavior Descrip>on: You’re puing your colored pencils back in the pencil case.

–  Example Behavior Descrip>on: You’re tying your shoelaces. –  Ra>onale: Behavior Descrip/ons let the child know that you are engaging with them,

while also modeling proper and developed language. Addi/onally, Behavior Descrip/ons help you avoid mind-‐reading and pull for the child to elaborate or provide the verbal narra/ve related to what they are doing. Note: You may want to use a slower rate of behavior descrip?ons depending on the age and personality of the child, as a higher rate may not be as age-‐appropriate for older children.

•  DO Ask Forced Choice Ques>ons

–  Example Forced Choice: Do you want an apple or an orange with your lunch? –  Example Forced Choice: Is your favorite color blue or something else? –  Example Forced Choice: Does a hexagon have four sides or six sides, or are you not

sure? –  Ra>onale: Forced choice ques/ons provide two concrete op/ons for the child, which

can help reduce anxiety about decision-‐making and verbaliza/on. Forced choice ques/ons also minimize the child’s tendency to engage in a non-‐verbal response.

Do’s

•  DO Ask Open Ended Ques>ons –  Example of Open Ended: What did you eat for lunch today? –  Example of Open Ended: What do you want to be when you grow up? –  Example of Open Ended: What did you do over the weekend? –  Ra>onale: As treatment progresses and the child develops a history of verbaliza/ons

with a specific individual, it is then appropriate to move on to asking open ended ques/ons. Open ended ques/ons can be more difficult for the child to answer, as it oWen requires decision-‐making, risk taking, or formula/ng one’s own answer. Similar to Forced Choice Ques/ons, Open ended ques/ons minimize the child’s tendency to engage in a non-‐verbal response.

•  DO Wait 5 Seconds to Respond

–  Example of Wai>ng 5 Seconds: “Do you want animal crackers or pretzels?” WAIT 5 SECONDS…. “Would you like animal crackers or pretzels?”

–  Ra>onale: AWer asking a forced choice or open-‐ended ques/on, make sure to wait FIVE SECONDS before repea/ng the ques/on. This gives the child a chance to process the ques/on (some children with SM may also have processing issues) and formulate their answer. If the child does not respond aWer 5 seconds, repeat the ques/on in a very neutral tone. It is important to wait five seconds between ques/ons in order to give the child an opportunity to respond because if the child is asked too many ques/ons with no opportunity to respond, a history of non-‐verbaliza/on is created and may be further reinforced.

Do’s

Labeled Praise for Brave Talking* Rehearse

Reflect verbalizations* Prioritize

Play-by-Play Announcer* (Behavioral

Descriptions) Shape

Wait 5” Use a Plan “B” prn

Forced Choice/Open Ended Q’s* Remain calm

*Italicized are specific, observable measurable

Don’ts •  DO NOT Ask Yes/No Ques>ons

–  Example of Yes/No Ques>ons: Do you have your homework? –  Example of Yes/No Ques>ons: Do you want snack? –  Example of Yes/No Ques>ons: Are you ready to line-‐up? –  Ra>onale: Yes or no ques/ons give the child an opportunity to use non-‐verbal

responses (shaking/nodding head or poin/ng) while also crea/ng a history of being non-‐verbal with the individual. Note: If you accidentally ask a yes/no ques?on and the child engages non-‐verbally, you can describe their behavior and reframe the ques?on into a forced choice ques?on. Example: “You are nodding. Do you have your homework… or do you not have your homework?”

•  DO NOT Mind Read –  Example of Mind Reading: (Child is stacking blocks.) “Looks like you are building a

castle!” –  Ra>onale: Although the ahempt to engage with the child is well intended, assuming

that the blocks are a castle when in fact the child may think it is something completely different may be problema/c. The child may not be at a point where he/she is able to verbalize and correct the individual, thus crea/ng more anxiety around verbalizing.

–  Alterna/vely, in this situa/on s/ck to Behavior Descrip/ons: “You are building with the blocks.” By simply describing what the child is doing you are posi/vely ahending to their behavior and your expressed interest may elicit the child’s desire to elaborate or give you the narra/ve.

–  Child: “It is a castle”. • 

Don’ts •  DO NOT Give Direct Prompts to Talk*

–  Example of a Direct Prompt to Talk: Tell me the answer to ques/on number 5 on the worksheet.

–  Example of a Direct Prompt to Talk: Tell the visitor your name. –  Example of a Direct Prompt to Talk: Turn to your partner and tell them your favorite

color. –  Ra>onale: The child may not be at a stage in treatment where he/she is able to succeed

at verbally responding to the direct prompt. If the child then avoids responding to the direct prompt, this adds to the history of non-‐verbaliza/on.

•  DO NOT Give Indirect Prompts to Talk*

–  Example of Indirect Prompts to Talk: Why don’t you sing the song with us? –  Example of Indirect Prompts to Talk: How about you tell me your favorite color? –  Example of Indirect Prompts to Talk: Why don’t you tell the class your name? –  Ra>onale: The child may not be at a stage in treatment where they are able to succeed

at verbally responding to the indirect prompt. Though the prompt to talk is framed in a different way, it has the same effect as a direct prompt and should be avoided.

Don’ts •  DO NOT Prompt for Hello, Good-‐Bye, Thank You, Please*

–  Example: “Hello Sara...(pause indica/ng an expecta/on to respond with a Hello.” –  Example: “Say Good-‐Bye to your teacher.” –  Example: “Please say thank-‐you to your friend for handing you the worksheet.” –  Ra>onale: Although we certainly want to ins/ll pro-‐social skills and posi/ve manners in

all of our children, these are prompts to verbalize. A child’s inability to verbally engage in these interac/ons IS NOT an indica/on that they are being rude or that they do not use these manners. These prompts for verbaliza/ons are oWen the most challenging for children with Selec/ve Mu/sm to succeed in. The added expecta/on to verbalize in these interac/ons and anxiety about how others perceive their inability to respond, as well as the really high rate of daily prompts for these interac/ons likely make the degree of difficulty higher. Addi/onally, adults discomfort with a child not engaging in these societally expected forms of verbal communica/on could add to the perceived pressure around these interac/ons. Please provide non-‐verbal accommoda/ons un/l a child is able to succeed verbally. Example: “Wave good-‐bye.”

•  DO NOT Use Nega>ve Talk –  Example of Nega>ve Talk: Don’t be shy. –  Example of Nega>ve Talk: You can’t go to recess un/l you answer my ques/on. –  Example of Nega>ve Talk: It’s impolite to not say hello/please/thank you. –  Ra>onale: Nega/ve talk may cause the child to become more anxious about verbalizing

and ul/mately cause talking to be viewed as a form of punishment.

Don’ts

Enable Indirect Commands to talk*

Mind read* Nega/ve Talk*

Ask child “Why?” Jump rungs on ladder

Yes/No Ques/ons* Get greedy

Direct commands to talk* Show disappointment

*Italicized are specific, observable measurable

Targeted Practice

•  The Special Sauce –  Exposure: An exposure is an Approach Task that helps the child successfully encounter or experience the very thing that they have been avoiding

•  Success-‐ oriented •  Repe//on-‐Consistency-‐Momentum •  Select 1-‐2 per situa/on/event

Exposures can be fun!

Scavenger Hunts, Brave Bingo, 21 Questions, I Spy

Games that Elicit Verbal (when ready!)

•  Go Fish •  Zingo •  Hangman •  Headbandz •  Guess Who •  Surveys of Favorites •  Spot It •  Tell Tale

Helpful Resources

•  Selective Mutism Group (SMG) www.selectivemutism.org

•  Child Mind Institute (CMI)

www.childmind.org

•  American Academy of Child and Adolescent Psychiatry (AACAP) www.aacap.org

•  Parent-Child Interaction Therapy International www.pcit.org

Upcoming Workshop on Selective Mutism

Climbing the Ladder: Crea/ng and Implemen/ng Approach Tasks Wednesday, January 15, 2014 6:15 PM -‐ 7:30 PM ET Dr. Steven Kurtz, PhD, ABPP, Director of the Selec/ve Mu/sm Program at the Child Mind Ins/tute will explain the whys, whens, and hows of exposure therapy so that parents and professionals can effec/vely guide children up the ladder.

Upcoming Events at CMI Parent Workshop Series Do Your Homework: Helping Your Kids Stay Organized Wednesday, November 20, 2013 6:15 PM -‐ 7:30 PM ET Parent Workshop Series Cuing the Apron Strings: How to Do it Safely and Sanely Wednesday, December 18, 2013 6:15 PM -‐ 7:30 PM ET

building brave muscles27c2s3mdcxk2qzutg1z8oa91-wpengine.netdna-ssl.com/... · 11/13/2013 ·...

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