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[00:00:00] DR. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast, where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

The past 12 is a new entirely digital tool that will help you discover whether students’ struggles are related to the pandemic. You can learn more at parinc.com/pass-12

Hey everyone, welcome back. Glad you’re here as always.

Today’s episode is another fantastic replay of a highly downloaded episode from 2019. This was one of the top five episodes from that year. It’s my interview with Dr. Aimee Kotrba, all about selective mutism. So we really dig into the details about assessment and treatment of  selective mutism and separating selective mutism from other anxiety disorders, autism and so forth. 

Aimee is a true expert in this area, which I think will come across very quickly. For her full bio, you can check the show notes. But I will say she’s a licensed clinical psychologist. She’s a group practice owner in Brighton, Michigan. She does a lot of consulting, diagnosis and treatment of selective mutism and other anxiety disorders. She has also written a book on selective mutism, which is linked in the show notes. So a lot to offer.

This is one of those episodes where I think you’ll definitely want to take notes if you can. If you caught it the first time around, that’s great. There’s  more  to check out this time and I think you’ll take quite a bit away from it again. And if you didn’t catch it the first time around, then today’s your lucky day.

All right, before I get to the interview, I want to invite any advanced practice owners to check out the advanced practice mastermind. The next cohort will be starting June 10th. And this is a group coaching experience for advanced practice owners looking to take your practice to the next level.

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Okay, without further ado, here’s my interview with Dr. Aimee Kotrba 

I’m excited to be here talking to you, Aimee. Welcome. 

Dr. Aimee. Thanks so much. I’m excited to come in at a good time for you, a patient in your practice.  

Dr. Sharp: Yeah, right. I’m being honest. That’s how I try to schedule these podcasts interviews, so a clinical consultation from Aimee. So, thanks for helping me with that. 

I did have a kid last week, actually. Maybe I’ll ask some questions about that. But I think this is, like I said, very relevant for a lot of folks particularly just differential diagnostic kinds of stuff, how do we look for selective mutism and just the ins and outs. So, I’m really grateful that you’re willing to sit down and chat with me for a little bit.

Dr. Aimee: Yeah, I’m excited. 

Dr. Sharp: Easy questions to start off. How did you get where you are right now? What does your life look like day to day from a clinical standpoint? 

Dr. Aimee: Yeah, absolutely. So I went to Wayne State University here in Michigan. During my graduate work, I never heard the words selective mutism. It was never brought up. It was never something that we were trained on. And then I did a post-doc near here, and while I was on post-doc, a kid came into the clinic needing treatment and he had pretty severe selective mutism. He had never spoken to anyone in school, never spoken to anyone in public, and about a year prior to coming into our clinic, he had stopped speaking to his parents. It’s a pretty severe presentation, more severe than we typically see with kids with SM. But in treating him, I was really interested and really engaged in trying to find out what the evidence-based interventions were and how I can best work with this family?

And it just didn’t seem like there was a wealth of information on evidence-based intervention at the time. And so I had to do a lot of literature reviews and go to conferences and talk to the well-known people in the field. Through all of that and just my enjoyment in treating this kid, I kind of accidentally fell into specializing in selective mutism. So that was about… I’m aging myself. That was about 12 years ago.

And now at this point, I own two clinics, and our specialty, not the only thing that we do, but our specialty is seeing kids with selective mutism. So we do diagnostic evaluations. We do the treatment as usual. We provide intensive options where families will come in and do an entire week of intensive treatment with us, exposure-based interventions. I run a camp for kids with selective mutism during the summer, and it’s actually coming up in 10 days. So the stress is on right now.

Dr. Sharp: Maybe we could take a little bit before we totally dive into selective mutism just to talk about this somewhat unique practice model you have with the intensive treatment. Would that be all right? 

Dr. Aimee: Sure.

Dr. Sharp: Let’s talk about that.

Dr. Aimee: We offer a few different kinds of intensive treatment. And I think of them as being in-clinic intensive treatment, on-location intensive treatment, and then a group intensive treatment, which we call camping. It sort of functions like a camp.

So the camp is a group intensive treatment where the kids come for one week. It’s not a stay-away camp. They attend from 9:00 AM to 3:00 PM. We try to make it like a classroom experience for them. We always do it the first week of August. So, we’re hoping to catch kids right before they go back to school so we can provide this sort of pretend or exposure-based intervention where it feels like a regular classroom setting. We go on field trips, we do classroom activities, but they’re all paired with a therapist for support.

And I do in-clinic and on-location intensive. So, that basically looks like 30 hours of exposure where we work with kids to help them be verbal first with us through behavioral interventions, and then we start practicing with other people, in public scenarios, and we do this in schools- that’s what I would consider to be on-location. I’ll actually go to the child’s school and spend a week in the school. And we train the parents also as a part of that week- these sort of paraprofessionals so that they can walk away from the week knowing how to both advocate for their child in school but also how to help their child be brave in public and family situations.

Dr. Sharp: It sounds really powerful. I’m assuming there’s some literature support for this kind of treatment model. Is that right? 

Dr. Aimee: There is. It’s just now coming out because it’s sort of a new way of treating kids with selective mutism. But there’s a lot of evidence that suggests that it’s more effective than treatment as usual and certainly faster than treatment as usual. I think it’s so much fun too. It’s my favorite thing.

Dr. Sharp: Oh, that’s wild. Let me ask a few logistical questions. I guess you have several therapists. So, are you able to see multiple kids per week on this intensive model?

Dr Aimee: We can. We typically just do 1-2 a week because I feel like otherwise, it would be a little bit of an overload for our clinic, but we couldn’t see more than that. Yeah.

Dr. Sharp: Got you. And how do you bill for it? Are you just private pay or is there insurance?

Dr. Aimee: We do take insurance. We only take Blue Cross Blue Shield, but we do take insurance. It is a mix of private pay and billable hours. So, a typical day would be billed as one parent training session because that’s always a part of it. So, one family without a patient present session, and then the rest of them are client elective services. 

Dr. Sharp: Okay. This is fascinating. This is really cool. And it’s clear that you have a lot of energy around it. I think this is something that I struggle with. I think others probably do too, where you would like to be able to just dig in there and work with a family but there’s some hurdles to putting that kind of model in place. So, I’m impressed to see that you’ve done it. 

Dr. Aimee: There’s a lot of hurdles to putting in place. Once you master those hurdles, it’s fantastic.

Dr. Sharp: Sure. I don’t want to dive too deep on that. I know that you’re recently on The Group Practice Exchange Podcast, I think talking all about this intensive model that you run. If people are really interested in that, I’ll link to that in the show notes. That’s Maureen Werrbach Group Practice Exchange podcast. For us though, we get to talk more about selective mutism today.

So you said that you just sort of fell into this area. I mean, in retrospect, can you identify anything that really has called you to this population that is personal or is it just, “Hey, this is an area that needs service and I’m going to go that direction”?

Dr. Aimee: I think it was a little bit of both. I do think that when I found a lack of information on treatment options for these kids, that did pull me in. They’re my favorite population to work with for a few reasons.

1) I feel like the treatment can be incredibly effective. And it’s very systematic, the kind of treatment that you do. I wouldn’t say that it’s manualized necessarily. There are caveats and there’s, of course, an art to it like any kind of therapy, but it feels very specific and solid to me which I like. It’s just the kind of treatment that I enjoy doing. I also enjoy that the gains that are made are so obvious. Unlike depression where it’s just sort of like, is it getting better? It’s hard to tell. Let’s do these questionnaires. When you’re treating a kid with selective mutism, you can identify, okay, now the kids are talking to extended family. Now they’re ordering in restaurants. Now they’re talking to their teacher. They started talking to the kids in their classroom and it’s very specific the gains that are being made. And so for me, it’s a great feeling. I enjoy that. And I like the specificity of it.

Dr. Sharp:  I can totally see that. As someone who gravitates toward testing, maybe others are the same, there’s that concrete element to it. This is what we’re doing. This is what you get from it. Very cool.

Well, so can you just give us some basic information? What is selective mutism? When does it tend to manifest? Is it more boys or girls? Just some basic info about it. 

Dr. Aimee: Sure. So at its’ core, selective mutism is a lack of speech in social and school settings where speech is expected. These kids can speak just fine. Typically just fine when they’re comfortable. Usually, in the home setting, they speak very comfortably to their parents but when they get anxious, so that’s usually in more social situations, they speak less or stop speaking altogether.

We know statistically that boys are less likely to be diagnosed than girls are. So girls are two times more likely to be diagnosed with selective mutism. Just from my practice, so take this with a grain of salt, we tend to see more boys. And it seems like when we see boys, lots of times the severity is greater. I have a few hypotheses about that. I wonder if maybe boys don’t get diagnosed until a little bit later because speech isn’t so much a part of play or social interactions for boys when they’re young, and so by the time they make a task, they’re a little bit older and a little bit more challenging to treat, but take that with a grain of salt. No doubt about it then.

Dr. Sharp: It’s worth considering.

Dr. Aimee: Right.

Kids can be diagnosed after six months of not speaking in a new situation. So for instance, the beginning of the first year of school or one month into not speaking after that in school situations. But a lot of these kids get diagnosed in preschool or in daycare because they go for an entire year in a Preschool setting, let’s say without speaking to preschool teachers. So, they can be diagnosed as young as 3 years old, but more frequently kids come into the clinic to get treatment more around, I would say 6 to 8 years old because they’ve entered school at that point. They’re not able to be evaluated by the school academically because they’re not speaking or not speaking much. And so then the school is alerting parents that this is an issue.

Dr. Sharp: That makes sense. That’s interesting. I had very limited experience, but the kids I’ve worked with who had selective mutism seemed like they were very young. It emerged pretty early which made it hard. There was some difficulty there just with normal development of language and like what’s going on here.

Dr. Aimee: Well, and I think a lot of times parents don’t catch it even though it does emerge young. A lot of these parents will say, I knew something was different from the start. And there’s kind of common characteristics that happen with this population like they tend to be more difficult to soothe than as a baby. They tend to have separation anxiety when they’re young. And then they don’t speak in these social situations. But when they’re 2 or 3 or 4, you don’t expect those kids to order at a restaurant. And so it’s not really identified as a problem until later on. The issue is that like most childhood disorders, the earlier the intervention happens, the easier it is, the better it is, the less it messes with developmental milestones. So, we try to get kids in as early as possible for a diagnosis.

Dr. Sharp: That makes sense. Are there any other signs that folks might lookout for early on that can help pick up on early identification?

Dr. Amelia: The biggest sign is just that a kid goes without speaking for a significant amount of time to school or school-like activities or in social situations. I always encourage parents to take it seriously and not just pass it off as shyness. And there’s a lot of kids who are shy, but those kids tend to warm up after a short period of time. And they tend to sort of be the same across situations. So, shy kids tend to be kind of inhibited in social situations, kind of inhibited at home, sometimes inhibited at school, inhibited at church, inhibited in the store.

Kids with selective mutism are almost like two different kids. The kid at home who’s loud and outgoing and talkative, and then you’ve got the kid who’s in social situations and they might look frozen and make poor eye contact. And sometimes they might even look angry or wear things in front of their face to protect them from being seen or engaging with other people. If you’ve got that kind of kid, I always encourage people to just go ahead and come in for an evaluation because I would rather identify it early and do the behavioral intervention, which wouldn’t be harmful to anybody, and in fact, I would argue, it’s fun and engaging, versus waiting too long and then having the treatment be so much.

Dr. Sharp: Yeah, that totally makes sense. It’s hard to go wrong with early intervention.

Dr. Aimee: I agree.

Dr. Sharp: Maybe we can just agree on that. All sounds good. Got you and you said that kids will show perhaps some separation anxiety as well, and just that sensitive kind of reactive temperament. Is that among the symptoms? 

Dr. Aimee: Exactly. And it’s interesting because historically there’s been this idea that selective mutism comes from a trauma in the background.

And so I think a lot of parents, when they start noticing this, try to think back to, did something happen to my child? Was there some sort of trauma they experienced? But we just don’t find that in research. We don’t find that those are linked or correlated, selective mutism with trauma in history. It’s not that it can’t happen, but we don’t believe that some come from trauma.

We really have a lot of evidence that suggests it’s partly genetic, probably. Apple and tree. I see a lot in my clinic when we’re doing the diagnostic evaluations. Partly it might come from modeling. I think a lot of it comes from accidental reinforcement of avoidance by parents or caregivers. So caregivers are accommodating the child’s avoidance because of maybe their own anxiety, but we don’t find that trauma is correlated. 

Dr. Sharp: I see. Are there other primary etiologies that you know of aside from genetic components?

Dr. Aimee: No, we don’t have any evidence that it’s highly linked to medical conditions or birth trauma or anything like that. So we think that it’s sort of that nature versus nurture mix that we see.

Dr. Sharp: Yeah, like 99% of everything. Does the research reflect anything about the trajectory of kids with selective mutism, like what kind of adults they turn out to be?

Dr. Aimee: Yeah, and it’s hard to say. I would say that there are two trajectories. So trajectory number one is kids who have SM as youngsters but maybe because of caregivers who sort of naturally understand what needs to happen or maybe because of kids who are internally motivated to be brave and talk or engage with other people, sometimes kids, I don’t like to say grow out of it, but even without treatment might progressively get better and become adults that maybe are inhibited a little bit or shy, but certainly don’t have any significant daily life functioning kind of problems.

Trajectory number two is kids who are not created with excellent treatment will end up becoming more and more inhibited, tend to have anxiety and depression in their teenage and adult years, have a greater likelihood of substance abuse probably to deal with the mood issues that they’re experiencing, have lower rates of marriage, lower rates of finding work as adults.

What I usually tell people is it’s like their world gets smaller and smaller because they tend to react to anxiety-provoking situations with avoidance. Which is just an anxiety disorder. And so then it becomes not just these speaking situations that they avoid, but the engagement situations, or the going to the doctor or attending school or getting a job or driving. And so the world is going to become smaller and smaller as they avoid all these potentially anxiety-provoking situations.

And then in adulthood, usually we don’t diagnose with selective mutism per se. So, they might be diagnosed with severe social anxiety, maybe some kind of personality disorder, like an avoidant personality disorder. But the pathology, I guess I would say, grows over time in that population. So, I wish I could tell you at 3 or 4 which trajectory a child was going to take but we really don’t have a way to tell. And so to me, I feel like let’s treat what’s going on so that hopefully we can push all of the kids into that first trajectory of successful adult life.

Dr. Sharp: Yeah, of course. I think that’s true with most of the things that we’re working with, but it’s also one of those major questions parents always want to know. What is this going to look like down the road? And that’s a really hard question. I wish we could figure that out.

So, let’s talk a little bit about the evaluation process. We sort of touched on the two ways to approach this. There’s the side of how do you modify a traditional evaluation for a kid who is selectively mute? And then there’s the actual evaluating of the mutism. Which one do you want to tackle first? 

Dr. Aimee: Let’s start with the diagnostic evaluation. Is this selective mutism? I think that will shed some light on how we do a psychoeducational evaluation for a kid with SM.

So, when a kid comes into our clinic for a diagnostic evaluation, we have a few different components that we always include, I guess I would say above and beyond what is typical for a diagnostic evaluation in our clinic. We always start with parents only doing an interview with them. Our beginning intake interview is 1.5 hours long. So, we’re doing all of the normal diagnostic intake questions, background history, educational history, medical history, family history, things like that.

But they’re things that we particularly include in kids who may have selective mutism. We’re asking a lot of questions about communication behavior. So, who does the child communicate with? And we try to get a very extensive list. So, I don’t just ask that as an open-ended question to parents. I’ll usually start with that and then I’ll really go through specifically, do they talk to teachers? Do they talk to staff at school? Do they talk to peers? Does it matter if it’s a man versus a woman? Will they talk to people in public situations? Will they talk to parents in public situations when other people can overhear them?

So, I’m finding out a long exhaustive list of who they talk to. Then I want to find out how they communicate with those people? Sometimes communication might just look like non-verbals like nodding or shaking their head or shrugging or pointing to things. Communication might be whispering. It might be something that we call an altered voice. So some kids with selective mutism, when they do talk, it doesn’t sound like their typical voice. Whispering is actually an alternative voice, but some kids will talk out of the sight of their mouth instead. Some kids will talk out of their teeth- they’ll keep their teeth closed and speak through their teeth. Sometimes kids will talk in a robotic voice or a voice that’s not theirs.

Then you want to find out about things like responding versus initiating. Will the child respond to a direct question but maybe not initiate it to a person? And find out where the child’s back? There review, who does the child talk to? How does the child talk? I1n what situations does the child speak? So physically and environmentally. Does the child talk at home? Does the child talk in school? Does the child talk in the playground? They talk at the store. So I’m finding out a lot about their speaking behavior.

And then I’m finding out a lot about parent accommodation and the lack of speech. And I try to normalize these parents because I think that parents can feel very pathologized when their child has selective mutism like they did something, especially that sort of from a piece that’s out there in the public but isn’t accurate. Did the parents traumatize the child? So, they very much normalize it. 

Parents accommodate kids because they want to protect them because they feel anxious about their child’s anxiety because they love their child, but asking mom and dad, like when do you find yourself answering for your child? Or when do you find yourself avoiding or having other people avoid talking to or asking your child questions? Because the parents play such a huge role in the treatment of selective mutism that I need to know where we’re starting.

Dr. Sharp: Of course. Well, and that’s that black box. I feel like with any of the evaluations that we’re doing is really getting a sense of what parent behavior is like and what things are like outside the office, and it’s challenging. I mean, do you find that parents are fairly forthcoming or do you have to dig a little bit? Because I can imagine there being some shame around this once they sort of get the clue that they might be reinforcing some of the mutism. Does that make sense?

Dr. Aimee: It does. I don’t find that parents tend to be in denial of their accommodation of their child. Most of them will say upfront, Oh yeah, I answer for them all the time. I find that parents fall into two categories though after that. “I’m totally willing to do it a different way. Please show me how to help. Versus I can’t manage my child being anxious, and so I don’t want to stop accommodating them.” Not so much in those words, but  I don’t have a good enough distress tolerance myself to watch my child be uncomfortable. So I can’t go there. If that makes sense.

Dr. Sharp: It does. What do you do with that? 

Dr. Aimee: I think it takes a lot more psycho-education for the parents. Sometimes honestly we’re recommending that they consider going into individual treatment for their own anxiety as well at the same time. And I think that it sort of slows down treatment in the sense that now we have to move almost at the parents’ pace as opposed to the child’s pace for distress tolerance. So, it can be a problem. And sometimes that’s when parents drop out of treatment.

Dr. Sharp: I can see. Do you run into folks who no matter what you say you are still thinking, oh,  I can’t expose my child to these anxiety-provoking scenarios, that’s going to hurt them worse because it’s so distressing? Is that something that comes up? 

Dr. Aimee: It does. And those are frustrating because maybe selfishly as a clinician, I feel like, Oh, but I can help your child if you would be okay with them being uncomfortable. So it can be frustrating but it does happen.

Dr. Sharp: I think just about parenting in general, it’s hard to see your kids in distress.

Dr. Aimee: Absolutely.

Dr. Sharp: About the evaluation process, so you’re digging in just really a deep dive into all things communication and what the kid is doing or saying different scenarios?

Dr. Aimee: Exactly. 

Dr. Sharp: You mentioned the alternative voices. Does baby talk fall into that? 

Dr. Aimee: It does. Good job. I missed that, but it does. Absolutely.

Dr. Sharp: I’m just curious again, thinking about kids that have come through our practice recently.

Dr. Aimee: Yeah, it can definitely happen.

So after we do that initial evaluation meeting, then we’re trying to get other pieces of evidence or other pieces of data from the parents. At our clinic, we give them the BASC-3 looking at just general behavioral issues. We do the SCARED questionnaire, but you could also do the MASC or just a different anxiety questionnaire.

The only question specific to selective mutism is called the Selective Mutism Questionnaire or the SMQ, which is okay.  It’s a good pre-post questionnaire or a good way of comparing a child with selective mutism speaking behavior to typically developing peers. It’s not incredibly sensitive so you can’t give it on a frequent basis. It’s not going to give you a sort of progression of treatment data, but it’s helpful in the diagnostic process.

We like to get a lot of multiple sources. So we talk to teachers, we call up schools, sometimes extracurricular coaches, things like that, or grandparents to find out how the child does in different situations. Not infrequently. We’re referring for speech evaluation if a child hasn’t had one because about 50% of kids with selective mutism will have a fundamental speech impairment or issue.

There are complexities to doing a speech evaluation for a kid with SM as well, but if you have a skilled speech therapist who could do that, that’s helpful. Or minimally, I like to see videos of the kids speaking comfortably at home so that minimally I’ll have an idea of the speech issues that may or may not exist. And also just sort of a good idea of where we’re going in treatment. Like, okay, well there’s the child at home speaking comfortably. That’s the kid that I want to see in the clinic, in public, in school. But that’s part that’s really helpful for me is seeing the kid comfortably speaking. 

Dr. Sharp: That’s really interesting. I like that. Yeah, so you have something to shoot for. That’s cool.

Just touching on the speech piece, what concerns do you see most common with kids with selective mutism and from a speech perspective?

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Dr. Aimee: It really runs the gamut, but the vast majority of the kids have expressive language delays. So sentence structuring delays, or word-formation issues. We don’t know how […] might end up having selective mutism because they understand that to some degree they’re not fluent and maybe they’re getting some responses from people that their speech is not fluent. So it could be that. The other possibility is it could be that kids who don’t speak a lot and don’t have a lot of experience in getting corrected for their speech end up developing speech delays down the road. So, it’s interesting this idea of what caused what. 

Dr. Sharp:  Yeah, absolutely. At least from my side, our audio is sort of glitching a little bit. And it sounded like you were just saying it’s hard. It’s kind of a chicken or the egg issue, like how do you know what’s driving what?

Dr. Aimee: Exactly.

Dr. Sharp: That totally makes sense. I can see that being really challenging. 

Okay. So then just to sort of land the plane on your evaluation process, at that point, are you doing any cognitive assessment or anything like that or is this just specific to the speech and the emotional functioning and behavioral function?

Dr. Aimee: We typically don’t do more testing unless it’s warranted, which we’ll talk about the psychoeducational evaluation in just a minute. I guess, one more additional component that we do at our clinic to help with the differential diagnosis is we do something we call a direct clinical observation. So I think that this is helpful for differential diagnostic purposes to determine the severity of the selective mutism and to see sort of where we’re starting in treatment.

The way that we do this is kind of like a hierarchical exposure happening really quickly and observing what happens with the child. So we have the child and the parent in a playroom by themselves. We have cameras in our playroom, but some people don’t have cameras naturally set up in their playroom. When I first started doing this, I would literally set up my phone to videotape somewhere in a corner and I’d watch it later, but we have a camera set up in our playrooms.

So the child and parent go into the playroom and basically, the spiel that we give them is thanks so much for coming. We can’t wait to play with you. Actually, I have a little bit of work left to do today, and I just want you to kind of get comfortable here and see the toys that we have. So I’m going to leave you and mom and here, you guys can play anything that you want. I might be in to clean up in a little while because it’s looking kind of messy in here, but I’ll just see you in a little while. And I’ll leave the room. And then from my office, I watch speaking or communication behavior between the child and the parent when no one is in the room. So, that’s step 1. 

Step 2, I enter the room but I pay no attention to the parent or the child. I put no demands on them. I just want to see how the child does when there’s a potential audience member listening to them speak. Does that change whether or not they’re willing to talk to their parents? Then I go over and I join in the game. Oh, you guys are playing Chutes and Ladders. I love this game. I’m going to play too. I’m going to be this character. And I go ahead and I start playing with them. So, now I’m paying attention and I’m seeing if the child will still continue talking to their parents in my presence while I’m paying attention. Then I start asking questions.

There are three kinds of questions that we use with kids with selective mutism communication. Yes/No questions, which we try not to use in treatment at all because it perpetuates a non-verbal response, like a nod or shake of the head. But here I start with those. Those are the easiest. So I’ll ask them some, yes/no questions and see if they respond. Then I ask them forced-choice questions or multiple-choice questions. Are you the blue or the pink player? Or, Oh my gosh, did you just get to move 10 spaces or two spaces? To see if they can respond to those.

Then I ask them more open-ended questions. So, who won that last game? Or what’s your favorite color? And I progressed through those, whether the child is responding to me or not. And then after all of that, I have the parents leave the room. So, I usually say something to mom like, “Oh mom, there are a few forms upfront that I need you to fill out. Could you go to the front and fill out those forms and we’ll be up in just a minute?” And I have the parents leave the room. And then I ask the child a few more questions to see if the child can speak to me without their parent in the room because sometimes that can influence whether or not they speak.

So after all of that, I’m looking at the video. I’m seeing how the child did in all of those situations. And it’s really helpful because if a child can tolerate me hearing his voice as I come into the room, that’s a much milder presentation in my mind than a kid who, for instance, doesn’t even talk from the moment they enter the playroom even with the door closed. That’s a much more severe presentation. And it also tells me maybe this kid is already able to respond non verbally or maybe they’ll already whisper some answers to me. And I’m starting at a different point in my exposure hierarchy with treatment than I would be for a kid who never spoke in the playroom at all even when I wasn’t in there. 

We also get some indication of autism sometimes in these situations. And that’s also helpful to see. So, autism is a big differential diagnosis when we’re thinking about kids with selective mutism because these kids can look autistic in the school setting. They look frozen. They have flat facial expressions. They’re not speaking or if they speak, they’re speaking in a strange voice. A lot of parents wonder if this is autism, but through that diagnostic interview, getting the history thing, seeing the video of a kid speaking comfortably at home, and in this direct clinical observation, usually we start to get a flavor of, is an autism evaluation component something that we need to pursue or is this a ‘typical’ kid with selective mutism?

Dr. Sharp: Right. I love that evaluation process or the observation process rather.

Dr. Aimee: It’s really helpful. 

Dr. Sharp: Yeah. Do you have that scripted out or is that a standard protocol that you got from somewhere or what?

Dr. Aimee: I do have it scripted out. I have a book that I wrote. So I plug from the book that I wrote for professionals. It has that script. And the whole process of evaluation is part of that book.

Dr. Sharp: Oh, very cool. Tell me the title of the book. I’d love to put it in the show notes.

Dr. Aimee: Sure. It’s called Selective Mutism: An Assessment and Intervention Guide for Therapists, Educators & Parents. So if you just look up selective mutism and my name on Amazon, it’s there.

Dr. Sharp: Perfect. I’ll put that in the show notes.

Dr. Aimee: Thanks. 

Dr. Sharp: Nice. That seems super helpful just to get some real-world “data” from how they interact with a stranger basically.

Dr. Aimee: Right. So that’s our diagnostic process. I feel like after kids come out of that, we have a good idea of affirming a diagnosis or switching gears and maybe testing for something else. And we have a good idea of where to start with treatment. And after we do that, we write up a short report. I want to say it’s usually like three pages of a little diagnostic report to give to parents and to give the schools that the parents relate to.

Dr. Sharp: I got you. Very cool. So, then maybe we could pivot just a little bit and talk about how to modify a more traditional neuropsychology evaluation for a kid who’s selectively mute.

Dr. Aimee: Yeah, absolutely. I would start with a few caveats. And my first caveat to this is, if you’re doing a psychoeducational evaluation for a kid with selective mutism, thinking about what is the purpose, will we get valid results even in the best-case scenario? I mean, I’ve tested hundreds of kids with selective mutism and  I don’t know that I can tell you that I always get a valid result from psychoeducational testing because of the anxiety component that’s there.

If the school is wanting services, could we explain to the school about the potential lack of validity of testing results and still get services instead? So can we kind of skirt around this without doing a full battery if it’s possible? And if the answer’s no, if we want to go ahead and do the evaluation, that’s fine. There are just some things to keep in mind. One of them is probably not going to be the most valid result, right? It’s just probably going to be slightly skewed.

And we’re probably going to have to go about testing in a way that may be slightly outside of the standard testing procedure because of what we’re dealing with. So for instance, some of the caveats or different things about testing these kids are, this is one case where I will test a longstanding therapy patient instead of referring out. And I know that that’s not usually mandated, but I feel like if I have a comfortable communication line with a child through therapy, I might get the most valid results at testing versus referring them to somebody that they have no experience in speaking to.

Dr. Sharp: That makes sense.

Dr. Aimee: We also would probably set up a few sessions prior to the actual testing where we’re building rapport with the child. So we usually will code those as therapy sessions to build rapport prior to testing because I feel like if you can get a child speaking to me in those sessions, then the testing is probably going to start a lot more valid than it otherwise would.

And then we kind of honestly switch a little bit of the testing procedures. So some of the examples of that would be things like I would allow whispering, I might not look at the child at all during testing because we know that for kids with selective mutism having somebody make a lot of eye contact with them can be very anxiety-provoking. So I might not look at them during testing. That might even be me sitting next to them instead of across from them even though that’s the standard testing procedure.

I might have parents in the room and tell the kids, you can tell your parents the answer so I can at least hear what they’re saying. I might prompt them to say, I don’t know even though that’s not standard protocol, or I might give them a little sign next to them that says pass or I don’t know that they can point to non-verbally so I can at least get some kind of response from them. I might change the order of testing starting with the non-verbals first so that they’re more comfortable by the time that we get to the verbal testing. I might fill out extra time for a verbal response. I’m noting all of these changes in a report. To me, this would at least increase the validity perhaps of the scores that I got from testing.

Dr. Sharp: Yeah, that all makes sense. And it’s validating as well. I’m thinking about our little guy last week and a lot of these things we ended up doing just to try to get some information, but it’s really challenging.

Dr. Aimee: It’s really challenging. I would say that psychoeducational testing for a kid with selective mutism, we end up scheduling much shorter chunks than we typically would with a lot of rapport building and kind of calming downtime. Testing just generally takes longer.

Dr. Sharp:  Sure. Are there any measures in particular that you would say are better geared for a kid with selective mutism?

Dr. Aimee: The ones that offer a non-verbal response are probably going to be easier for them. So evaluations that allow them to point or write their response are going to be easier than the verbal response piece. We actually don’t typically give non-verbal IQ tests to our kids with selective mutism.  What I found is that schools don’t particularly feel like that’s a great indicator of their cognitive ability. And so what I would rather do is spend more time getting them comfortable in building rapport and then be able to do something like a WISC instead even though I know that things like comprehension are going to be complicated or vocabulary because they require such a longer response than information or similarities would. 

Dr. Sharp: Yeah. Do you have kind of your standard line in the report about,…. this may be not being valid. I mean, how do you phrase it in the report? 

Dr. Aimee: Well, I don’t have a report in front of me so you’re catching me a little bit off guard, but we’ll say something like “Due to modifications from the standard testing procedure as well as over anxiety observed in the testing secondary to a diagnosis of selective mutism, these scores may not provide the best or most valid indicator of child’s ability” something like that.

Dr. Sharp: Hey, that was pretty good. That totally makes sense. I’m just again thinking about the kids that we’ve worked with. And I think this is a theme that has come up in different ways across the podcast with different guests. There’s like an undertone of you just got to be okay with what you get. It’s not going to be the best estimate and that’s just what we’ve got. You get the data you can, you work with that and do your best, right?

Dr. Aimee: Absolutely. I mean, even for “typically developing kids”, you can have a bad day or be angry. So, so you get what you got. 

Dr. Sharp: Exactly. Got you. So are there ever any times when you would just scrap the evaluation completely and say, this is not good, we can’t do this? And then what do you do if they need academic data? How does that play out?

Dr. Aimee: There have been a few where I felt like the information that we were getting wasn’t even in the remote vicinity of valid or reliable or helpful indicators of a child’s ability in any way. And in fact, I felt like, should I continue down this road of the evaluation, the school might misinterpret the results. No matter what kind of caveat I wrote into the report or disclaimer, they might misinterpret the results and it might hurt the child. So they might disturb my guest score in an impaired range that I don’t feel is a good representation of their ability. The school might move them into a contained classroom that would be harmful to them.

So I have a few times in the past scrapped testing and basically said, now is not the time. The kid is going to need some treatment before we’re going to be able to do a valid testing measure. In the meantime, what can we do to sort of put together a plan at least for school services because that’s usually what we’re talking about is how do we help this kid at school? How do we get them some school services? So kind of going, what else can we do? Let’s think creatively about a way to get this kid services and not totally write off testing, but put it off until we can make some movement with behavioral intervention for this kid. 

Dr. Sharp: Got you. I would like to talk with you about intervention and treatment a little bit. If possible, before we jump into that, could you talk any more about differential diagnoses to be aware of for selective mutism and how to separate it from say, autism or just generalized anxiety or social anxiety? How do we sort through those?

Dr. Aimee: Sure. I think of selective mutism as being, it’s almost like a specific phobia of communicating or speaking. And so, a lot of these kids do have generalized anxiety, but the nearest speaking tends to be above and beyond, sort of sticks out as the biggest of daily functioning issues. 90% of kids who have selective mutism do have social anxiety. So in 90% of the cases of kids that I’m evaluating, they have a secondary diagnosis of social anxiety.

The 10% that don’t, you can kind of tell because they’re not hiding. They look very much like they want to engage. They just don’t seem to be able to engage verbally. They’re playing with you from the very start. They like being the center of attention. They’re on stage during their classroom musicals. They’re not talking but they’re dancing out there in the middle. They might sometimes get attention from peers in school via other ways, like making noises, not verbal noises but pounding on their desk, tapping other kids. But the vast majority of kids do have social anxiety in selective mutism.

And then for autism spectrum disorders,  what I’m typically looking for is when the child is comfortable, are they able to speak in those situations, you know, speak typically? And do they seem to have appropriate social skills in those situations? It’s hard because these kids don’t oftentimes interact with peers at all. And so asking parents what their social skills are like when interacting with peers, most parents can’t even report on that because they’ve not seen it. And so sometimes we do have to see how the child interacts as treatment gets started. As you know, working with kids with autism or on the autism spectrum, you can start seeing signs and signals of it fairly early on when you’re interacting with them.

Some things that you would expect to see with a kid with selective mutism are, you would expect to see them not necessarily responding to you, or a long latency to respond, or flat affect, or a lack of eye contact. But I wouldn’t expect him to have difficulty with, let’s say, following an eye gaze or a finger pointed at something like, “Oh, look at that” The kids are going to turn and look at it. Or having parents or peers talk to them about experiences, these kids would be able to report really well on their experiences or feelings about things. 

Usually, they wouldn’t have repetitive behaviors or repetitive interests. So, if you see any of those kinds of things, then I do have my antenna up for this may be autism or autism in addition to selective mutism because those two things in my mind can co-exist. The DSM says that other things have been ruled out like autism, but what clinically we see is we see kids who have autism or autism-like characteristics and have selective mutism because they speak comfortably in the home setting.

Now, maybe pragmatic speech isn’t fantastic or feelings, identification, or things like that, but they speak very comfortably at home. And then out in public, they don’t speak. So those kids, I think they have both. I think that there’s a co-occurrence.

Dr. Sharp: Sure. That answered one of my big questions. Thank you. And that makes sense. I can understand that.

Can you talk a little bit about treatment and how we might help these kiddos particularly after we’ve completed an eval and what we might recommend outside the home. And it sounds like a number of treatment approaches, but I’m thinking about, how do we talk to teachers in schools and what would be helpful there?

Dr. Aimee: Yeah, absolutely. I think treatment is a really long conversation. So, I’ll give you kind of the quick and dirty version of what we would be looking for in a good treatment plan. We know that exposure-based behavioral treatment is the gold standard for kids with selective mutism. So, you know, our treatment on a very basic level looks like starting with psycho-education for both the parent and for the kid and then moving into an exposure-based behavioral treatment.

So, we talked to the kid about practicing being brave, and then we as the therapist set up a hierarchy of increasing the number of people and places the child can talk to. Like any hierarchy, we do that slowly and systematically, and we usually add a reward system to that in order to increase motivation. Our treatment, it’s practicing first having the child speak to us in the clinic and then adding in new people probably in the clinic setting.

My poor receptionist didn’t know that when she got hired, she was going to be a part of many, many therapy sessions.

Dr. Sharp: Oh, my goodness.

Dr. Aimee: And then we’ll practice at the hall of the clinic. We’ll practice in the waiting room. Then we start going out into public and we’re practicing speaking, ordering at the ice cream store, and going Bowling so that we can order our shoes and get a soda while we’re there and going to Home Depot and doing scavenger hunts asking the employees where things are located. And the whole time, the parents are really involved in the treatment because it’s not sufficient for the child to be able to talk to me. That’s great. It makes me feel good, but it’s not sufficient. And so my goal is to teach the parent how to elicit speech in all of these settings as well.

In relation to that, I would say that this diagnosis is one that requires the most case management, probably similar to a score refusal treatment that you really have to be working with the school too because most of these kids experience the highest anxiety and the worst selective mutism symptoms in the school setting. And so, I’m working with the school to get IEP plans set up for the child, treatment plans put in you know, determining who’s going to be working with them in the school setting on an individual basis, and then continuing facilitating and consulting with the school at that point. 

Dr. Sharp: I see. That totally resonates. I can understand that. From a practice management standpoint again, how are you billing for all of that time involved in coordinating with the school?

Dr. Aimee: Yeah, that is out of pocket. We have not yet found a billing code that the insurance is going to pay for school consultation. So, unless I’m going into the school and doing an intervention, and in that case, I can code for treatment but just with a different modifier for location, I’m consulting with the school. That is out of pocket.

What I have found though is that if I can explain it to parents, they do understand the need for me to consult. I’m not consulting every week. I try to spread it out after that initial education for the school, but if a child’s not getting intervention within a school setting, we’re really limiting the generalization of these new skills that they’re developing.

Dr. Sharp: Absolutely. Like you said, that’s a primary spot where selective autism is happening. So you got to go to target that somehow.

Dr. Aimee: Absolutely.

Dr. Sharp: Well, I know that was a very quick overview of treatment. And that’s something that apparently you can write an entire book on. So we’re summarizing that very quickly. But if you want to find out more, they can check out which will be in the show notes.

Let’s see. I feel like we’ve covered a lot of ground. Are there any things that are still kind of hanging out there that you want to touch on or highlight before we wrap up? 

Dr. Aimee: I think I would just encourage people to be willing to treat selective mutism. Interestingly, I love it. It’s my favorite thing to treat, but I found a lot of psychologists find it intimidating perhaps, or feel stuck with it. And I would just encourage people to get good training in this exposure-based behavioral model to treat SM because it’s really enjoyable to treat. And it’s in my opinion, very rewarding.

There is good training out there. There are other books that are written that are fantastic on the subject. Our office provides clinical professional training if people are interested in where people come out and they visit us for several days in a row and they come a long way with the kid doing an intensive intervention. At the same time, they are taught how to do the treatment for selective mutism. So that’s a cool opportunity if professionals are really interested in getting their feet wet and learning treatment for selective mutism. 

Dr. Sharp: Absolutely. And it’s the best way to find… are those just on your practice’s website or is there a different resource to find those?

Dr. Aimee: No, it’s right for my practice’s website.

Dr. Sharp: Fantastic. Yeah, I’ll put that in the show notes as well. This was one of those little niches that I don’t know that PESI is going to offer training on selective mutism that is any good. 

Dr. Aimee: Well, and now Jeremy, I used to do training for PESI on foot.

Dr. Sharp: Of course you did. Okay, in that case, fair enough. That’s great. But if you want the real deal, do this.

Dr. Aimee: Do you want the real deal? There is also a selective mutism association, which is selectivemutism.org. They’re a non-profit organization that provides all kinds of fantastic information about selective mutism. And once a year, they have a conference. This year in Vegas in October. And it’s fantastic as a good training opportunity for professionals looking for more information

Dr. Sharp: Nice. I’ll put all these things again in the show notes so that folks can check it out if they’re interested. If people want to get in touch with you, what is the best way to do that? 

Dr. Aimee: They can either go to my website, which is thrivingmindsbehavioralhealth.com or they can email me. Direct email is probably the best way to contact me. And that’s akotrba@thrivingminds.info.

Dr. Sharp: Great. I would imagine you might get some questions after this.

Dr. Aimee: Sure.

Dr. Sharp: Well, this was great. I really appreciate your time and your knowledge. I mean, you clearly have your mind wrapped around this whole topic, and you’ve done a lot of work and you’ve written a book, that’s pretty cool. I’m just so grateful to be able to chat with you. And I would definitely learn some things and I hope that listeners have too. 

Dr. Aimee: Thank you so much for having me. I appreciate it.

Dr. Sharp:  Of Course. And I’ll have to look you up next time I’m in Michigan together and see your clinic.

Dr. Aimee: That’s great. Fantastic. 

Dr. Sharp: All right, well thanks, Aimee. Take care. 

Dr. Aimee: Thank you. 

Dr. Sharp: Okay, y’all, thanks as always for listening. I really appreciate it. Hope you enjoyed the last two clinical episodes which were replays of really popular episodes from two years ago. I’m just lining up my content calendar and some interviews for the coming weeks. So, we’ll be back with fresh interviews and a masterclass over the next month or two. 

If you’re an advanced practice owner and you are looking for a group coaching experience to have some accountability and help take your practice to the next level, check out the advanced practice mastermind that starting June 10th is the next cohort. And you can get more information and schedule a pre-group call at thetestingpsychologists.com/advanced. I would love to see you there. And it’s already starting to fill up. I’ve already got 2 folks on the waiting list. So, there are six spots total. If you want to jump in, go for it, make that happen.

All right, everybody, take care. I will get back with you on Thursday.

The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs. 

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