Climbing Up the Exposure Ladder: Where to Start with SM Treatment and How to Keep Going
A diagnosis of selective mutism can provide a lot of clarity for children and their parents, explaining why it is difficult for kids to speak in certain environments and how the cycle of anxiety and accommodation can cause symptoms to worsen. However, once it’s clear that the speech avoidance is not due to an extreme case of shyness or stubbornness, you may wonder what to do next. This article explains how to create an exposure ladder in order to support your child in taking incremental steps toward finding their brave voice.
Exposure therapy involves planned engagement with a feared stimulus — for SM, this would be speech or other communication — in order to gradually replace escape, avoidance, and safety behaviors with adaptive responses. When planning exposures, it is helpful to create an exposure ladder, which organizes feared scenarios from least to most distressing. Starting small and working up prevents causing intense distress which can be counterproductive to therapeutic progress.
Imagine an 8-year-old boy that is speaking freely at home and in the community with family but not speaking to anyone in school. He is highly motivated to participate in therapy because he really wants to talk with his friends at school. This is a pretty big goal, so let’s break it down into smaller steps.
Speech in the community with novel adults. Making just one change at a time — in this case, introducing a new speaking partner in a setting where speech is already established — is a helpful guideline when creating an exposure ladder.
Speech in school with an established speaking partner. In this case, the one change being made from baseline speech is the location in which speech is occurring.
Speech in school with novel adults. Individuals that children with SM have regularly avoided speech demands from may become contaminated, which makes it harder to establish speech with them. Starting with a new person is generally more successful.
Speech in the community with novel peers. It is often harder for children with SM to respond to peers compared to their adults, but this is not always the case. Be sure to consider what each individual child finds distressing and organize the ladder accordingly.
Speech in school with familiar adults. Next we can tackle speech with familiar adults, starting in structured environments like small group instruction or class.
Speech at home/in the community with familiar peers. Try having playdates with structure and prompts to facilitate verbal communication.
Speech in school with familiar peers. Start with structured interactions, work up to spontaneous interactions, and celebrate all of his wins!
Each of these steps can be broken down even further with changes such as responding to vs. initiating speech, increasing volume, increasing utterance length, and moving throughout the space (classroom vs. cafeteria vs. playground, etc.). It’s okay (and frankly, necessary) to adjust the ladder over time based on your child’s successes and difficulties.
Now we’ve built our ladder, and we’re ready to start climbing! But what happens if your kid freezes during the first exposure? Or the fifth? Luckily, the response to exposure challenges stays the same at any stage of treatment. First, repeat the prompt. Your child might need some more time to find their voice, and repeating the prompt gives them another chance to do so. If they still need some more help, return to the last successful step on the ladder (or baseline speech if you’re on step 1) and prompt there. This reorients your kid to prior bravery, reminding them that they can do hard things. Progress will not always be a steady forward march; what’s most important is being responsive to cues that indicate how much progress is reasonable for that day. If you’d like more guidance with creating exposure ladders, Thriving Minds is here to help! Contact us at (734) 433-5100 or visit this link to learn more about our treatment options.