Good morning everyone and welcome to this press conference from the 48th annual meeting here in Davos it's the third day of the meeting a lot has happened already this week and We're we're adding to this exciting agenda with a wonderful announcement today here So welcome to you here in the room and welcome to our audience on the live stream Whether you're watching on the website Facebook or Periscope. Thank you for tuning in this press conferences Dedicated to the launch of a exciting new partnership to deliver last mile health care It is a wonderful panel. I'm Presenting to you now to my immediate left. We're joined by Katherine Milligan. She's the head of the Schwab Foundation for social entrepreneurship Which operates under the umbrella of the World Economic Forum? Next to her we're joined by Raj Panjabi the chief executive officer of last mile health and a Schwab social entrepreneur Right in the heart and center of our panel We are joined by Chuck slaughter who is the founder of living goods and also a member of our Social entrepreneur community and last but definitely not least. We're joined by Hubertus coops He is the head of UBS and society Here from Switzerland, of course. Thank you very much for for being here Without further ado and Raj, let me jump to you What is the exciting announcement you have to make today? Please share with us. Well, thank you. Geog We are proud to be part of this extraordinary partnership and part of the inspiring community of Schwab Foundation social entrepreneurs Today we know that illness is universal and access to care is not Last month in fact the World Bank and the World Health Organization released a report that revealed that the world over half of the world's population 3.67 billion people lack access to essential health services like prenatal care Vaccines and treatment for malaria and what's worse is the world lacks access to the health workers lacks the health workers needed to close this gap In fact, we are experiencing the greatest health workers shortage in history Today we lack more than seven million health workers. That's a number that is forecast To more than double to an 18 million health worker shortage by 2030 Now we believe that the power of mobile technology makes it possible Makes it possible for us to transform this problem virtually every other sector from retail to banking To taxis has been reinvented by mobile technology now. We believe it's time for technology To help reinvent access to health care for the poor So we are empowering community health workers with mobile technology We're helping them to save more lives in partnership with governments and visionary funders like UBS We are deploying thousands of community health workers with simple but powerful digital tools To deliver quality health care door-to-door These women are delivering professional care for their neighbors Far faster and at far lower cost than ever before our smart health app automates diagnoses for of the deadliest conditions Helping ensure that we can capture accurate real-time data to help manage thousands of far-flung health workers and The Community Health Academy will provide a powerful new digital education solution that brings training into the palm of community health workers hands We've been at this Raj and I for for ten years and we've proven the impact of this digital-enabled health worker model number one and most importantly at save lives a Randomized control trial is showing that this model is reducing child mortality by over 25 percent Number two, it's incredibly cheap. We can deliver this comprehensive home care for as little as two dollars a year per person And third it's important. That's why we're here It's super scalable and just the last three years living goods has scaled up from one million to five million people served And in West Africa last mile health is training the next four thousand community health workers and four It can stop pandemics Raj and his team Literally risk their lives in the front lines of the Ebola crisis And they know all too well that capturing data on home health in real-time is the key to halting outbreaks before they become deadly pandemics and Last importantly, it's creating jobs and empowering women Deploying health workers saves lives. Yes, but it's also creating lively hoods for thousands of women Building their confidence building their financial security and their status in their communities Now what we're excited to announce is a dream team really a visionary Philanthropists including Richard Branson Jeff Skoll the Elma Foundation and Chris Hahn of the Children's Investment Fund foundation are Committing 50 million dollars in a challenge grant to kick off a shared campaign to deploy 50,000 of these Empowered community health workers to reach 34 million people over six countries Now to unlock this magic commitment Raj and I have to go find another 50 million dollars from new sources over the next four years But this is an exciting challenge because for new backers the offer offer offers the opportunity to double the impact of their investments Now on behalf of all those we serve We're really thrilled to be here with ups who is stepping up in a bold way to make the first major commitment To this campaign. It's a bit unusual. You know, we know typically in in the social sector It's it's not uncommon for philanthropy to be a bit siloed bureaucratic But this collaboration is showing it really doesn't have to be that way It shows how business and philanthropy can be both collaborative and nimble Humane and hard-nosed and it shows that when committed caring partners link arms that big change is really possible Thank you very much Chuck and also. Thank you Raj. Let me let me I guess begin really by it by framing one more time What this is really about this is about bringing health care to 34 million people who don't have it today That's a really significant number and that is exactly the type of thing that The clients of UBS want to have an impact on we as the world's leading wealth manager We think we have a role to play in helping things like this come to fruition and as a result of that actually We've been working with our clients for many many years Because we know from studies that we've done the last one actually just a few years ago that 90% of UBS's clients are Involved in philanthropy in some way shape or form But only 20% of them think it's being done effectively or they're doing it effectively What we're also seeing is that maybe a few years ago a client may have said I'm happy to build a health care center You know somewhere in Africa to make sure that a local community is served Or they'd say I'm happy to have a few wells dug to make sure that there's clean drinking water in a village today Their ambitions are much much bolder They want to make sure that they give smartly with a lot of impact and they don't want to solve The health care issue in a particular town or a particular city They would like to tackle the issue that one billion people don't have access to health care And so that's why we are pledging today and stepping up to say As Chuck just just outlined They have a 50 million commitment, but they need another 50 what we will be doing is we will be granting 10 million from UBS for Every one dollar that we give or sorry We'll turn around the other way for every two dollars that our clients give we will match that with one dollar Up to an amount of 10 million. So that means in total out of that we should get around 30 million That would contribute to this cause so 10 million from UBS another 20 million from our clients Should should help Raj and Chuck get started now For us, this is not something new and it's not something that we haven't Organized in in a similar fashion in the past the way that we will do this is through the UBS Optimus Foundation Which is a foundation that we've had form since 1999 Which currently has 180 projects globally? 150 million in grants under management and About three thousand of our of our high net worth and ultra high net worth clients give to the foundation every year last year we had grants up to 60 million which we then grant back out right away and interestingly and not coincidentally Both Raj and Chuck's organizations have been organizations that we've granted to For quite a few years. We actually worked very very closely with Raj in in his really when he was in his in his building up phase of last mile health and we're on the ground with him very very early in Liberia when when evil ahead and we've been also working with Chuck for quite some time in in Uganda So for us, this is this is a you know, this is a Process that we've been through in the past and that We're very very familiar with which is also why I'm quite confident that we will be able to get the match from our clients I think I'll leave it at that We are open for your questions if there are any here in the room. Thank you, Bernice First of all, I'd like to invite Catherine. I mentioned already that that Chuck and Raj are part of the of the Schwab Foundation of social entrepreneurs But let me ask you a simple question. Why is the World Economic Forum? Actually engaged in that area and what's the work the community is doing? Thank you So Klaus and Hilde Schwab of course Professor Klaus Schwab the executive chairman and founder of the World Economic Forum and his wife Hilde created the Schwab Foundation for social entrepreneurship 20 years ago today social entrepreneurship is a Widely understood term back then it really wasn't but they felt that There was a critical voice missing in Davos, although we had brought civil society leaders for decades even by that point and that's really these entrepreneurs these visionary leaders who were and are continue to leverage market forces and business principles to solve social problems as distinct from charity and That was you know sort of the origin of the of the idea and of the foundation of the community And so for now 20 years the Schwab Foundation has been selecting and engaging Outstanding social entrepreneurs bringing them together with each other for peer support for collaboration, but also critically with For partnership with other key stakeholders of the World Economic Forum So throughout this week, of course, you're meeting not only with philanthropic partners Others are meeting with business partners But critically there's the role that the public sector has to play as well and that might be health ministries in this case It might be other ministries education ministries in other cases But we are seeing more and more of this kind of large-scale population change What we would call system change that social entrepreneurs as the innovators are able to drive not in isolation but in partnership with other key stakeholders, so I just want to congratulate you both for your dedication and and your commitment and Really want to take this opportunity also to congratulate UBS for coming into this very exciting partnership Thank You Catherine and allow myself to get a question in first You mentioned women, right and we had a Chetna Zinna another of your Members of the community. She is also co-chair this year. She spoke about Working with women particularly and Mohammed Yunus is famously always saying I'm only giving money to women Can you can you elaborate a little bit on that aspect? Well, there's I mean I'd start with this. There's it's it's very well known that Interventions in health care and livelihoods when they're focused on the female head of household just Deliver far greater benefits to the family than where they're focused primarily on the male head of household And think again about the work that we're doing it's focused tremendously on children And on pregnant mothers and so that's really our customer so from just from a business and a behavior change point of view We're gonna get a lot farther and a lot faster if we use a woman as the agent of change And we're trying to change behaviors and mothers and children and to give an example of Chuck's points the There's a woman. I was just working with one of the community health workers in Liberia and her name's Musu Musu lives in a village that is About four hours away from the nearest clinic. She she was About 25% of Liberian women have a chance to finish primary school only 25% But Musu had been persistent. She'd finished high school by the age of 18 And when she came back to her community what she found were children in her village dying from conditions No one should die from in the 21st century malaria pneumonia now she was a Leader someone who wanted to take care of her community and the power of mobile technology the advances we've seen in the In the healthcare industry with point-of-care diagnostic test You can equip her with a $1 rapid test kit for malaria You can give her a backpack full of medicines that can treat those patients and you can provide as we are in this partnership a Smartphone for her to help her automate diagnosis so that she's treating and providing quality of care now with all of that someone like Musu Went from some being someone who cared about her community and wanting to do something about it to actually being able to do something about it and Importantly being able to have a chance to get a job, which is absolutely central right now In this fractured world is to be able to invest in human capital to invest in people and provide jobs So someone like Musu and now thousands and soon to be tens of thousands of workers like her women in these communities We'll have a chance to have careers as health workers. Thank you. Maybe maybe let me add one more thing I think that is has been stressed a lot at this web But I think it's it's important to repeat it here And that's also the point that you mentioned Chuck that the key here is really to have people work together and collaborate I mean the two of you run in a way very similar You know approaches, but didn't start together. You started independently of each other Raj is a Harvard educated doctor. You are a very successful entrepreneur Bringing you two together even from a from a you know point of having two experts that are very complimentary is a fantastic start Then you have a lot of experience in Uganda. You have the experience in Liberia You both worked with mobile technology, but you have had slightly different approaches and marrying that is what we find Attractive is that you know you get two experts who've proven that they can do it Slightly different approaches who now tweak and push each other to bring health care to 34 million people and that's what excites us and they yeah, I should point out that From a partnership point of view, there's a big fundamental partner who's not represented at this table right now And that's in both in West Africa and East Africa our government partners So this is this work is only possible when we do it in very close collaboration with the national governments counties districts And really this is not a NGO Centered activity this are partners coming together to support a net national community health systems And so from an operational point of view a policy point of view and a financing point of view This only works when you have government when you have civil society and business all coming together Thank you I'd like to invite you just for one minute to maybe elaborate on the point of technology Because especially our online audience might not be familiar how you actually do the work on the ground Maybe you can expand on the technology aspect a little bit So it's it's rather simple So we provide an Android phone to every one of these committee health workers and that phone has a simple app on it We call it smart health and the app allows them to do an automated diagnosis for three of the leading killer diseases in Africa Malaria Diarrhea pneumonia and it helps them register and triage pregnancies. It's a big part of the impact and when they finish that Diagnosis and registration the app will then give specific instructions to the parent and to the health worker about what medicine should be prescribed Whether the patient should be referred and but it doesn't stop there The app will if it's prescribed if you prescribe a medicine the app will send automated messages to the mother about When to each day to complete the course of treatment and if they're referred to a facility It sends messages to help them follow up, but the other the other very important piece Is it's not just a diagnostic and support tool for the health worker? It provides end-to-end performance management system for the health system So this is a big challenge. These women are working in very far-flung remote locations It's very hard to supervise them and now their managers the managers managers and even the funders behind this can see The performance of these health workers in real time and really on any device anywhere And so before digital that sort of performance management feedback was all done on paper It was fairly in Iraq inaccurate and it could take up to two months We're now getting that literally on a day-to-day basis The other aspect of this you know being a physician. I think you know as you heard Chuck say You know this is coming after ten years of building strong health systems So this isn't dropping smartphones and parachutes to try to Have community members save lives This is the best marriage between what is already a high touch activity, which is health care and high tech So many industries are worried about automation stealing jobs This is a place where automations creating jobs and in addition to the performance management Smart health app the community health Academy Will provide digital training solutions for these workers So doctors like me can now use smartphones around the world to keep up with the latest in Medical science to be able to provide the best care to my patients Well community health workers to date are living in rural communities like Musus where to get the next training The next skill she has to get in a canoe paddle up river four hours get to a health center to get care When she gets there she's being trained with flip charts and markers You know why shouldn't community health workers like Musu have the same access to quality education as I do and again there These smartphones are making it possible. We're partnering in this collaboration with digital campus Which has developed a open-source mobile application called apia mobile that is providing video and audio Instruction supplementing the instruction that these workers get from nurses on the hands of smartphones and we're starting this month with with a module on pneumonia to help Kills one out of one out of five deaths preventable deaths amongst children in these communities is due to pneumonia simple lung infection That can go wrong and get worse. We know the treatment, but sometimes community health workers have a hard time diagnosing it And so these the smartphone will actually put right video showing how kids With pneumonia look when they're breathing Difficultly so that community health workers like Musu can identify those workers more quickly and and sorry to tie this to a lot What's happened talk being talked about at the forum this week This is it this disruption is very similar to the disruptions you were seeing in so many other sectors And where mobile is coming in it's shifting power from institutions to individuals So the old model in healthcare was when you got sick you had to go out go trudge to a place Wait online and hope that your medicine was in stock the new model is more like what we consumers are expecting now from Media for mobile money. It's on demand and it comes to them So with this model they call us One of these health workers comes to them and they use the technology to do a diagnosis in their home And then provide the medicine on the spot and what does that get you from a health point of view? It means people are going to access care a lot faster So the health systems are going to be burdened with far less acute and complicated cases and fewer people are going to die because of it Yeah, and then maybe one final point on technology that's in you know really important from it from a donor from a philanthropic point of view is that Donors care about impact. They want to know what's been achieved and In the past that process is cumbersome really really difficult paper-based and you know eats a lot of resources With technology it's far far easier and far far better And so you can report back to the donors and say this is the impact that you actually had and you know We've talked a lot about impact at this web as well impact measurement is a really really key point in getting private money Into solving causes like this To drive that point home Much of course of the conversation this week here at Davos has focused on the fourth industrial revolution and I think they're You know there is a risk that it feels very abstract That it might exacerbate Tensions and the divide between haves and have nots But you know really what we're seeing here and the agenda that we at the schwa foundation want to continue to advance Throughout this year and beyond is really looking at how these emerging and disruptive Technologies can be applied in a low-income low resource type of setting. This is a brilliant example of that But there are so many examples of it that we as a community of social entrepreneurs have been exploring throughout the week Including you know, Nate natural language processing and machine learning to help disabled people communicate looking at Artificial intelligence to help refugees reconnect with their family members looking at Drones to be able to deliver critical medical supplies at lower cost So it's not just about being able to measure the impact is also about being able to do it more cost-effectively in difficult challenging places to work and So earlier this week for example, we brought the social entrepreneurs community together with technology pioneers and tech experts to even look At applications like blockchain and artificial artificial intelligence and what are the relevance for these types of models? So it's just it's super exciting to hear that this is the direction that you're going in And I think it's going to be absolutely fundamental for people looking to solve social challenges that they're incorporating Technology into the business models from the outset The forum all this week I question I often get is cheese. Can you bring that to the US to Europe? You know, I'd love to have my health care delivered to my door And I think this is it could potentially be one of these examples where you have a peripheral technology that starts in the African market Look at mobile money It's a light year ahead in East Africa from where it is in the Western markets We could be a pioneering a home health care model in in the developed markets, which will migrate back and the developing markets It'll migrate back to the developed markets. Thank you. Chuck mindful of the time I know we haven't gotten to questions from the floor If we could get the microphone here And if you could state your name and organization for the sake of our online audience, please Thanks. I'm Catherine Cheney and I'm a reporter for DevEx So I'm glad that Chuck brought up government partners earlier and I'm curious to hear from both Raj and Chuck I'm very cautious in stories about mobile technology to always make sure that Yes, technology is part of the solution, but we have to think about health systems and all these relevant players So I'd love to hear from your perspective What are some of the challenges you anticipate that you'll have to overcome to reach the kind of skill you want to reach? And sort of what beyond technology will be critical to the success of this beyond technology and funding And then I'd love to hear a little bit more From the philanthropic perspective. I thought it was really interesting that you said Seeing the impact is important to your clients What else about this particular? Mission is is exciting to your clients. I'd love to hear how your clients look at this opportunity among many things that they could Consider. Thank you Catherine. I'm happy to start Chuck. Please. Thank you Catherine for that question I think you're absolutely right, you know, so the the best this is tech enabled tech empowered, but it lies on the backbone of a strong Infrastructure and infrastructure here is a human infrastructure, right? It's a networks of people from their own villages caring for their own neighbors that are tied to the rest of the health care system So the first ingredient is partnership in Liberia We've been fortunate for the over the last decade to partner with the government of Liberia and a host of other non-profit actors like partners in health international rescue committee plan international Samaritan's Purse all of whom are working together under one government plan to Help the government of Liberia reach the last mile to reach the last million people who have no access to care because they live Too far from a doctor But they're extending the government's health care system if if a health if you know this is critical because if if a community health worker like musu for instance finds a Child with pneumonia who needs to be hospitalized. She's tied to a nurse who's tied to a clinic who's tied to a hospital Eventually and so I think that is one piece. So the second piece and I'll turn over to Chuck I think is a is long-term engagement, you know this We train these workers we hire them we equip them with not just a smartphone But the medical with medicines with diagnostics they're coached by nurses to be trained and supervised They're recruited in selective ways to ensure their performance is high and they're paid and that's one critical thing with community health workers is that you know Around the world there's a debate whether they should be paid or not And yet there is increasing gaps in in in our ability to provide jobs in the world It makes no sense to us from a health care perspective not to When you're short and going to be short 18 million health workers by 2030 doctors and nurses will be important to fill that void But not enough why not leverage? Community members themselves, but it's also makes so it makes sense practically to do that But it's also important for people to get paid for the work they do And I think one of the challenges in the health sector is that it's unclear with just as in other sectors when you have an informal Lower labor and lower skilled labor workforce. What the value of that workforce is well as Chuck said in his sites They're seeing child mortality being cut by at least 25% in our sites we're seeing access to Treatment for malaria pneumonia diarrhea increased by up to 60 percentage points Getting mothers into health care increased by up to it's up to 84 percent where it was only 55 percent In in in research studies So it makes sense that if we can put the data more clearly as Chuck said Into the hands of these ministries of health into health care systems decision-makers to show them how valuable According to the outcome these health workers achieve that they're better outcomes even at a lower cost if we can Expose really that these workers are being undervalued, but then find a way to professionalize them We can actually create value in in the health care workforce through through this So those are the pieces that I think are also important when in addition technology Chuck would you add anything? one word leadership, you know We have a choice, you know this this we've been given a great Resource here Significant amount of money. It's going to allow us to expand in a couple new countries and we have to decide where we're going to go And I think if you look at the most Valuable ingredient in this it's leadership and leadership that holds their systems accountable So when we look at where we want to deploy that money Local strong local leadership commitment to the health sector. I think it's going to be our top criteria top priority Thank you very much since we're out of time can I can I still give the answer to why our Why our clients would be interested in this for reasons I tried a very hard to find three, but it's actually four so one It's tried and tested. Okay. This is these guys have been successful in the past And that's a very very important point second its scale Okay, we are not talking about two thousand people that we're addressing in a in a village with a health care center It's 34 million people Third and I think this is really important to understand for every $2 that our clients give they activate an additional four one from us and three from that community of Extraordinary philanthropists who have started this challenge with with these two gentlemen and last but not least Through the Optimus Foundation they get reporting and controlling So they get numbers and they also are ensured that what's being done is being done in the right way One thing maybe that I would add to the point that you guys just mentioned The other thing that we can bring to the table and that we do bring to the table on occasion in Ventures like this is that through the institution UBS we can help, you know Organizations like this to actually talk with governments to open doors and to bring another, you know voice the table in terms of pushing for change Thank you very much Chuck rush you have about 1500 business leaders to hunt over the next two days to follow the good example of UBS And about 300 government ministers to talk to so we won't keep you any longer. Thank you very much for your wonderful work Thank you to be UBS for supporting this work and thank you for being here today on this panel. Thank you very much


Verification. There was a great movie out there. I don't remember the name of it because it was so good. A little line that said trust, but verify. Right? So that's a verification. It's all about trust, what you got, but verify it. Science doesn't get anywhere without verification. So we use verification in our field to find out whether or not we've ruled out... Oh no, shoot.  To find out whether or not we've ruled out concomitant variables also called confounds, also called the enemy of science. So we use those reversal techniques. We use those withdrawal techniques, the ABA design, the ABAB design. We use all of that stuff to establish verification or as a verification procedure to say, here's the baseline. Then we do this intervention, right? So here's the baseline and we do this intervention and behavior goes up. And we go, hmm, I wonder if that was due to something else. So I don't know, let's verify it by removing the intervention and see if behavior goes back to baseline. But we're still not convinced. So we go, we put it back into place, the intervention. We go, we've not only verified the baseline, we've also verified the independent variable. And we are probably at this point have completely ruled out all of confounds, which is pretty damn cool, especially since we didn't use a statistic.


Hello and welcome to Pukie Ponders, the podcast where I explore big questions with brilliant people. Today's question is, what is selective mutism and how can we help? And I'm in conversation with Gino Hippolito. My name is Gino Hippolito, I'm a speech language therapist. I work for St George's NHS Foundation Trust and I specialise in selective mutism and I've also got a wife and two children and living in South London. Could you start off just by telling us what is selective mutism? And is that the right phrase as well because I've been questioned on this. No, it is. Well, at the moment that is what it's called based on the diagnostic statistical manuals. So that is the term. It used to be called elective mutism before and then it's just changed in 1994 in the DSM fall. So I'll first explain what selective mutism is and then how what some people might propose it should be called. So the way it's what selective mutism is, it is a considered anxiety disorder. And that was recently just acknowledged in the DSM fight. And the great thing about that is there's been a lot more research now and a lot more interesting finding out more about selective mutism since that in 2013. But it is considered a bit like a phobia of speaking or a phobia of being heard and like with any phobia when you're confronted with a threat. So the threat is being heard or where there's a situation where there's an expectation to speak. And when you're confronted with that threat, then your responses are that you fight, you fight, avoid the situation totally or you freeze. And so a lot of people will freeze and in doing so then they can't get their words out. And so just like with any kind of phobic reaction, if you are aware of the threats, your hyper vigilance, you're constantly aware of where that threat might be. And it's quite exhaustive for the individual with selective mutism. And so when you think about the situation, say in a school situation, there's constant expectation to speak in school. And so the poor child with selective mutism in a school situation is exhausted by the end of the day because there's that constant threat, constant hyper vigilance. So what some people don't like about the title selective mutism is they feel that it's because the individual with selective mutism has control over it that they select, they specifically select to speak when they want to and when they don't. And that's where the misinterpretation comes in. And sometimes it can be unhelpful, but I think the, the idea behind it is that they speak and select situations and don't in others. But a lot more people are saying that actually a better term is maybe called situational mutism, where there are specific situations where the individual with selective mutism is mute. And once I work with pediatrics, I will try and as much as possible say the individual with selective mutism just because there are adults with selective mutism as well. And for a long time, a lot of people have been talking about children with selective mutism, but actually there are adults with selective mutism as well. And that's really important to acknowledge. So it sounds like that kind of phraseology is a bit like I do a lot of work in self harm. And if we go back a few years, we used to use the term deliberate self harm. And we've lost the deliberate for kind of similar reasons that it sort of puts the onus on the individual and makes it sound like this is entirely of their choosing. So from what you're saying, then selective mutism, it's about the fact that sometimes a child will be able to speak and sometimes not. Is that right? That's right. Depending on the situation might be who is near where the person might be out. Again, it's that where there's that expectation to speak. And so and it changes, it may seem like it changes all the time, but often there is a pattern to it. However, each of those profiles that the child or individual young person experiences is different. There's a diverse population where some may not speak so much at home and it might be the opposite. They might speak outside of the home. But more often or not, we find that it's more difficult to speak outside of the home and they're feeling more comfortable when they're speaking to close relatives inside the home. And are the kind of underlying reasons for mutism often similar? Or is this a kind of a symptom of many different things? To be quite similar, in a sense, there's a predisposition like with a lot of anxiety disorders, the behavioral inhibition temperaments. And then there's often tend to be kind of family history. So there would be some form of genetic predisposition. Then there's also the environment where might where there might be a lot of pressure with communication. And so if you're behavioral inhibited, quite sensitive to things, and then all of a sudden you put in a pressure situation, then that can then trigger the selective mutism. Often we find the onset tends to happen between the ages of two and five, which is when a child transitions into nursery or school, because the communication environments, they're so different.  It's kind of child-led often. And then whereas when you're at school or nursery, often it's adult-led in terms of the adult asks you a question, you then respond when it comes to a learning environment. And also then it could be quite overwhelming for the child because there's other children there who you've got to learn to share with who are snatching your toys. And then if you're just shocked and overwhelmed by that, then that can be enough to just trigger the anxiety which then tightens their vocal folds and find it difficult to then speak in those situations. And if that's continued time and time again and reinforced, then it then becomes selective mutism. And who is affected and how prevalent is it? It's really difficult to say a lot of studies if you look in the literature, you've got clinical studies, you've got studies in the community. Generally, generally a ballpark figure is in the under eights population, it's more prevalent, which is understandable and says roughly one in 140. And that was from a study by Bergman in I think 2002. And then with the older children between seven and 12, there was another study done and roughly about one in 550. And then there was a dissertation by Sutton, who is actually an adult with selective mutism, who wrote a paper on adults with selective mutitism. And he suggested that there's roughly maybe one in 2400 in terms of prevalence for adults with selective mutism. Wow. And do we see lots of co-morbidity with other conditions? So would we diagnose selective mutism in some young people who are non-verbal autistic, for example, or is that a different thing? When it comes to non-verbal autistic, then you wouldn't call that selective mutism. But certainly there is co-morbidity with selective mutism and autism. And I think the DSM-5 can be quite confusing there because if you read the DSM-5, it may seem like you can't have selective mutism and autism at the same time. But actually, you actually can. Particularly, the main thing is you need to establish that the person can actually speak in other situations. So they have to be verbal before they're given a diagnosis of selective mutism. But common co-existing conditions is communication difficulties, so ranging between 10% to 50%, depending on the studies. And then also anxiety disorder, co-morbid anxiety disorder and social anxiety disorder, sort of specific phobias and separation anxiety, often the high prevalence anxiety conditions. Are there things that we should be kind of looking out for? Is this a kind of instance where if we can pick up sort of early warning signs, for example, that we're able to do work around prevention or not? Absolutely, no, definitely. We know that the onset for a lot of children with selective mutism tends to be the ages of 2 and 5 and can easily be picked up as a nursery in school. What's really challenging is just our view of communication and that often, and also view of children and behavior within school, that if they're quiet, then they're not kicking up a fuss. Therefore, we don't really need to sound the alarm bells here. But so often those children that might have other behavioral difficulties and communication difficulties that they might then be referred. But actually a silent child, a quiet child is actually someone in nursery or school needs to just keep an eye on. And so when it comes to selective mutism for a diagnosis, they need to have a clear pattern where they speak in some situations and do not in others. And also this pattern continues for more than a month. And if it's first month in school, then add another month to the first two months of school. Because it's quite common for children to be quiet and silenced in that first month, because it's such a big change. But we would then expect children to start to vocalize, start to interact more. But if children continue to be silent, that's when I suggest after that one month period, or if they've just started the school after two month period, refer on to whichever agency takes the lead in selective mutism, whether it's the speech and language therapist, the education psychologist, the local authority. Another thing too, there's high prevalence in the bilingual multilingual population. Four times more likely to have selective mutism and another study they saw the red flags would be if the child was bilingual multilingual, but also had an anxious predisposition that were more likely to develop selective mutism. So a lot of practitioners might be confused because of the silent period. But this is where I'd suggest if the child has an anxious predisposition to maybe then investigate further, ask the parents whether is the child speaking to them when they're outside of the home. Or do they stop and be quiet when there are people nearby? Or do they are they quite in front of other relatives to those kind of that kind of information can be really important because a bilingual child will be speaking their own language to their parent in different environments. Are there any other groups that we might see sort of interesting things in terms of communication I'm wondering about. Twins, for example, so I know that I've got two daughters the same age and they did that. What turned out to be quite a typical twin thing of not speaking to anyone except each other with their own kind of language for quite a long time and then developed completely normally and I just wondered if there's, you know, sort of anything with those kinds of examples. There are examples in the literature but also in our caseload in one sense where maybe one of the twins might have selective mutism. In terms of the prevalence I don't know the exact prevalence of that but it is yeah it makes sense because I've often heard anecdotally that yes they do have their own language to communicate or sometimes rely on the other one who might be a bit more confident perhaps verbally. I know there are times when we don't need to worry so sometimes you know someone might be listening to this and then suddenly thinking about a particular child in their care I mean are there times when we might kind of have a false alarm or is there any kind of thing we can look to in terms of reassurance. One thing to look for reassurance is if the child is starting to feel more comfortable in the environment and then starting to be more verbal in that situation. However if they plateau or what's really important as well as another thing gets missed is with selective mutism you might have high profile selective mutism where it's really clear can't that the child or young person or individual does not speak in specific situations like school. There's low profile selective mutism where they may speak or respond when they absolutely must say maybe in a class situation where the teacher is giving pressure and they might respond maybe in one word answer but they never initiate. And those children are the ones that are really high risk of just continuing on through the school years and they often then develop other comorbid anxiety disorders as well. So I think I would rather err on the side of caution and refer on and then you can always say no nothing to worry about or maybe you'll keep an eye on that kind of thing. But I as a practitioner I'd encourage people if they're not talking consistently if you're not seeing improvements if they're plateauing then at least speak to another professional about that or make a referral. I'm just keeping it real a moment because we all know how hard it is to get through referral processes. What should you know if a parent or carer and member of staff at school is concerned about a child. What does that referral need to look like what are the things that you're expecting to learn from us so that you know whether or not this is a case you need to take on. If the child is is not speaking to either adults or peers within the setting. This is from the point of view of school. And if usually for a diagnosis it would have to impact social communication and also education but I would say if one of those things are happening that will eventually affect education or that will eventually affect social communication. So I'd say just refer if I see that pattern and it continues for more than a month that I would say refer and I as a practitioner would want to accept that as a referral. Now at the same time I can't say that for all services because different services have different criteria. But I think we I think there is a need to to identify this a lot earlier for a lot of children because I'm just speaking to a lot of parents who have gone through a lot and a lot of individuals, teenagers, adults who have gone through it and it wasn't picked up earlier on. They're in Sutton study only a really small percentage got diagnosed in childhood. So if anything I as a professional would rather air on caution. But what is tricky like you said there are there are gaps in service and service delivery and that's really important and even within our profession and just to encourage those in education psychology. All those work in local authority that there needs to be a service for children selects mutism in every local authority or every NHS area, but some profession has to take the lead for that. And that's the tricky thing is because sometimes maybe speech therapists might say it's not our remit even though raw colleges speech language therapists say it is a remit to at least be involved in children with our many young people with selects mutism. But then other situations that education psychologists might say it's not our remit or sometimes cams might even say it's not our remit. So it's really important that wherever you are in your local situation that then needs the conversation with professionals to work out who's going to take charge because there are a lot of gaps right now across the UK in terms of provision for SM. And how can we help like should the adults who are supporting a child are the things that they should be doing before they even seek that help or you know what can we do that might help and and really importantly what might we do that might make things worse inadvertently. Yeah, I mean things that will start with the things that make things worse because at least that can be something we can really say we're just going to stop doing that. First we're putting pressure on the child to communicate. That's going to make it worse. Also making comments about the child that they don't speak or they can't speak those kind of things will affect the child's confidence to speak in and start. They'll start to see themselves as okay this is just who I am I just can't speak I can't do this anymore. Also when maybe take when adults take it personally I think adults can easily take it personally, whether it's a teacher or maybe a relative. If the child's not speaking to you sometimes they feel that okay they're rude or maybe they've got something against you. What's really important by understanding it's anxiety disorder. It's not it's not because of you and and to if anything get over yourself and focus on the child because once we take things personally like that then it will react. It will impact our interactions with the child and we will have whether we are aware of it or not convey negativity to the child and that's not going to help at all. If anything what I would suggest is first we'll take the pressure off speaking or that pressure for that child to speak and if anything create opportunities for the child to communicate and participate like with all the other children. I think if ending that's the first step to to to help the child enjoy themselves in that environment. So we're going to enable them to participate but without vocally participating. Yeah it doesn't have to be vocally they don't have to participate vocally. So what I'd suggest is first of all maybe even before considering speaking think of is the child actually focused in the activity. Are they attending to the activity because they might be just totally just in freeze mode and not even engaging with the actual activity. So then they practice and they think okay what can I do to make it easy for them to actually just engage and attend to the activity.  And then maybe the next step are they interacting the activity, even if it's non verbally, because that's what you want them to do is actually participate and interact and it doesn't have to be verbally at this stage.  The child will then be able to start saying maybe one word and then maybe a few words and then maybe eventually sentences within that educational setting. But it happens it can speed up a lot quicker when the younger they are so in nursery age we find that the process can be a lot quicker there. After we find after year one it can be take longer for them to move up those stages of confidence speaking. Is that because it's kind of become such a habit or their anxiety has got really high or do we know why? I think yeah both I think it's just been ingrained when I look at those two longitudinal studies and done in the 2000s. And what's interesting that their age of referrals roughly eight and a half and they accessed a psychology service and they tracked them into adulthood. And they found that roughly I think I wrote this down somewhere about 42 to 61% still had SM in adulthood because they had SM for five years before they were referred. Now this is not doom and gloom for those who are late referrals but if anything there is an emphasis where when children are referred early I was involved in a team in Kent where we did an audit of children who referred in nursery and reception and we tracked them. All we did was we offered training for parents and also teachers and then we set up a meeting where we talked about things you can do to change the environment make it easy for the child to speak. And we just tracked these children and by the age of by the end of year by the end of reception. So by the age of six 86% of the children had resolved without any other kind of work. So just like touch but earlier on can be really effective. Whereas you know once they're in year one or two or onwards or in teenage years then I mean once you're in teenage years you're dealing with likely to have comorbid conditions. But certainly in the early primary school years you do find it can take several years to then resolve after that. Are there any kind of universal sort of strategies that we can you know use within an education setting in particular that would make it less likely for like all children to develop these kinds of issues. So that taking that approach that sometimes when we look to help individuals we can end up kind of helping everyone. Yeah absolutely there's a thing which a speech therapist we one of our bread and butter strategies or forms of intervention is parent child interaction therapy or adult child interaction therapy where when you're interacting we do this with children with who have a Stammer or who might have language difficulties to help develop the language. But what it does it actually takes the pressure of communication but in doing so it actually helps develop communication. So an example of that is trying not to ask too many questions and just make comments. So if you're dealing with children and say earlier on in nursery or reception play with them build rapport do something that's fun. So they're interested they're more likely to engage and try not to ask too many questions just comment on it almost like a commentary thing and also pause to allow time for the child to respond as well. But with selective mutism there's a slight difference the way I'd work with the child with language difficulties and a child with selective mutism that situation.  But with a child with selective mutism I contact can be very confronting and quite overwhelming. So what I suggest is actually with the adults to be side by side or alongside when you're playing with the child so you're not making that you know I contact they're taking that pressure off you're making comments and you're doing something fun the child is more likely to make comments feel more relaxed and then start speaking that situation and then little by little you can then step it up into more of a educational activity. But that's what we call the research calls that defocus communication. And that's something which any one could do in any nursery staff or reception practitioner can do. And it's great for all children to develop their language skills. It's great for children who stammer as well because you're pausing giving them time to interact and respond. And you're doing something fun when you're having fun it's it's hard to be anxious. It's hard to to be tense. But if you're having fun you start to relax and you're more likely to speak. And I guess that really helps with building that kind of that trust and that relationship as well doesn't it. Absolutely and that's feeling a sense of acceptance of the child that there's a common theme there when reading adults experience of selective mutism and even actually when I saw there was an adult with selective mutism who spoke actually at the Royal College of Speech Therapist.  And she said that was the first time and she tweeted this was the first time she spoke in 12 years in front of an audience in public. But what she said was actually I wrote these things down because they're really important. She said she felt accepted included and not pressured, and that lowered her anxiety, which made it easy for her to speak. And I noticed that your interview with Caroline a few weeks ago to there was the same kind of theme of just acceptance of the person who they are, and just enjoying that time with them. That takes the pressure down pressure off. So there's those common themes absolute those interpersonal things. It feels like a bit like the advice here to adults whether they're working with or living with a child that it's almost that we should just try and relax a bit and have fun and almost try and forget about this difficult thing and just try and get on with the day to day of enjoying a child and hoping to create a bit of a bond there. Absolutely. And that's why a lot of people when it comes to speech depth is working with young children. It seems like all we do is play. And my children asked me, well, what do you do dad and I said, I will I do a lot of play with children and talk about the different toys are playing this I want to go to your work. But that's it. That's essentially it is looking for particularly young children looking for things that's fun with the child. And using just ways where there's no pressure to speak or communicate. But having fun this often then gives the child motivation to want to speak and share and interact because children with selective mutants they do want to speak. And when they're in situation where they feel comfortable, they will speak and you will probably talk to their parents or siblings that they can talk forever. Often when they come home as well, they're just very chatty perhaps because they have been silent for the whole day. So they do want to speak is just giving them an opportunity to do that. And should we use like other methods of communication or does that kind of impound the the mutism like should we allow them to write or draw or something to show us what they mean if they find it difficult to talk or is that not a good idea. No, absolutely. I think that's great because what we want to send the message we want to send across here is communication is important any form of communication. Now, when it's a young child or younger child. Similar to that what I was mentioned before about is the child attending as a child participating as a child interacting non verbally, then you move up to any form. So, writing or using gestures things like that is a non verbal form of communication but still interaction and we want to encourage that with younger children we do want them to have the opportunity to speak. It goes with young people as well. But the more you get older with SM, then it's also important to just consider that sometimes these difficulties may not necessarily go away. And actually we got to think about maybe how to how to cope with having SM. And not only that but also as a society, how are we going to respond. Because it's impacting their access to things it's impacting their access to jobs it's impacting the access to just doing things like other adults are doing, you know, catching a train. It can be very difficult to asking for a ticket or whatever it might be there's so when it comes to adults with SM. I probably not the best to be able to convey that in fact I kind of articulated as well as those adults with SM. So what I would do is signpost you to ispeak.org it's a website developed by adults with SM. And they talk a lot about the social disability model and about just how there's things that society can do to make it easier to for them to be included for them to be accepted and for them to have access to things like that. Because when we think about it, we live in a very verbal centric society. And in a subtle way that not many people are aware of where a lot of adults with SM are experiencing prejudice. They're not having access to things like everyone else. So from social disability model we as society need to take responsibility and make some changes as well. Now I don't have all the answers to all those things, but there at least is a conversation that can be started. Absolutely. And presumably when you are supporting a child with selective mutism, you're also supporting probably quite a worried and maybe frustrated family. Yes, absolutely. I mean, yep. I mean, with any child with in that situation, I think a parent will be very worried and concerned. I know I would be. But also alongside that often, children with SM. Often there's family members who might have anxiety disorders as well, comorbid conditions. And often would find in case history that maybe one of the parents might also have anxiety. And so there is that element there. And occasionally I would have to talk to parents and just say what's really important is to be aware of our own anxiety and how we might project that to our child. And also when I talk about the child taking risks, I encourage parents and children to take risks and for the parents to model that as well. So it's what we call a have a go attitude. So it doesn't have to be in relation to speaking. It could be anything could be like a physical challenge. It could be a vocational challenge or academic challenge. But the idea is to take a risk because of the behavior inhibition, they're reluctant to take risks that children and young people just people with SM tend to be risk averse. So what we encourage is the parents and the child, but particularly the parents to model taking risks and also talking through the child about that and how they felt and how they overcame that. Because then it just sets up a great model for the child to do that. And often a lot of parents will have lots of experiences where they'll have to play or literally feel that they are taking a risk, maybe in a social situation or could even just be talking to the bus driver or talking to the shop assistant. That could feel like of taking a risk. Sounds scary actually the idea is a parent being told right you need to do this and role model it for your child and simply there we're looking at kind of supporting and scaffolding to try and make sure that the risk is taken but the outcome is not negative. Yes, that's right. So there's also ways in what we might encourage the parent. There's a strategy which Maggie Johnson and Allison which is came up with it's called the weight weight technique. And the idea is say when the parent and his child is maybe at the shop. And they're obviously the parents talk to the child that this is what's going to happen that if the shop assistant or maybe with their in public someone asked the child a question. Often it might be on what's your name or how old are you. That's often the questions that shop assistants or sometimes strangers might might say so we encourage parents to wait five seconds. Again, then creating an opportunity for the child to respond. If the child doesn't respond in the parent might turn to the child and then turn decrease the communication risk by turning into a choice question so saying also are you. Seven or are you nine. So then the child and the child is then looking at the parents so then it takes the pressure off they're not looking at the shop assistant. So you've got proximity change there so all these by doing these little strategies it takes the pressure off or decreases the pressure anyway for the child. And then the parent waits again for another five seconds. And in those situations some children might then say something and then the parent can model it back or repeat it. And then if the child doesn't respond in that situation then the parent might say oh you're nine aren't you and then move on. But the idea in that situation you actually creating two opportunities for the child to communicate. And so you're not avoiding but you're also like I said scaffolding to make it easier. And if a child was able to speak in that situation and that was kind of unusual should we be kind of celebrating and praising that or do we just kind of quietly move on maybe acknowledge it later. Yeah I wouldn't make it too much of a who are. It's interesting because in say the states they often talk about praise and but maybe it might be culture specific because I know in the states they're very big on on making things big. But in the UK we're a bit more reserved. So I what we've had conversations about this. Those who work in SM like about the difference in cultures and then how our approaches to intervention what we would say in the UK is just acknowledge it but not make it a big deal. Because sometimes if you make it a big deal it then puts the spotlight on the child and sometimes in that situation that's the last thing actually a lot of times that's the last thing the child wants. So if you move that into a classroom situation if a teacher said oh well done for talking great job. Then that's the last thing the child would want because everyone's been looking at the child spotlights on the child and they're thinking I never want to do this again. So just acknowledge it and then move on. But then they can maybe have just a word say hey that was great job well done for you know being brave and saying those things you know maybe on a one to one situation. And would you maybe be communicating that with home as well so parents can acknowledge it with their child and feel maybe reassured or. Yeah, that's right. Yeah, I say you same kind of strategies at home and also in school too. And what's the role of support staff because I do loads of work with support staff kind of our school nurses are learning support assistance all those different stuff who are often alongside our kids and often will have a really important role with any child who's working for whatever reason and I would assume but you'll correct me if I'm wrong that maybe a child might build like a really good relationship with maybe one member of support staff who might be able to really help with this. Yeah, absolutely. And in fact, particularly with the younger children. I find that the support we work through the support staff. In fact, there's with younger children. There are a lot of children who have never met me before as a therapist and I worked purely through the parent and and the teachers because they're the ones who are with the child saying they out they're the ones who are most important to the child. If the child never speaks to me ever again then there's no no problem with that from their side of things. And there are situations where I've actually never met the child in terms of we had assessment but in terms of in school setting and things like that because I've purely just been meetings with the parent and the teaching or teaching staff. And if anything they're the most important people involved when it comes to supporting children with selective mutism because they're with them day in day out. So we involve them if they're younger we just give them these strategies early on in nursery or reception. Once we move into year one onwards we tend to then have a more formal structured small steps program. So we might do shaping or sliding in and that support stuff will be really key in that. Sliding in sliding is stimulating or it's a strategy technique where you expose the child to to the anxious situation. So of an adult being near them or approaching closer to them while they're talking. And the idea is so for an example the child might be with a parent or someone who they feel comfortable with speaking to. So they might be in a room playing a game or activity or maybe they might be counting or doing some sort of activity which is fun and lighthearted. And then the new adult who that you want to introduce into the child's talking circle will then move closer and closer they might be outside of the room. Eventually once a child is continuing talking feeling comfortable they may be open the door and then maybe the next step might be then moving in just outside inside the door. Eventually maybe moving in closer to the table eventually then sitting at the table eventually maybe then participating in the activity and eventually maybe asking a question or talking in that activity. So it's a really small steps approach of moving that new person involved and eventually that person becomes a new talking partner. And when that person becomes a new talking partner then the often the parent often then moves out and it's faded out. And then from that point onwards that new talking partner helps slide in other children and other support staff in the school. So that's sliding in shaping is a similar one shaping is when maybe the parent or comfortable communication partners not involved for some reason or rather. And so what's the the adult who is doing the shaping work who might be maybe a speech therapist to start with or it could be if it's true if the speech therapist is training. The practitioner the education practitioner then the idea would be in really small step approach moving from nonverbal communication to maybe eventually sounds. It could be maybe with instruments and then sounds and blowing with like a recorder to eventually making sounds with the mouth to eventually making syllables to eventually words and phrases and sentences. So small step approach to community verbal communication. And then once that's established in terms of from a conversational point of view, then similar to sliding in then you can then slide in other children or other adults within the school setting. And how long does this kind of process take like how long would a child normally be going through this kind of therapeutic approach. It really depends again depends on how collaborative the work has been. If everyone is on board. And we recommend at least if they're doing this approach to do at least three times a week. So it can be challenging sometimes when it comes to working it out in the school day. And also finding rooms available as well. So it's hard to say hard and fast because some children they may move up really quickly. Others it does take some time but you would expect at least probably would expect some progress after several sessions. I'm not saying they're going to be speaking freely but at least this progress in terms of allowing the person to be in the room with the child hearing their voice. However, if the select mutism is really ingrained what's really important is to break the step down into really small steps. And that's where you might need a speech therapist or educational psychologist involved to problem solve and work out what that small step might look like. And do you ever get issues where like if there's a long holiday or say the period of lockdown where a child might revert to previous behaviors having kind of overcome it once. Absolutely. Yeah. That often happens. And I often reassure parents and teachers that this might happen. But often I find that children bounce back quicker. And that's a good sign when they do that because at some point in time there's going to be a transition. They're going to transition to another year group or different teachers well and so it almost starts again. So my almost. Yeah, I talked to parents and teachers to expect this to happen and to kind of normalize it. But what we do want to see is the child to then also improve probably at a slightly quicker rate than it was before. So do you often see that there's a step back when a child like transitions into a new class or like between primary and secondary that's presumably quite tricky. Yeah, it's a big transition that one. I mean, it's interesting because again, like each child is different. Some children surprise me and they might come into the new year group or maybe even go into secondary because no one else knows them and say, OK, I feel comfortable because no one knows that I don't talk, but I can talk now. So they they then start talking in secondary that might happen also in transition. But more often or not we do find there is a bit of a setback. But as long as there's things in place to support that transition, often that setback is is shortened. So things that we would suggest is maybe transition book. If it's moving across year groups, then the child to build rapport with a new teacher. We encourage schools to find out. I know some schools don't release the new teacher will find the teachers don't even know who that what they're teaching, you know, until the end of term three. But what we encourage schools to do is to identify that for the sake of this child and then identify who that new teacher is and then look for in that last term in term three to start building rapport with that teacher. We encourage schools to bring the child to that teacher to deliver errands or something like that. Or sometimes some schools they might have the new teacher go into that classroom and teach some subjects or so towards the end of year three so that they build that rapport. Some teachers are great. They might send a message over the holidays and looking forward to seeing you. Also a transition book can be really helpful in just maybe taking photos of the new classroom. The new environment or where the toilets are going to be where you know that the food hall is going to be if things have changed. So that the child just leading up to that new year can then look at those things and just to be aware. Okay, that's where I need to put things or that's where I need to do things because they what they don't like is that change and not knowing. I've worked with a child once and she found she really struggled in a transition from a reception to year one because she didn't know where to put her coat. She was anxious about she didn't know where she's going to put her coat on the coat peg.  This is where you put your bag when you come in. This is you get your name tag when you come in you put name on the board whatever the procedure is but so that the child will know what's happening and that can at least bring down the anxiety to make it easier. And if a teacher knows that they've got coming into their class a child who's got history of selective mutism whether it's current or kind of previous. Are there any specific things you think that they as the as the class teacher or sort of designated support staff should specifically be doing for that child and for their family. Yeah, I mean, what would be amazing this to be in an ideal world is if the teacher or the support staff can do a home visit before that new year. I know it's not always possible with schools. But when I've seen that happen and when schools have allowed the teacher to do that or the teaching system to do that is made such a difference. And sometimes that can really help build that rapport earlier on and make it easy for the child in their transition in one thing it's going to be really important we'll be talking to the parents find out what was helpful what wasn't. What does the child like so they can have in the back of mind things that the child enjoys so that you know if the child is feeling anxious that they can then think of activities the child can do to bring that anxiety down. And also ask the parents what what helps in different situations for the child. So communication is really really important is really important between home and school it's so important I find that when there's the lack of that communication often there's the progress is slower. And could be sorry gone or I also know the point is if maybe one of the two are not on board, then often we find the progress is being slower. Okay, so we kind of want to do that kind of genuine sort of child centre team around the child kind of approach. And just thinking about the home visit suggestion which yeah sounds like a wonderful thing to do but not always possible. Do you think that like doing it like this I presume is that something that would be helpful or not so much. You know what that's really interesting that's because I wouldn't have thought of that until covered 19 and what's really interesting. It's not the case for all children but some children actually find this type of interaction easier because there's a proximity there because you're just on the screen you're not there in person there on the screen. At the same time there are some children do find it difficult. Another thing also notice is that the younger children they're so exposed to social media and the parents using this that actually it's the kind of desensitised to it so it's easy for them to communicate and interact. At the same time, some do find it difficult. In the last few months when I've worked with child with select to mutism and their parent, what we tend to do is I interact with the parent we do some games or playing with these younger children. I play with some of the toys and little by little the child then might be outside of the screen but little by little as they relax and become more comfortable see that this is fun. They start become coming into the screen and then with this particular child I worked with eventually she was then interacting asking me questions or making comments about what I was doing at play so some you can use a kind of graded approach again also in that kind of interaction. It must be so great when you have a child who's been me who then does choose to interact with you that must feel brilliant. It is amazing. I don't want to have that I don't want to chase that in that being the thing I would chase for as a therapist, even though it is such a rewarding thing but I know that some. I know sometimes when that becomes the goal in my mind it can be as a therapist anyway it can be frustrating and I don't want that frustration because sometimes that's my expectation. But yes absolutely is really rewarding. Yeah. And can you tell me a bit about your research that you're doing some NIHR. Yes. That's right. I'm recently Maggie Johnson and I we wrote a chapter about some selective mutism and pragmatic language impairment and there's some papers have suggested that maybe children with selective mutism may have underlying pragmatic language impairment. In this chapter that we wrote we suggest that it's not the case for most children with SM. However, some pragmatic language impairment is it's kind of like ASD but it's without the it's more of the difficulties with the pragmatic service social use of language rather than aspects of rigidity. And so there is difficulty with social communication but it's more from the pragmatic language side of things. So what we're suggesting is that is not the case for a majority of children with SM but however like with any child they might have pragmatic language difficulties. And if you if we did have a child like that this is how we would assess the child or this is how we would provide intervention. So that's one of the things that we did on the during the fellowship but also I've been working on a systematic review as well looking at non pharmacological interventions. And what's interesting there's been a lot more research since the change in terminology and DSM five becoming anxiety disorders there's been several RCT so just writing up that paper at the moments and playing to do a method analysis there with some of the RCTs. So that's something in the pipeline. What's really interesting trend is that those the intervention that I've noticed are effective. There is that report building. There is the changing the environment or students approach in a way, but also there's always a behavioral element there as well. Did that surprise you or did it. It was actually that there was a lot of people were talking about that already and actually a lot of studies were using that but never really talking too much about it. So there was yeah that it's something which we noticed what was interesting there was a you using CBT but with online web application. And this particular study. It was just the clinician and the child. So there wasn't any teacher involved. There wasn't a parent involved parent had a bit of homework but that was it. And what was interesting the child didn't make much progress. And if anything the active control made slightly better progress. But the active control was playing computer games. Now what I might hypothesize about that is that actually with computer games there's no pressure to communicate. But you also build a rapport as well. But with this situation. I see that there is such an important role for parents and teachers to be involved. And if it's just a clinician and the child is only so far you can go in terms of generalizing the communication the speech and other situations you really do need other people on board to help that generalization to support that young child or individual in communicating other situations. Yeah, which is great to hear. And you've given us some really good and practical ideas about things that that people can do to help. And I wondered if you would mind kind of closing with I always kind of create these instant insights of the you know the minute if you only listen to one minute this is the one of maybe some just a very brief overview of the things we can helpfully do where we're worried about child. But the identification and access to services really important for clinicians parents teachers and we all have a role to play. What's really important address it and acknowledge the speech anxiety with the child so that they know that you know. And also that they know that that what you want to do is create opportunities to communicate participate and have fun and you want to take the pressure off speaking. And also whatever you do small steps is really important and do things in small steps and it doesn't have to be just in speaking. But also with any kind of goal that will think that the child wants to achieve try and do things in small steps to take that pressure off. And also collaboration is so important parents teachers clinicians all working together and also if the greater society can also make some changes as well to allow for access for adults with SM that would be great.


So, Noah, huh? That dude was the last of the anti-Diluvian patriarchs in Genesis. He built a huge boat, invented wine... You know, he seemed like he's a pretty busy guy, but he did live to be about 950 apparently, so it's not like he wasn't having any fun in that time. We watched the movie recently, partly because it kind of fit nicely with our recent Sumerian epic series, The Great Flood, go and check it out, and there were a few things that struck us as worth talking about. For one, only after watching it did we realize that there's a sense that the movie could be set at any time. We know that it's the past because we know it's the story of Noah and that whole thing, but otherwise it could be set a thousand years in the future in some dystopian society, or you know, a bajillion years in the past for all we know. The movie never really makes it clear, and I think that's part of what makes it so interesting. At its core, Noah is a movie about our connection, or rather, disconnection, with the Creator. And while the original legend is Hebrew, the movie never actually calls the Divine God, a sentiment that upset more than a few religious critics. At its heart, many classical Christian themes are generally brought up though, stuff like love and forgiveness, overhate and lust, and the concept of personal mercy, the idea that we are the ones who decide if we're worth saving and returning to the Creator, rather than the Divine being the one making those choices. But we want to look a little bit deeper, at a more core spiritual level, and ask, what is it that makes Noah tick? As he embodies everything from being a divine messenger who is championing the idea of everything having a place, and being super vegan, all the way to a crazy, almost fascist who sees nothing wrong with killing his own grandchildren because he believes it's the will of God. And then in the last second, you know, find some compassion. Bear in mind, we're obviously talking about the movie here, for the old-school biblical Noah never wanted to kill his kids, although he did curse Ham out for seeing him naked, but hey, what family doesn't have drama, right? Anyways, from the beginning of the movie we're introduced to Noah, and he seems to be living in complete harmony with nature. He gathers his food from berries and shrubs, makes his clothes out of natural textiles, and even teaches his kids the important concept of only taking what one needs.  In a nutshell, he seems to have most of his lower chakras pretty balanced and in tune if you know what I'm saying. He's surviving just fine, living off the land, has three healthy kids, beautiful wife, and a strong determination and willpower, and seems to have some pretty hardcore energy reserves for carrying huge bags and going on hikes. His root, sacral, and solar plexus are all completely in balance, or at least working pretty good. He knows how to live and how to act out his desire calmly and rationally in the physical dimension. An important distinction is made early on too in that Noah doesn't actively look for signs from the divine, he simply goes about his life and allows the signs to come to him, approaching them each with careful thought and from a position of acceptance. When he gets his wet dream, no, not like that, about the coming flood, he decides to visit Grandpa Methuselah, who bears all the hallmarks of your typical shaman. He lives in a cave in the mountains, is old and wise, and reminiscent of Taoist sages, and even gives Noah a drink that not only induces magical visions, but also looks an awful lot like ayahuasca.  After his plant medicine experience, Noah starts receiving instructions to build the ark, along with some help from the now friendly watchers, who totally want to help and not kill everybody for some reason. And so, sorry, I should probably give some backstory here. In the book of Enoch, the watchers are angels dispatched to earth to watch over humans, but they soon begin to lust for human women, and at the prodding of their leader, defect en masse to illicitly instruct humanity and procreate among them? Yikes. The offspring of these unions are called the Nephilim, savage giants who pillage the earth and endanger humanity. And straight up, the deluge itself was a force from God to wipe out these Nephilim specifically. But hey, I guess in Hollywood, you gotta change some things around from time to time. Kinda makes sense too, as the watchers were depicted as rock monsters in the movie, and human watcher offspring might be freaky.  Anyways, after his ceremony, Noah's higher centers start to come into focus, and he can receive messages from the divine. Coupled with his powerful root chakras from earlier, he can now channel an idea from the source, and put that into informed action and make a change in the world. Naturally, this attracts the attention of Tubalcain and the other humans in the cities. Wait a second, Tubalcain? Is that his name? I just call him the big hairy bad guy. But either way, it makes sense that they'd noticed, because a huge forest growing apparently out of nowhere isn't exactly inconspicuous. Interestingly, Methuselah's idea about how God would end the world in a blaze of fire and brimstone is exactly how the cities in this movie are depicted. They're filled with hedonism, the fires of industry, and enough blood to make even the Aztecs happy. And much like Tolkien and his environmentalism, one of the main sins depicted in the movie is our disconnection with the natural world. Noah and his family live in a place reminiscent of Eden, with lush greenery, foods and animals of every kind living in harmony with nature and the divine. The cities, however, are industrial havens that have sucked the life out of nature around them. When Noah crosses that threshold and sneaks into one of the cities to see how people live, the experience is so traumatic, and he's so disturbed by what he sees that not only does he run away, but also has come to the conclusion that everyone has to die, including his own family because the capacity for sin is also in them. There's a scene here where Noah sees himself looking back at him, but this time, an evil Noah, dark shadow Noah, which really pushes him into a darker state of mind. The thing is, what he doesn't take into account is that being in this evil place, he is being affected by everyone else's bad vibes and perceptions. He takes seeing evil him as a sign from God that he has to die too, not that he is being affected poorly by his environment. Too bad Bruce Lipton wasn't around back then to explain to him the biology of belief and epigenetics, but this scene, while powerful, actually makes a bit more sense when viewed through the lens of the chakras. See, we've talked about Noah's lower centers being active and some of his higher ones being engaged while he receives the messages and signs from the Creator, but we haven't yet touched on the middle one, the heart. Now there's a lot of debate in New Age circles about which box to put the heart chakra in, as some people claim it's a part of the lower centers as it governs love and connection to our physical life and others claim that it's obviously a higher center because love itself is the purest of spiritual emotions that is channeled from the divine. But what if it's both though? Generally speaking, most would agree that the heart chakra helps us with empathy and compassion, things that Noah seemingly lacks until the end of the movie. Oops, spoiler alert. It seems as if Noah's heart chakra goes through a sort of journey, from being partly open to closed and finally back to balance. In the beginning he's depicted as a caring guy who looks after his family, takes Ela in when she has no one, and tries to save an injured animal and then prepares a cute little funeral for it. This Noah is probably the best suited to start building the ark since he receives a message and starts acting on it out of care for the animals and his family. Once he gets emotionally scarred by the city though, his heart closes and he loses that connection to love and compassion that made him so great in the beginning. You could even look at it from the other side of the coin. He's doing so to find Ham and Japheth wives, but maybe also Loki wanting to see if other humans can be redeemed and act of pure love. Going into it, his heart could just as easily be too open, making him unconsciously absorb every emotion and character of the city without any filter. Maybe he becomes too empathetic and absorbs everything, lust, fear, anger, chaos, whatever is going on in the city, and eventually he just snaps, leading to the closing of his heart. This idea of a filter makes a lot of sense. Perhaps we can see the heart as the bridge between our lower chakras and our higher ones, the bridge between the physical and the spiritual bodies, kind of like our own internal avatar Aang. When no one gets a message or sign from the Creator, it's filtered down through each chakra until it meets the heart and the intent is passed onto the lower centers to be carried out in the physical. With every chakra in balance, such an intent is filtered through a loving and compassionate lens, which also means that the act carried out is done lovingly and with compassion. With a blocked or disconnected heart though, our intuition or understanding of messages and signs from the Divine is skewed and we would struggle to interpret things properly. Once Noah gets back from the city, he is almost completely a different person. He becomes exactly like the other humans, being solely driven by his root or sacred chakra. Interestingly, when he asks for signs from here on out, they either don't come or he misinterprets them, perhaps because he's seeing them from a purely physical sense of what they mean on the surface without considering the deeper meaning found in love. This idea of not communicating properly with the Divine is also echoed by Tubalcain when he rallies his armies. He's about to storm the ark and he tries to talk to God, asking him, the problem is he's approaching that communication from a place of anger and resentment. He feels entitled to communication because he believes, I am in your image. I give life and I take it. How are we not the same? He's actually not wrong. Humans do have the ability to create life and take it away, but by acting out in anger or not from a place of love, he simply perpetuates the reality that he's living in. Back with Noah, it finally gets to the point where Illa is revealed as pregnant and has two baby girls, who he immediately decides to kill because they might be able to have more kids in the future. Try not to read into how, since Noah and his family are supposedly the only ones left alive. Killing in general is pretty bad, but killing your grandkids probably tops the list of worst grandpa ever, and it's seemingly like Noah has no sense of love whatsoever. When the rain stops, we see an interesting dualism of perspective from Illa and Noah. The rains have stopped. The Creator smiles on our child. The rains have stopped because of your child, yes. Illa, who is coming from a place of love for her children, believes the flood stopping to show that the children are innocent and worthy of coming into this new post-flood world. Noah, however, thinks God is now angry, more sinners have been brought into the world, and will continue to wash everything away once these kids are killed. Depending on how you look at it, God arguably never actually answers Noah here. If anything, there's a lack of an answer. Which Noah interprets as God giving him the all clear to just, you know, go up and knife his kids. But I think it's obvious at this point that this is Noah's ego deciding for himself rather than inaction on the divine's part. He interprets the lack of a message as a message in itself, and in this moment where he is seemingly ignored by God, Noah becomes that which he is fighting against, angry dirty beardy bad guy, taking action based solely in a loveless mindset. Later on, we find out that God left the whole thing up to his interpretation anyway, and did so to allow Noah, who at this point represents, you know, all of humanity, to choose whether they were worthy of coming into the new age. If Noah teaches us anything, it's that all of our chakras must be in balance, and you can't rely on living on only one side of the spectrum. If even one of your centers is not open enough, or even too open, it can affect all of the others quite negatively. More importantly, his journey from unknown bliss to blockage and finally to balance to love teaches us the importance of the heart chakra in interpreting messages and synchronicities from our higher self. Without a balanced heart to filter the energy through love and compassion, we can't successfully integrate and understand the divine elements of ourselves or put those incredible intuitive emotions into physical action without losing ourselves in the process. In the end, when Noah discovers that God puts him in charge because he knew he would make the right decision, he acknowledges the fact that all he had in his heart was love, a sentiment that we should always consider when making a decision or interpreting the meaning of things. With that, thank you so much for watching. If you liked this video, be sure to like, comment, and subscribe, you know, spread the video around, and we'll see you again next week for something new. As always, strive for balance, compassion, and always live life through a lens of love.