La Salle’s CASTLE Center is helping clients afflicted with selective mutism, while providing practical experience for graduate speech-language pathology students.

By Matthew De George

Evelyn Klein, Ph.D., and Cesar Ruiz, SLPD, had been at La Salle University for more than a decade when a client brought them together in the lab.

The professors of communication sciences and disorders have long histories of clinical experience, dating to the 1980s. Klein has worked with clients with speech and language disorders for decades, as a speech-language pathologist and psychologist. Ruiz specializes in swallowing disorders, having worked with patients at La Salle and in various clinical settings.

The client, identified by the pseudonym Lenny, presented selective mutism—an anxiety disorder that leads to inability to produce speech under specific social conditions. Lenny, then an adult, presented a new concern about difficulty getting his voice started. Klein consulted with Ruiz to investigate the connection between difficulty initiating speech and selective mutism. During the initial assessment at La Salle, Lenny described his difficulty speaking and discomfort initiating his voice. Ruiz attributed Lenny’s concerns to tension in his vocal system, what Ruiz refers to as a “vocal-control issue.”

Klein and Ruiz published their first paper on Lenny in 2014. The protocol they used then has been refined through dozens of client evaluations and forms the basis for the CASTLE Center at La Salle (Comprehensive Assessments with Speech Technology for Language Expansion), solidifying not just the unique work they do for clients but creating a one-of-a-kind avenue for La Salle students to learn alongside them while gaining valuable clinical experience.

Both professors have long balanced their teaching duties and research at La Salle with private practice away from the University. Klein specializes in a broad range of speech disorders, in children and adults, including disorders on the autism spectrum. Ruiz has worked in a variety of hospitals and in private practice for a decade alongside his teaching at La Salle. In selective mutism, they find common ground on a condition at the intersection of their specialties.

“Having the opportunity to teach and then go to other places, to learn about new things, and then being able to bring videos to the students and say, ‘This is what this looks like, not just what’s in the book,’ it’s always very helpful,” Ruiz said.

Selective mutism is classified as a childhood anxiety disorder. It affects about one in 140 children, according to the UK’s National Health Service, with a 2:1 ratio in girls to boys. A timid temperament is usually evident early on in the child’s life. The cause is multifactorial, and it can present in a variety of different ways. (To borrow from the title of one of the books Klein has authored, speech disorders like selective mutism have “social, emotional, and cognitive dimensions.”)

The condition can be extremely frustrating, for clients and their family members. It is a condition that is likely underreported and can easily be misidentified as simple, if extreme, shyness. Their symptoms present in a variety of different ways and with varying severity. With young children, time is of the essence to reduce their periods of anxiety-induced silence for the benefit of their social skills development. For families, it can be a perplexing and stressful condition with which to contend. “Parents wonder why their children are not able to generate speech when they encounter people they don’t know, or when they feel like they’re in a performance situation like school,” Klein said.

With such a complex condition, screening and treatment isn’t one size fits all. Those intricacies inform the value of Ruiz’s and Klein’s intersecting expertise. From a teaching perspective, that nuance reinforces the value of clinical experience that the CASTLE Center offers, in teaching graduate students how to approach a vulnerable population.

Klein has worked with some 200 clients with selective mutism in her career, including around 50 in tandem with Ruiz since the CASTLE Center was founded in 2017. The pair have mentored some 20 graduate students at La Salle, including a dozen since the CASTLE Center came into existence.

The Center’s curriculum involves students in La Salle’s Master of Science in Speech-Language Pathology program in the client evaluation process. CASTLE Center clients, for a nominal fee, receive a comprehensive evaluation led by Ruiz and Klein in which they assess the child’s developmental history and conduct testing related to voice, the oral mechanism, hearing, speech sound production, speech fluency, and vocabulary knowledge, among other areas. Students are able to interact with the clients, following scripts and protocols honed by the Center over the years. Students also learn how to interface with parents, guardians, and siblings, who are often a pivotal part of the evaluation process.

Once the evaluation is completed, students join Ruiz and Klein in a debrief with a client’s family. They also help prepare a lengthy report on what the client is presenting and in delivering suggestions for treatment strategies.

“The students have the ability to see us interacting with the clients,” Klein said. “They get a sense of how you interact with clients in a professional way.”

That type of hands-on clinical experience is rare for graduate students and valuable as they venture into their professional careers. Kathryn McDonald, ’19, arrived at La Salle after completing her undergraduate studies at Geneva College. She worked with Klein and Ruiz in evaluating 10 to 15 clients at the CASTLE Center. She used the experience to land a job after graduation with Mastery Charter Schools in Camden, N.J., working as a speech-language pathologist in Mastery’s six schools, from the elementary to high school level.

The ability to put a face to the condition and understand what the theory looks like in practice made her ready to step into professional life.

“That was an experience that gave me so much confidence about the process of what to do when someone comes to you with something out of the ordinary,” McDonald said. “… Even in classes, you’re learning about all these experiences, but until you have that face-to-face exposure with a client, it’s nerve-wracking. Having that hands-on experience, especially guided by Drs. Ruiz and Klein, was really important for me.”

Given the complicated nature of the condition, Ruiz and Klein are always happy to be a resource for former students when they enter clinical practice. Even decades into their careers, they often run up against aspects of speech disorders and selective mutism that are new. Being there for former students and collaborators when they do the same in their work is part of the network that the CASTLE Center aspires to create.

“Not only are they learning from us, but they’re feeling comfortable that what they’re learning is right on target,” Ruiz said. “It’s based on research, it’s evidence-based, and they know that if they find someone that might be related to that, they can always call or send an email or meet with us.”