What Can We Do To Assess &

Treat Selective Mutism?

Evelyn R. Klein, Ph.D., CCC-SLP, BRS-CL Elisa Shipon-Blum, D.O.
Donna Spillman-Kennedy, M.S., CCC-SLP

Sara Cohen Phillips, M.S., CCC-SLP Janice A. Gordon, B.A.

Emma Petrucci, Graduate Student
Selective Mutism Anxiety Research
& Treatment Center (SMart Center)
La Salle University, Philadelphia, PA Jenkintown, PA
klein@lasalle.edu www.selectivemutismcenter.org
Goals of Today’s Seminar:

„ Background of Selective Mutism (SM)

„ Assessment of speech and language of

children with SM

„ Development of a treatment plan to

improve social communication
Involvement at the SMart Center
„ Generally see the following types of children
during initial visit with presentation as:
‰ The ignorer (non-communicator)
„ Completely ignores or ignores the less familiar

‰ The nodder & pointer (nonverbal & anxious)

„ Responds & initiates through gestures

‰ The mime (nonverbal & not anxious)

„ Expresses self interactively but no speaking

‰ The whisperer (transitional)

„ Parent is usually the verbal intermediary

‰ The talker
„ Verbal child
Background of SM
We know that…
„ Anxiety can affect a person’s
‰ word retrieval ability
‰ verbal working memory for more complex
material
‰ sentence formulation ability
‰ response time

„ In addition,
‰ Communication deficits may increase
a person’s anxiety when asked to speak!
„ Anxiety and Selective Mutism (SM) appear to
go hand-in-hand.

„ But why is SPEECH the function that children

with SM withhold? Ultimately it is FEAR.

„ Speech & language deficits or delays also make

communication difficult.

„ Children learn to become ‘shadows’ and wait for

specified people to speak for them.

(Anstendig, 1999)
According to the DSM-IV-TR (2000), SM…
„ involves a consistent failure to speak in specific
social situations and is not thought to be due to a
lack of knowledge with spoken language.

„ symptoms must be present for at least one month

(not including the first month of school).

„ interferes with education, occupation, and/or social

communication

„ is not better accounted for by a communication

disorder.
Prevalence Rate of SM Over Place & Time
Study Rate Country N Age- Dx
Sample Criteria
Steinhausen .54 Germany 4,093 Mean= Clinic
& Juzi, (1996)
9.74 yrs. ICD-10

Kumpulainen 1.90 Finland 2,009 7-10 yrs. School

et al. (1998)
DSM-III-R

Bergman et .71 USA 2,256 Kdg-2nd School

al.
(2002)
DSM-IV

Chavira, .50 USA 190 8-17 yrs. Clinic

Stein, Bailey,
& Stein (2004) DSM-IV

(Viana, Beidel, & Rabian, 2009).

Selective Mutism Develops in Childhood

„ Current accepted prevalence ranges from .47 to .76

or 4.7 - 7.6 children in 1,000
(Source from previous slide)

„ Associated with signs of temperamental inhibition.

„ Often diagnosed when the child starts school

‰ (3-6 years old).
(Anstendig, 1999; Cohan, Price, & Stein, 2006).
It may be more readily diagnosed when
school starts…
„ Separation issues

„ School interactional rules

„ Decontextualized language - imagination,

interpretation, & inference

„ More challenging language demands with

unfamiliar people
Speech-Language Assessment of
The Child with SM
 Speech-language Assessment for SM
„ Parent questionnaires / surveys
(The SMQ: Selective Mutism Questionnaire by Bergman, Keller, Piancentini,
& Bergman (2008) is new and focuses on communication at school, in family
home, and at social-public settings)

„ Record reviews and structured interviews

(Vecchio & Kearney, 2005)

„ Functional assessments (interviews with people who know

the child)
(Schill, Kratochwill, & Gardner, 1996)

„ Non-standardized testing
‰ at home using videotaping for language sample analysis
‰ parent-elicited story-retelling using the SNAP
(Strong Narrative Analysis Procedure, Strong, 1998)

„ Receptive language measures only

 Newer Research
„ Parents of 130 children, 5-12 years old were
surveyed
„ Children with SM fell into 1 of 3 groups:
1. Anxious - Mildly Oppositional
when pressured to speak but in reality it is ‘defensiveness’
2. Exclusively Anxious
3. Anxious – Communication Delayed
This group was found to have greater symptoms of SM and
more externalizing problems (acting out when comfortable).
Cohan, Chavira, Shipon-Blum, Hitchcock, Roesch & Stein (2008)
 SM may involve subtle
expressive language
deficits that remain
undiagnosed exaccerbated from
lack of experience in the
expressive domain!
 We need to provide schools with
standardized speech-language test results
so that children may readily qualify for
direct services with
a legal and viable IEP.
OUR STUDY
Through a private foundation grant, our study
attempted to answer the question:

„ Can parents assist in the administration-only of

language-based assessments to
their children with SM following training
and real-time supervision?

„ University IRB approval was obtained prior to

conducting the study.
Participants
„ 33 children diagnosed with SM: 19 girls & 14 boys

„ Ages 5-12 years old

‰ Mean age = 7.3 years (sd=1.7 yrs.)
‰ Mean birth weight = 7.2 lbs. (sd=1.7 lbs.)
‰ Majority (64%) were in kdg. or 1st grade
‰ 91% lived with both parents

„ 70% of parents reported a history of anxiety in the

immediate family.

„ Families were recruited from websites for SM,

regional workshops, and treatment specialists.

„ Participation was voluntary.

Direct Assessment (video recorded)
„ The SLP provided all scoring and interpretation
„ Parents were trained to only administer
‰ Peabody Picture Vocabulary Test – 4 – Receptive
„ Dunn & Dunn, 2007

‰ Expressive Vocabulary Test – 2 - Expressive

„ Williams, 2007

‰ Test of Narrative Language

Narrative Comprehension & Oral Narration
„ Gillam & Pearson, 2004

‰ Word Memory subtest from Test for Auditory Processing

Disorders – 3 – Serial Word Recall
„ Martin & Brownell, 2005
Added Questionnaires
„ BASC-2 (Reynolds & Kamphaus, 2006)
Behavior Assessment System for Children
‰ Structured Developmental History
‰ Parent Questionnaire Internalizing & externalizing behaviors
‰ Teacher Questionnaire
„ SM-CDQ (Shipon-Blum, 2005)
SM - Child Development Questionnaire – Brief
‰ Parent Questionnaire about history & current functioning with SM
„ CELF-4 – ORS (Semel, Wiig, & Secord, 2003)
Clinical Evaluation of Language Fundamentals
Observational Rating Scale
‰ Parent Questionnaire
 Procedures
„ Parent(s) came with their child to the SMart Center.
„ Informed consent was obtained.
„ Parents received step-by-step instructional
training for each portion of testing.
‰ A highlighted reminder page was given for parents to view
during testing.
„ Order of tests was: PPVT-4, EVT-2, TNL, TAPS-3-WM
„ The SLP observed parent testing sessions real-time
through a one-way mirror.
Who Tested the Children?
All children were given the testing battery by both
their parents and again with the SLP.

The order of test administration was randomized

and counterbalanced

Approximate Time for Testing:

1st evaluator – 1:15
Break 30 min.
2nd evaluator -1:15
Total 2:30 testing
Randomized & Counterbalanced Design

„ For 18 children, parents 1st, SLP 2nd

„ For 15 children, SLP 1st, parents 2nd

„ For 32 of the 33 children, it was the mother

who conducted the testing. One evaluator
was a father.
Case: LR
„ Male, 5:3 years, attending preschool
„ Hearing & vision normal. Highly sensitive
to smells, sounds, textures of food, etc.
„ PPVT-4 82nd percentile
„ EVT-2 94th percentile
„ TNL-Comp. 50th percentile
„ TNL-Oral 1st percentile
„ Anxiety Score = 58th percentile (avg.)
„ Withdrawn Score = 90th percentile (high)
Information about LR from Parents
„ LR has difficulty making friends.
„ May speak when mother is present.
„ At home he speaks readily to his family.
„ In public settings he generally doesn’t respond to
others but he will whisper to his mother as a verbal
intermediary.
„ At school he may talk to one child after sitting next to
the child in class for some time.
„ He communicates nonverbally in class to his teacher
and peers.
Recordings were taken…

„ You will see LR responding to test items.

„ He is comfortable with his parents.

„ Notice how his behavior changes with the

evaluator compared to his parents.

„ Notice how his response patterns decrease

as the language demands increase.
„RESULTS
Variation in Ability by Language Tasks
for 33 Children during Parent Testing
80 75
70
60 57 57
% 50
correct 40 35 33
30 23
20
10
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„ The child’s ability to speak to the SLP (an
unfamiliar adult) was not related to order of
testing (parent or SLP first).

„ A chi-square test of independence was

calculated comparing the frequency of
speaking to the SLP when tested by parent
or SLP first. No significance was found
(x² (1) = 2.53, p>.05).
Parental Quality of Test
Administration – 96% Accuracy
„ 11 parents were randomly chosen and rated on
their test administration abilities by graduate
students, an SLP, & a school psychologist.
‰ General Test Administration Practice Checklist (Sattler, 2001)

‰ 40 items rated from 1 (poor) to 5 (excellent).

„ Two professionals at a time acted as separate
judges.
„ Interrater agreement ranged from .72 -.88
„ Parents received an overall test administration
accuracy score of 96%.
„ On all measures, all 33 children (100%)
responded to their parents during test
administration.
„ With the SLP the following % of children
responded:
100 100
90
80 74
70
61 61
60 55
50
40
30
20
10
0
PPVT-4 EVT-2 TNL-C TNL-O TAPS-
WM
Performance During Parent-Administered TNL
For TNL-C: For TNL-O:
F (1,32) = 5.98, p <.05, Cohen’s d = .84 F (1,32) = 9.67, p <.01, Cohen’s d = 1.08

12 10.56
10 8.4
8.17
8

6 4.53 TNL-C
TNL-O
4
Mean=10
2 SD=3
n=20 n=18 n=13 n=15
0
Spoke to SLP Didn't Speak to SLP
Number of Children with SM Who Had
Speech-Language Difficulties
9

14 ExpLang
Rec+Exp
Fluency
4 Artic
Note: Some children did
not have difficulties in
more than one speech or
9 language areas.

Each piece of the pie represents 33 possible children.

Number of SM Children without
Speech-Language Difficulties
19
24

ExpLang
Rec+Exp
Fluency
Artic
24
Note: Some children with
fluency or articulation
29 problems also had
language difficulties.

Each piece of the pie represents 33 possible children.

So… What can be done to help children
with selective mutism communicate?
Treatment of SM: A Best-Evidence Synthesis
revealed…

„ Behavioral treatment is more effective than no

treatment (p<.05); effect size = 1.635

„ Found that 78% of cases reviewed in the meta-

analysis indicated successful treatment outcomes.

(Stone, Kratochwill, Sladezcek, & Serlin, 2002).

Also…
„ Treatment that occurs closer to diagnosis
time of SM (younger children) has the biggest
impact on treatment effect!
‰ Contributed to 62.9% of variance in effect size
for treatment gains.
?
Treatment
Effectiveness
Explained

‰ This was based on 7 studies meeting criteria

to be entered into a regression analysis (Stone,
Kratochwill, Sladezcek, & Serlin, 2002).
 S.C.A.T.
Social Communication Anxiety Treatment

Developed by Dr. Elisa Shipon-Blum

Knowing predisposing
and precipitating
factors that led to or
maintain SM is key to
understanding the
child and developing a
treatment plan.
Elisa Shipon-Blum, 2009
PREDISPOSING FACTORS

- Anxiety in family
‰ Genetic, neurodevelopmental
-Inhibited temperament ÆSocial Anxiety

‰ Environment: Parent & school

misunderstanding, pressure to speak,
enabling behaviors
 PRECIPITATING FACTORS

- Bilingualism
- Speech/Language Disorder or Delay
- Learning Difficulty
- Developmental Concerns
- Neurodevelopmental Delay
- Sensory Processing Disorder/Difficulty
 MAINTAINING FACTORS

- Disorder is misunderstood and ‘mutism’ is

reinforced

- Misdiagnosis and mistreatment

- Misinterpretation of ‘testing’

- Older age = More conditioned

- Avoidant behavior

- Pressure vs. Enabling

 “Many children/teens
suffering in silence are
unable to communicate nonverbally
as well as verbally,
and many
cannot communicate at all
when anxious
and/or feel an expectation
for speech and communication”

‘Just pointing or nodding can elicit feelings of anxiety and be impossible to do!’
 SM is a complex disorder. Many explanations
for it’s development have been given including
psychodynamic, behavioral, family systems,
trauma-related, and genetic.
They may in fact be inadequate.

SM evolves from a multitude of individualistic

and environmental interactions that take
place at many levels over time.

Viana, Beidel, & Rabian, 2009; Cohan, Price et al., 2006

Understanding SM as a Social
Communication Anxiety Disorder…
„ Children with SM have social communication anxiety
that changes from setting to setting and person to
person.

„ For example: A child can be chatty with one person

in one setting, see that same person in another
setting and shut down or remain nonverbal.

„ Feelings of comfort and/or a sense of expectation

affect the child’s ability to communicate!
 Let’s

TALK
STAGES
of
Selective Mutism
BASIS of SOCIAL COMMUNICATION
ANXIETY TREATMENT (SCAT)

Understanding the
Social Communication Bridge
 Each Child has UNIQUE BRIDGE
Child moves BACK and FORTH across the BRIDGE
based on setting and people present.
TO BEGIN helping the child in the REAL
WORLD

Need to determine the child’s

BASELINE level of social
communication.
NC-NV-TV-V
 KEYS TO SCAT TREATMENT
“(1) Addressing the predisposing, precipitating,
maintaining factors of Selective Mutism
(2) Parent Education to rid pressure to speak and to
encourage social communication based on child’s
level of comfort . Implement ‘understanding,’
consistency, routine & structure at HOME.
(3) School Education and accommodations &
interventions to help the child feel less anxious, build
social comfort, progress communicatively & reach
academic potential.

Copyright © Elisa Shipon-Blum 2006

 KEYS TO SCAT TREATMENT
(4) Helping the child acknowledge, understand &
assess feelings; feel less anxious & more confident;
unlearn conditioned/learned behaviors,
(5) Helping the child ‘in a strategic manner’ to develop
long term coping skills to combat anxious feelings &
to enable for comfort in socializing and progression
of communication in ALL settings.”
Copyright © Elisa Shipon-Blum 2006
KEY to becoming VERBAL
„ BUILDING SOCIAL COMFORT!
Therefore if a child is NOT comfortable,
verbalization will NOT occur.
„ HOW to build social comfort?

‰ With teachers: 1-1 time with or without parent,

with or without 1 other peer

‰ With peers: Play dates, buddies, very small

groups, friendship groups out of room, adult
facilitated interaction
General Guidelines TO MASTER!
SMALL environment
1 on 1

FEW people present

small group

QUIET environment
less stimulation
 Modify the Environment

„ IS the child COMFORTABLE with ALL

peers?
„ Is the child engaging with ALL peers?

If either of the above are NO, then emphasis

on BUILDING social comfort in a 1-1 and
very small group NEEDS to be done!

Without THIS approach, the child will make

MINIMAL, if any, communication progress.
Stone, Kratochwill, Sladezcek, & Serlin (2002)
THE CHART & UNDERSTANDING
“CLUB MEMBERS”
„ Child generally will only speak to those
WHO have completed a chart.
„ Can put club members together, but
non-club members will create mutism again.
„ Child can speak to club members, but an
area of the classroom needs to be created
where it is away from non-club members
initially.
SCAT combines…
„ Family systems therapy
‰ considers the larger social system of the child
(Johnson, Rasbury, & Siegel, 1986)

„ Behavior therapy
‰ emphasizes environmental factors affecting behavior and
helps the child unlearn conditioned responses
(Stone, Kratochwill, Sladezcek, & Serlin, 2002)
‰ found to have the largest effect size of the major various
treatment approaches including psychodynamic, family
systems, and biological in effectively treating children with
SM (Stone, Kratochwill, Sladezcek, & Serlin, 2002)
SCAT Helps the Child acknowledge/assess
Feelings
‰ using charts

‰ heights of building blocks- younger kids

‰ using hands/fingers to gauge feelings

Help child rate feelings of being scared or

uncomfortable and determine where it is
difficult to communicate

They can often gauge the extreme ends, but need

help with the middle ground
 Level of scaredness

100

90

80

70

60

50

40

30

20

10

0
5 4 3 2 1 0
IS SM About ‘CONTROL?’

Yes, absolutely!

Help the child transfer control

from ‘mutism’ to strategies for
social communication!
Build Social Engagement & Nonverbal Communication
(Stage 0Æ Stage 1)

Gestures (nod, point)

Handing over, Taking over… Passing things out!
Sign Language
Communication Boards/Scripts (photos, picture symbols)
Transitional Stage (stage 2)

Nonverbal Æ Verbal communication

HOW?
 Tools To Transition From
Nonverbal Into Verbal
(Going from stage 2Æ3)

„ Single Message Voice Output Device

(Talking Picture Frame, Clip Talker)
„ Multiple Message Voice Output Device (Go Talk)
„ Use these communication modes to respond or initiate
within a social interaction
Getting the message across using
an object or another person
Using child’s feelings as a GUIDE to
increase Behavioral Objectives
„ Use person or object who child can speak to:
ÆWhisper close up
ÆWhisper at fist length away
Æwhisper at half arm length away
ÆWhisper at full arm length away
ÆWhisper across table
ÆLook in direction of person
The Ritual Sound Approach

„ Excellent method for the ‘speech phobic’

Good Method for the child who already makes

sounds- grunts, groans, audible laughing,
makes animal sounds, etc.
What does it feel like to make particular
sounds?
„ H= Deep breath in/out
„ P= Pop sound
„ S= Teeth together, push air thru
„ W = Blow a feather or cotton ball or just air
„ And more.

Talk to the child about what it feels like.

Discuss it and write down the letter.
You can complete the entire alphabet.
Use of Sounds
„ For some children begin with a YES/NO
activity (SSSS) (NNNN) or a fun game using
and interview “get to know you” format.
Do you like dogs? Do you like sports?
Do you like chocolate covered bugs?

„ Play 2 snaps/taps = YES & 1 snap/tap = NO

Try to stimulate sounds.
Make no eye contact.
Use of Sounds, continued

„ Let child know they made a particular sound

Æ Child CROSSES OFF letters of the alphabet…

ABCDEFGHIJKL
MNOPQRSTUVW
XYZ
Go through the entire alphabet making no eye contact in a
matter-of-fact way.
 Progress to other ‘simple CVC words’
Use rhyming words (keep words in view)

„ Sit, Pit, Hit, Mit, Sat, Pat, Cat

Progress to sentences
„ The CAT SAT on the HAT
 Letter Alphabet Yes/No Sit Word Sentence
People I want Game Pit chart chart
to feel more P Hit
comfortable H Mit
with S
T
„ --->Relaxed body language
„ --->Better eye contact
„ --->Smiling more
„ --->Child laughing (with or without sounds)
„ --->Initiating without effort
„ --->Increased communication interaction
(responding and initiating)
Sample Yes/No Question
Ask child to provide answers to Yes/No questions.
Give the child a chance to ask you questions.

„ Child is to respond using achieved communication mode

(gesture, writing, or verbally).

„ If verbal, use sound blending to support word production if

needed.

„ Use sound YYY or SSS for Yes, NNN for No or whole word if
possible.

1. Did you watch TV?

2. Did you play with the Wii game?
3. Did you play with your dog?
Example Word Practice Activity Continued

„ Procedures:
„ Communication partner(s) circle words with crayon or marker.
Increase speed of circling over time.
„ ______ says word and X/crosses word out.

Super bowl quarterback Giants referee

Touch Down sack off sides extra point
Forward pass field goal offense defense

Half time show Patriots Rock-n- Roll time-out

Tom Petty & flag on the play Fans It’s Good!

The Heartbreakers
Sample Choice Questions

„ Procedures
„ Ask _____ choice Question and give 2 possible
responses.
„ ______ is to respond in writing or verbally.

Do you like to go to bed early or late?

What do you like better winter or summer?
Which do you like best vanilla or chocolate ice-cream?
Good for non-readers or struggling readers at NV, TV or V
communication mode for responding or initiating.
Open Ended Questions for Child to Answer

„ Procedures: Ask _______ the provided questions.

„ Parent to provide weekend update or actual questions. Parent
to review questions with ______ that morning .
„ ____is required to provide audible multi word answers

Example:
1. Your sister had a play date with girls from her class at your house for
the very first time. Who came over?
2. What toy did the girls take turns riding?
3. The girls played with something your Mom keeps in a big plastic box.
What did all the girls play with all afternoon?
 Working on expanding expressive
language and improving pragmatic
skills are often needed in treatment
as children continue to
work toward improved discourse
and conversational abilities.
Key to Treatment Involves:
(1) Addressing the causes/propagating factors of
Selective Mutism
(2) Parent Education to rid negative reinforcement
and to enable for ‘understanding,’ consistency, routine
and structure at home.
(3) School Education and school-based
accommodations/interventions
(4) Helping the child unlearn conditioned/learned
behaviors
(5) Helping the child develop long term coping skills
to combat anxious feelings & to increase comfort in
socializing and progression of communication in ALL
settings.
 SM is an anxiety based
communication disorder.

Children with SM miss out on

opportunities to formulate language.

SM may also be a unique disorder

involving language development
for some children.
(McInnes, Fung, Manassis, Fiksenbaum, & Tannock, 2004)
Evaluate and put the pieces of the puzzle
together to build the individual treatment
bridge.
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