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Selective Mutism:
A DIR Approach to Assessment
Joleen R. Fernald, PhD, CCC-SLP, BCS-CL
 Speaker Bio
▪ Joleen R. Fernald, PhD, CCC-SLP was awarded Board Specialty Recognition in
Child Language from the American Speech-Language-Hearing Association. Dr.
Jo follows Greenspan and Wieder’s model, DIRFloortime® when working with
children and families. She is the author of the "Comprehensive Guide to
Selective Mutism" and has a special interest in the social-emotional
development of young children and its impact on their speech and language
skills. She co-founded a private school called REConnections Education Center
in the Tampa Bay area of Florida which supports children with various individual
differences.

2
 Disclosures
▪ Presenter Disclosure: Financial: Joleen Fernald was paid an honorarium for this
presentation. Joleen is a Training Leader and Expert DIRFloortime provider and
has a private speech-language pathology clinic. Non-financial: No relevant
relationships to disclose.
▪ Content Disclosure: This learning event does not focus exclusively on any
specific product or service.
▪ Sponsor Disclosure: There is no external sponsor for this course.

3
 Learning Outcomes
After this course, participants will be able to:
▪ List DSM-V criteria for a diagnosis of selective mutism.
▪ Describe at least 2 tools to assess a child with selective mutism.
▪ Identify a child’s DIR profile, including Functional Emotional
Developmental Level.

4
5
 Q1

The Diagnostic and Statistical Manual

of Mental Disorders, 5th Edition (F94.0)
Mute Interference Duration

• Consistent failure • The disturbance • The duration of

to speak in interferes with the disturbance is
specific social educational or at least 1 month
situations (in occupational (not limited to the
which there is an achievement or first month of
expectation for with social school)
speaking, e.g., at communication
school) despite
speaking in other
situations)
6 (American Psychiatric Association, 2013, p. 195)
 Q1

DSM-5 (F94.0)
Second Language Differential Diagnosis

• The failure to speak is not • The disturbance is not

due to a lack of knowledge better explained by a
of, or comfort with, the communication disorder
spoken language required (e.g., childhood-onset
in the social situation fluency disorder) and does
not occur exclusively
during the course of
autism spectrum disorder,
schizophrenia,
or another psychotic
disorder
(American Psychiatric Association, 2013, p. 195)
7
Second language development / Silent Period

Persistent silence

Repeating words

Beginning the process of practicing words and

phrases in the second language quietly and
noncommunicatively

“going public” with the new language

(Toppelberg, C. O., Tabors, P., Coggins, A., Lum, K., & Burger, C. (2005). )
8
Bilingual Children with SM

Mutism in
Mutism lasting
Mutism in both several Inhibited
significant
languages unfamiliar temperament
periods of time
settings

(Toppelberg, C. O., Tabors, P., Coggins, A., Lum, K., & Burger, C. (2005). )
9
 Etiology

Neurobiological/
Family
Over-reactivity of Environment SM
predisposition
the amygdala

(Chavira, D. A., Shipon-Blum, E., Hitchcock, C., Cohen, S., & Stein, M.B. (2007).
(Stein, M.B. & Stein, D.J., 2008).
10
11
12
Who diagnoses SM? – A Team!
§ Mental health treating professional
§ Assesses anxiety and other psychological challenges
§ Precipitating, predisposing, and maintaining factors
of selective mutism
§ Speech language pathologist
§ Assesses child’s speech and language skills
§ Expressive
§ Receptive
§ Pragmatic (Initiation of communication & Response)
§ Assesses selective mutism severity and verbal
stimulability
13
Multidisciplinary Assessment
§ Occupational therapist
§ Assesses sensory processing and motor development
§ Educator
§ Assesses child’s academic skills
§ Parents / Caregivers
§ Offers insight into child’s “dual personality” in different settings and with
different people
§ Physicians
§ Assess any biomedical concerns
Dow S., Sonies B., Scheib D., Moss S. Leonard H (1995)
14
DIR – What does it mean?
I
Individual
Differences
R
D
Relationship-
Developmental
based

Floortime

15
16
Q2-Q5
18
19
20
SM and Individual Differences
§ Receptive language processing
§ Expressive language
§ Sensory reactivity
§ Motor planning
§ Visual spatial processing
§ Bio-medical differences

21
22
Name of Child:____________________________ Completed by:_________________________ Date:________

Selective Mutism Questionnaire* (SMQ)

(to be filled out by parents)

Please consider your child’s behavior and activities of the past month and rate how freque ntly each
statement is true for your child.

AT SCHOOL
3
Always
2
Often
1
Seldom
0
Never
To determine FEDCs,
1. When appropriate, my child talks to most peers at school.
2. When appropriate, my child talks to selected peers
(his/her friends) at school.
X
X check visually to see
3. When called on by his or her teacher, my child answers. X
4. When appropriate, my child asks his or her teacher
questions.
5. When appropriate, my child speaks to most teachers o r
X where the majority of
X
staff at school.
6. When appropriate, my child speaks in groups or in front
of the class.
X the Xs are located,
How much does not talking interfere with school for your
child? (please circle) Not at all Slightly Moderately Extremely
then add 1.
WITH FAMILY

Always Often Seldom Never

7. While at home, my child speaks comfortably with the
other family members who live there.
8. When appropriate, my child talks to family members
X

X
School = FEDC 1
while in unfamiliar places.
9. When appropriate, my child talks to family members that
don’t live with him/her (e.g. grandparent, cousin).
10. When appropriate, my child talks on the phone to his/her
X Home = FEDC 3
X
parents and siblings.
11. When appropriate, my child speaks with family friends.
12. My child speaks to at least one babysitter.
X
X
Other = FEDC 1
How much does not talking interfere with family
Relationships? (please circle) Not at all Slightly Moderately Extremely

IN SOCIAL SITUATIONS (OUTSIDE OF SCHOOL)

Always Often Seldom Never

13. When appropriate, my child speaks with other children
X
who s/he doesn’t know.
14. When appropriate, my child speaks with family friends
X
who s/he doesn’t know.
15. When appropriate, my child speaks with his or her doctor
X
and/or dentist.
16. When appropriate, my child speaks to store clerks and/or
X
waiters.
17. When appropriate, my child talks when in clubs, teams or
X
organized activities outside of school.
How much does not talking interfere in social situations
for your child? (please circle) Not at all Slightly Moderately Extremely
25
Name of Child:____________________________ Completed by:_________________________ Date:________

Selective Mutism Questionnaire* (SMQ)

(to be filled out by parents)

Please consider your child’s behavior and activities of the past month and rate how freque ntly each
1. Total Section,
statement is true for your child.

AT SCHOOL
2. Divide by the
3 2 1 0

1. When appropriate, my child talks to most peers at school.

Always Often Seldom Never
X
number of items
2. When appropriate, my child talks to selected peers
(his/her friends) at school.
3. When called on by his or her teacher, my child answers.
4. When appropriate, my child asks his or her teacher
X
X 3. Compare to
X
questions.
5. When appropriate, my child speaks to most teachers o r
staff at school.
X norms
6. When appropriate, my child speaks in groups or in front
X
of the class.
How much does not talking interfere with school for your
child? (please circle) Not at all Slightly Moderately Extremely School: 0/6 = 0
WITH FAMILY

Always Often Seldom Never

7. While at home, my child speaks comfortably with the
X
other family members who live there.
8. When appropriate, my child talks to family members
X
while in unfamiliar places.
9. When appropriate, my child talks to family members that
X
don’t live with him/her (e.g. grandparent, cousin).
10. When appropriate, my child talks on the phone to his/her
X
parents and siblings.
11. When appropriate, my child speaks with family friends. X
12. My child speaks to at least one babysitter. X
How much does not talking interfere with family
Relationships? (please circle) Not at all Slightly Moderately Extremely Family: 14/6 = 2.33
IN SOCIAL SITUATIONS (OUTSIDE OF SCHOOL)

Always Often Seldom Never

13. When appropriate, my child speaks with other children
X
who s/he doesn’t know.
14. When appropriate, my child speaks with family friends
X
who s/he doesn’t know.
15. When appropriate, my child speaks with his or her doctor
and/or dentist.
X Public: 3/5 = .60
16. When appropriate, my child speaks to store clerks and/or
X
waiters.
17. When appropriate, my child talks when in clubs, teams or
X
organized activities outside of school.
How much does not talking interfere in social situations
for your child? (please circle) Not at all Slightly Moderately Extremely Total: 17
Enrique – 4 years old
School: FEDC 1
§ SMQ score = 0
§ Compared to peers, Enrique is slightly more
severe (average .33)

Family: FEDC 3
§ SMQ score = 2.33
§ Compared to peers, Enrique is less severe
(average 1.62)

Public: FEDC 1
§ SMQ score = .60
§ Compared to peers, Enrique is less severe
(average .28)

Total: Overall, Enrique’s SM is less severe than his

peers who also have SM
Test Your Knowledge
§ Vincent: 5 years old
§ At home, Vincent speaks in complete sentences and is successful
with his verbal communication
§ Parent’s concerns:
§ unable to verbally communicate his wants / needs (question of selective
mutism)
§ “anxiety is causing social impairments which may result in learning
challenges”
§ “developed a fear of germs and bugs and has become obsessive about a
variety of things”
§ Watch short clip and ask yourself the following questions to
determine Vincent’s DIR Profile
29
Questions
§ What is Vincent’s FEDC?
§ FEDC 1: Is he regulated and engaged? Is he responsive?
§ FEDC 2: Is he “wooing” his therapists or able to stay engaged by their overtures? Is
he gesturing but non-verbal?
§ FEDC 3: Is he using affect to convey intent, making requests? Is he making any
sounds?
§ FEDC 4: Is there a continuous flow of interaction? Is he verbal?
§ What are Vincent’s Individual Differences?
§ Regulation (hyper or low affect/tone?), Postural Control (strong core or floppy?),
Language, Visual/Spatial Processing, & Praxis
§ Bio-medical differences (anything parents reported?)
§ What are Vincent’s relationships like?
30
31
Answers
Does Vincent meet the DSM-V criteria for Selective Mutism?
What is Vincent’s FEDC?
FEDC 1: Is he regulated and engaged? Is he responsive?
FEDC 2: Is he “wooing” his therapists or able to stay engaged by their overtures? Is he
gesturing but non-verbal?
FEDC 3: Is he using affect to convey intent, making requests? Is he making any sounds?
FEDC 4: Is there a continuous flow of interaction? Is he verbal?
What are Vincent’s Individual Differences?
Regulation (hyper or low affect/tone?), Postural Control (strong core or floppy?), Language,
Visual/Spatial Processing, & Praxis
Bio-medical differences (anything parents reported?)
Germ and bug fears, obsessive about things
What are Vincent’s relationships like?
Didn’t observe, but parents seem concerned and aware of some of Vincent’s needs

32
 Goals
▪ Use the data chart, determine where the child is and create goals
based on those levels
▪ Example:
▪ Vincent will participate in sensorimotor activities during speech session
▪ Vincent will respond gesturally during interactions with therapists
▪ Vincent will respond gesturally during interactions with peers
▪ Vincent will make sounds with his mouth during speech session

34
Review of Key Points
§ It takes a team to best assess a child with Selective Mutism
§ Patience – expect the child to communicate and provide opportunities for him/her to do so
§ Considering the whole child will support development across all areas – not just the “not
talking”:
§ Functional Emotional Developmental Capacities (initiation / response)
§ FEDC 1 – Child with SM is non-responsive
§ FEDC 2 – Child with SM may gesture, but is still silent
§ FEDC 3 – Child with SM may begin making sounds
§ FEDC 4 – Child with SM is more verbal
§ Individual Differences
§ Regulation, Postural Control, Language, Visual/Spatial Processing, & Praxis
§ Relationships are the foundation upon which we develop trust and build connections with those around
us
§ Diagnosis is easy… it’s the treatment that’s hard
35