6

Strategies for Children with

Communication Problems
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

Mark is a 6-year-old boy who has great difficulty speaking to

others. His school psychologist believes Mark has selective mutism
but the problem seems associated with communication deficits
as well. For example, people other than Mark’s parents have great
difficulty understanding what Mark says. As a result, Mark often
whispers to his parents or communicates nonverbally by pointing.
Mark’s parents have adopted the habit of translating information
conveyed by their son. Mark was fairly reserved and quiet during
kindergarten and did not play much with others. His parents and
the school psychologist became more alarmed about Mark’s ability
and his unwillingness to speak to others at the end of kindergarten
when reading difficulties surfaced.

R ecall from earlier chapters that some children with selective mutism,
such as Mark, display communication problems in addition to
failure to speak. Some children seem quite hesitant about speaking in
part because they are not fluent, have difficulty forming words or sen-
tences, or cannot understand what others have said to them, among
other communication problems. Specific language impairment or other
developmental delay may be present. These children may also show
some anxiety about trying to speak to others and withdraw from social
interactions. Some oppositional behavior may be present as well, but
many children with communication problems and selective mutism
Copyright 2010. Oxford University Press.

tend to avoid others and avoid situations in which speaking may be

expected.
A key aspect of intervention for children such as Mark is to address
possible underlying speech or language deficits in conjunction with
techniques described in this book for selective mutism or reluctance
113
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 114 helping children with selective mutism and their parents

to speak. This chapter introduces the concept of specific language impair-

ment and communication disorders prior to a discussion of comorbidity
with selective mutism. The chapter then outlines typical intervention
procedures for specific language impairment and communication disor-
ders prior to a discussion of how these interventions can intersect with
techniques to address selective mutism or reluctance to speak.
A complete description of specific language impairment and com-
munication disorders is outside the scope of this book, so the reader is
referred to the references provided in this chapter for additional infor-
mation. In addition, I strongly recommend consulting or working with
a speech pathologist who can coordinate necessary language programs
with your intervention for selective mutism. Children with communi-
cation disorders and selective mutism will benefit most from a multi-
disciplinary approach that includes parents and various school-based
specialists.

Specific Language Impairment and

Communication Disorders

Specific language impairment refers to problems in understanding or

producing language, especially in comparison to normal nonverbal
ability. This is sometimes defined as a low score on a standardized lan-
guage measure without additional impairment such as deafness or low
intellectual ability. Problems of vocabulary, grammar, comprehension,
word reading, verbal working memory, and phonology are common.
Specific language impairment occurs in about 3–7% of children and
tends to affect more boys than girls. The long-term outcome for many
of these children is good because many early language impairments
resolve with age, but associated reading difficulties and motor coordina-
tion problems may be present (Bishop & Snowling, 2004; Gathercole &
Alloway, 2006; Hulme & Snowling, 2009).
Specific language impairment overlaps to a degree with various
communication disorders outlined by the Diagnostic and Statistical
Manual for Mental Disorders (4th ed., text revision). These disorders
include expressive language disorder, mixed receptive-expressive lan-
guage disorder, phonological disorder, stuttering, and communication
disorder not otherwise specified. The sections that follow discuss each
of these disorders in turn.

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 Strategies for Children with Communication Problems 115

Expressive language disorder refers to a situation in which a child’s

scores on a standardized measure of expressive (verbal or sign) language
are substantially below scores on standardized measures of nonverbal
intellectual ability and receptive language (American Psychiatric
Association [APA], 2000, p. 58). These children may demonstrate lim-
ited vocabulary, omit sentence structures, and have trouble recalling
words, producing lengthy or complex sentences, using correct tense, or
demonstrating fluency. The problem must interfere with social com-
munication or academic or occupational achievement, criteria for a
mixed receptive-expressive language or pervasive developmental disor-
der must not be met, and the language problems must be in excess of
mental retardation if that disorder is present. Expressive language
impairment may occur after some period of normal development or
may be more lifelong in nature.
Mixed receptive-expressive language disorder refers to a situation in
which a child’s scores on standardized measures of expressive and recep-
tive language are substantially below scores on a standardized measure
of nonverbal intellectual ability (APA, 2000, p. 62). These children
may demonstrate features similar to expressive language disorder in
addition to severe comprehension deficits. Comprehension deficits may
come in the form of confusion when spoken to, difficulty understand-
ing words or sentences, trouble with auditory processing, inattentive-
ness, and withdrawal. The problem must interfere with social
communication or academic or occupational achievement, criteria for
a pervasive developmental disorder must not be met, and the language
problems must be in excess of mental retardation if that disorder is
present. Mixed receptive-expressive language impairment may occur
after some period of normal development or may be more lifelong
in nature.
Phonological disorder refers to a situation in which a child fails to
use developmentally expected speech sounds appropriate for his age
and dialect (APA, 2000, p. 65). Children with phonological disorder
often display errors in sound production, use, or organization, or omit
sounds such as final consonants in a word. The child may lisp, form
words poorly, show unintelligible speech, mix sounds, or otherwise
demonstrate inferior articulation. The problem must interfere with
social communication or academic or occupational achievement and
the language problems must be in excess of mental retardation if that
disorder is present.

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 116 helping children with selective mutism and their parents

Stuttering refers to a situation in which a child has problems of

normal fluency and time patterning of speech inappropriate for her age
(APA, 2000, p. 67). The child may frequently repeat or prolong sounds
or monosyllablic words, use many interjections or broken words, pause
often in speech, avoid certain difficult words, and show great physical
tension when speaking. The problem must interfere with social com-
munication or academic or occupational achievement and the language
problems must be in excess of speech-motor or sensory deficits if pres-
ent. Finally, communication disorder not otherwise specified refers to sig-
nificant problems in communication that do not fit the criteria for the
disorders just described.

Communication Disorders and Selective Mutism

Several researchers have noted a connection between communication

disorders and selective mutism. One research group examined 130
children with selective mutism and found that 43.1% displayed
anxiety and communication problems, especially on measures of expres-
sive and receptive communication. The degree of selective mutism in
this group was also more severe than other groups (i.e., purely anxious
or oppositional). However, expressive and receptive communication
deficits were not strong enough to warrant a diagnosis of mixed recep-
tive-expressive language disorder. This suggests that many children with
selective mutism also have low-level aspects of communication prob-
lems (Cohan et al., 2008). Kristensen (2000) estimated that 30–65%
of children with selective mutism have a language disorder or language
delay.
Other researchers have also noted substantial overlap between
selective mutism and communication problems such as poor articula-
tion, expressive language disorder or phonological delay, stuttering, and
auditory verbal-memory problems. Others have noted developmental
disorders such as Asperger’s disorder or other developmental delays in
youths with selective mutism as well (Kristensen & Oerbeck, 2006;
Remschmidt et al., 2001; Steinhausen & Juzi, 1996). Many children
with selective mutism also have academic or reading problems or receive
special services in schools (Bergman, Piacentini, & McCracken, 2002).
As mentioned in Chapter 2, evaluating a child with possible selective
mutism should include a speech and language assessment.

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 Strategies for Children with Communication Problems 117

Interventions for Communication Disorders

Various interventions have been designed to address communication

disorders and these interventions have good efficacy with respect to
expressive syntax, phonology, and vocabulary as well as receptive syntax
and phonology (Law, Garrett, & Nye, 2004). The next sections provide
a general overview of common language interventions for preschoolers
and school-aged children. The descriptions are necessarily brief and so
I encourage you to consult with a speech and language pathologist and
the references provided here for greater detail. These sections precede a
discussion of melding language training with techniques for addressing
selective mutism or reluctance to speak.
One general approach to language intervention for young children
involves teaching adults such as parents and teachers to appropriately
respond to a child’s attempts to communicate and strengthen her skills.
Parents and teachers may be instructed to model, modify, or expand a
young child’s attempts to communicate. When a child elects to com-
municate, parents and teachers could smile, praise the speaking behav-
ior, model the correct way of producing speech, modify the child’s
syntax or semantic information, and expand on the child’s idea. A child
may say “coo-ee ee” (“cookie eat”) to a parent, for example, who could
model proper pronunciation (“COOK-EEE”), modify syntax (“eat a
cookie”), and expand the child’s statement (“You want to eat a cookie”)
(Warren & Yoder, 2004).
Another general approach to enhance communication ability
among young children is to directly teach language. This approach is
adult-initiated and involves direct prompts for speech, reinforcement,
frequent and massed trials, and specific goals of intervention (e.g.,
saying a word correctly). A teacher may, for example, hold a small
cookie near her eye, issue a command to the child to say “cookie,” and
reward the child for doing so correctly. Direct teaching of language via
applied behavior analysis involves various stages of intervention. The
process typically focuses first on nonverbal requests as well as motor
imitation and social play. Receptive language in the form of applying
labels to items and actions is next. Expressive language is then empha-
sized as children categorize objects, form words and short sentences,
and engage in more social speech such as answering questions from
others. Academic communications such as counting or reading and
self-help communication such as asking to use the restroom represent

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 118 helping children with selective mutism and their parents

higher-end tasks. Although effective, direct teaching requires good

child attention and generalization of language to other, more natural
settings. Effective language training for very young children often
involves a combination of child- and adult-initiated methods (Sallows,
2005; Warren & Yoder, 2004).
A downside to teaching communication skills is that the approach
depends heavily on a child who initiates or copies speech. A relatively
quiet child will thus receive little adult feedback. To address this,
parents and teachers may establish indirect and direct prompts for
speech. Indirect prompts involve modifying the child’s environment to
facilitate the likelihood of speech. For example, a parent could deliber-
ately leave a cookie on the counter for a child to see, provide pictures to
a child who offers them for items he wants, or sing songs or use puppets
with the child. Or a teacher could place several enticing play options
before a child. Direct prompts involve specific solicitations of speech,
perhaps via open-ended questions (e.g., what activity should we do
today?) (Gallagher & Chiat, 2009; Webb, Baker, & Bondy, 2005).
A related approach to direct teaching is structured teaching
(the TEACCH model) designed primarily for children with autism.
This approach emphasizes helping a child understand how the world is
organized and predictable. To do so, children engage in a planned and
routine sequence of school-based learning activities, including speech
therapy. Visual and spatial stimuli are also established to help children
understand where they are supposed to be, what they are supposed to
do (and for how long), when the task is complete, and what will happen
next. A key component of this approach is an emphasis on spontaneous
communication in addition to formal training for receptive and expres-
sive language. A child may learn, for example, to use a meaningful word
such as “restroom” in a real-life situation. Such an approach will hope-
fully increase generalization of speech (Mesibov & Shea, 2005).
Another general model of language intervention emphasizes a
child’s affects and relationships with others. This model focuses on an
intensive, home-based program of 20-30-minute daily sessions involv-
ing spontaneous interactions between a parent and child and senso-
rimotor and spatial activities as well as comprehensive speech and
occupational therapy and special education if necessary. Intervention is
geared toward a child’s affect, so a reserved child may receive more
active encouragement from others during play. Intervention is also tai-
lored to a child’s developmental level with respect to sophistication of

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 Strategies for Children with Communication Problems 119

communication. Older children, for example, are better able to engage

in reciprocal interchanges than younger children who are more respon-
sive to communications initiated by others (Greenspan, 2005).
Other researchers believe that language problems largely result
from auditory processing deficits that lead to great difficulty recogniz-
ing speech and its nuances, expressing thoughts clearly, and reading.
A language intervention based on this premise emphasizes phonemic
awareness in spoken words, logical thinking about how a sentence is
formed and expressed, verbal working memory to retain and manipu-
late information about speech and other tasks, and discriminating
acoustic signals such as rapid and successive sounds. Computer-based
exercises are used so a child can practice acoustic reception as well as
syntactic and semantic skills. Phonics training, for example, helps chil-
dren identify specific sounds within words and distinguish words that
differ by only a first or last consonant. Environmental distractions are
also kept to a minimum (Madell, 2005; Miller, Calhoun, Agocs, DeLey,
& Tallal, 2005).
The Lindamood–Bell program of language intervention is also
quite popular. This program is based on the idea that phonemic aware-
ness and symbol imagery (mental images of letters that form phonemes)
are critical for good communication and reading. Language training
focuses on asking a student questions about consonants and vowels and
articulation, labeling phonemes, and identifying and sequencing sounds
within syllables. Pictures, creative labels, and blocks are often used to
facilitate this process and enhance self-correction of mistakes. Some
children may require imagery or language comprehension training
prior to this process (Bell, 2005; Lindamood & Lindamood, 2005).
The next section discusses ideas for how interventions for communica-
tion disorders and selective mutism might be integrated.

Integrating Interventions for Communication Disorders

and Selective Mutism

A child with selective mutism and some aspect of a communication

disorder will likely benefit from multiple techniques to address both
problems simultaneously. Keep in mind however, that some children
require extensive language or other interventions prior to any attempt
to remediate selective mutism. If the child you are addressing has severe

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 120 helping children with selective mutism and their parents

language deficits or significant developmental delay, then intense and

basic language training or self-care skills training may need to be con-
ducted first. Coordinating your intervention with developmental special-
ists will obviously be necessary in these cases. In addition, children with
substantial communication problems may require a lengthy timeline
with respect to intervention for selective mutism or reluctance to speak.
Other children display moderate levels of communication prob-
lems or developmental delay. A common associated condition with
selective mutism, for example, is Asperger’s syndrome. Children with
Asperger’s syndrome typically have severe social skills deficits, eccentric
or repetitive or ritualistic behaviors, coordination problems, and diffi-
culty understanding language in context. The latter commonly involves
poor eye contact, little facial expression, and trouble understanding
body language and subtle communication cues provided by others.
As such, some children with Asperger’s syndrome withdraw from others
and may rarely speak, which could qualify them for a diagnosis of selec-
tive mutism. Children with moderate levels of communication prob-
lems or developmental delay may benefit from a combination of
language and social skills training with the techniques described in this
book for selective mutism. The following sections outline suggestions
for such a combined approach.

Exposure-Based Practice

Exposure-based practice is a key aspect of treatment for selective mutism

and reluctance to speak and was given considerable attention earlier in
this book (Chapters 3 and 4). Several aspects of exposure-based practice
are compatible with a language intervention program, especially one
based on principles of applied behavior analysis. Recall that principles
of applied behavior analysis for language intervention include direct
prompts for speech, reinforcement, frequent and massed trials, and spe-
cific goals. Each of these principles applies as well to exposure-based
practice: adults prompt speech from a child in various situations, reward
a child for meeting goals associated with frequent and audible speech,
conduct regular exposure sessions, and have a clear end-state goal such
as reading aloud to classmates or conversing with new friends.
Exposure-based practice and applied behavior analysis for language
intervention are also compatible in that both approaches rely on a gradual
stage model. That is, each approach emphasizes subdividing the

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 Strategies for Children with Communication Problems 121

language and speaking process toward an end goal such as good articu-
lation or frequent and audible speech. Doing so allows a child to sys-
tematically progress in small steps that are manageable and that increase
the likelihood for success. Recall, for example, the discussion of hierarchy
development and successive steps from Chapters 3 and 4 for exposure-
based practice.
How specifically might exposure-based practice for selective mutism
meld with an applied behavior analysis program for language develop-
ment? A traditional applied behavior analysis program for language
development progresses through multiple stages such as matching,
motor imitation, play, receptive language, verbal imitation, expressive
language, categorization, early sentences, social speech, early academ-
ics, and self-help (Sallows, 2005). Aspects of exposure-based practice
can be integrated into each of these stages.
Matching refers to increasing basic skills of paying attention and
complying with instructions from an adult such as a parent or teacher.
Imitation refers to asking a child to copy a simple act during play, which
also requires attention and compliance. Matching and imitation are
similar to what I recommended during the early home visit section of
exposure-based practice (Chapter 3). Your initial exposure-based inter-
actions with a child are designed to build rapport. A specific focus on
interactive abilities such as attention, compliance, and physical imita-
tion may indeed build rapport but can also facilitate the next stages of
language development and the reduction of selective mutism.
The play stage of applied behavior analysis for language develop-
ment involves asking a child to imitate an action that leads to a vocal-
ization or rudimentary verbalization. Examples include humming or
singing a part of a favorite song, labeling a desired object, or greeting a
child by saying “hi” and hoping for a response (Sallows, 2005). The
play stage dovetails nicely with initial forays of exposure-based practice
to reduce a child’s anxiety to the point that he will initiate vocalizations
or one or two words with you. We discussed how these early vocaliza-
tions or verbalizations can be whispered or barely audible to begin but
must later progress to full-volume speech. You can see that the process
of developing language as well as audible speech can be a painstaking
one at this point.
Shaping can begin at this stage as well. A child who vocalizes
“mmm,” for example, can be asked to add an “ah” sound to form the
word “Ma.” Or a child could be asked to repeat a certain syllable or

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 122 helping children with selective mutism and their parents

phoneme several times (e.g., “ah-ah-ah” or “ma-ma-ma”). The instruc-

tor can also present the phoneme string so that the child can imitate it
and immediately receive a reward. More phoneme strings can be added
over time and can eventually shaped into specific words. Ideally, these
specific words are labels the child can use to request and receive some-
thing desirable such as a toy or cookie––the words should have as much
communicative value and function as possible. Others such as parents
should be asked to encourage and reward these phoneme strings and
labels as well during the week.
Receptive language is also a key target of applied behavior analysis
and involves asking a child to listen and comply with various instruc-
tions such as “sit,” “stand,” or “pick up the toy.” Physical prompts may
also be used by instructors to enhance this process; they may, for exam-
ple, sit on the floor as they say “sit.” Developing receptive language in
this manner can dovetail nicely with teaching a child to use relaxation
and breathing techniques (Chapter 3) to quell physical symptoms of
anxiety. These exercises need no explicit verbalization from the child
but do require attention, compliance, imitation, and receptive ability.
Developing receptive language ability and anxiety management skills
may thus be conducted simultaneously.
Direct physical prompts are often necessary to prod speech in
young children, but as mentioned earlier, researchers also recommend
indirect prompts for language development. Indirect prompts involve
modifying a child’s environment to facilitate the likelihood of speech.
Consider the earlier example of a parent who leaves a cookie on the
counter to prompt speech from her youngster. Use of indirect prompts
parallels the discussion of impromptu exposures in Chapters 3 and 4.
Impromptu exposures involve taking advantage of naturally occurring
situations to prompt a child to speak. Examples include asking a child
to answer the telephone when it rings or say hello to someone who
greets her at church. The idea here for both language development and
reduction of selective mutism is to always be looking for opportunities
to increase the likelihood of well-articulated, fluent, frequent, and
audible speech. Parents and teachers who adopt this default pattern of
always expecting more and better speech will greatly enhance the
chances for intervention success and help prevent relapse.
As a child’s verbalizations and receptive ability increase in scope
and proficiency, he may expand his vocabulary and begin to express
more abstract concepts. Children at this stage can be asked to provide

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 Strategies for Children with Communication Problems 123

more information about something they want, especially with respect

to color, size, and class (Sallows, 2005). Providing more information in
this way dovetails nicely with the hierarchical system in exposure-based
practice that involves moving from single words to short sentences.
A child who wishes a cookie, for example, may be required to tell you
which kind of cookie he wants from a choice selection (e.g., chocolate
chip, oatmeal, or sugar). Exposure-based practice at this point would
discourage the use of pointing and the simple expression of the word
“cookie” in favor of a more descriptive response such as “sugar cookie”
or, better yet, a longer phrase such as “I want a sugar cookie.”
These early conversations should be rewarded not only for their
increased complexity (language development) but also for their fre-
quency and audibility (reduction of selective mutism). These early con-
versations can then be extended to more social types of interactions.
As mentioned in Chapter 3 for example, children could be encouraged
to discuss things most enjoyable to them such as their pets, family
members, or toys. Such a practice increases generalization of speech to
social situations (language development) and increases a child’s willing-
ness to discuss multiple topics with you and to lower his anxiety about
speaking (reduction of selective mutism).
Later stages of language development from an applied behavior
analysis perspective involve greater generalization to other children, aca-
demic settings, and self-care tasks. These stages match well the hierarchi-
cal process for selective mutism when exposures are conducted eventually
in community and school settings. Children are increasingly but gradu-
ally expected to converse with a greater number of peers, verbally par-
ticipate in class and group projects, and issue requests for help such as
asking a teacher to use the restroom. Stimulus fading can be especially
useful in this regard. Systematically adding more stimuli to a speaking
situation, such as the number of classmates, will serve to generalize lan-
guage development and reduce selective mutism. Consistent feedback to
a child about his use of language as well as his frequency and audibility
of speech must continue as well. Language development as well as relapse
prevention for selective mutism must be an ongoing process.

Self-Modeling

Recall from earlier chapters that self-modeling involves audiotaping

or videotaping a child as she speaks clearly in a comfortable situation

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 124 helping children with selective mutism and their parents

such as the home and then replaying the recording in a low-frequency

speaking situation such as your office at school. The child is then praised
or given tangible rewards for the clarity, volume, and beauty of her
voice. Self-modeling can be used in conjunction with various language
intervention programs, especially those that help increase articulation
ability.
As mentioned, children sometimes have difficulty recognizing
speech and its nuances, expressing thoughts clearly, and reading.
Phonemic awareness––or the ability to hear, identify, or manipulate
phonemes––is a key skill that needs to be developed for these children.
Children are thus taught to blend and sequence various phonemes and
distinguish words that differ only slightly (e.g., “set” and “sit”). Emphasis
is also placed on learning and articulating vowels and consonants and
discriminating continuous sounds such as “m” and “s” from stop sounds
such as “t” and “k.” Various teaching programs have been developed to
increase phonemic awareness.
Self-modeling may be useful during this process because it gives
you a mechanism for providing feedback to a child not only about the
qualities of her voice but also about the competence of her speech. You
may notice over time and during extended self-modeling sessions that
a child becomes better at articulating certain words, and this should be
identified and praised. Self-modeling also allows you to provide feed-
back about specific aspects of a child’s speech and affords an opportu-
nity to ask the child to work on the clarity of one or two words in your
office. As you watch a child say a particular word, for example, you
could “play dumb” and ask the child to repeat the word for you (I rec-
ommend blaming the sound quality of the camera in this regard). This
helps build language and reduce selective mutism at the same time.
Self-modeling also provides a child an opportunity to correct mistakes
made during the videotaped speaking session if she desires.
Self-modeling may be useful as well to help a child reduce stutter-
ing. Interventions for stuttering often involve protracted syllable-
by-syllable speaking, improving airflow, slowing the rate of speech, and
other methods to increase fluency. Self-modeling provides a mecha-
nism by which a child can practice fluent speech and receive feedback
and appropriate consequences for effort and success in doing so.
Interventions for stuttering also involve anxiety management, which
matches nicely with exposure-based practice and relaxation and breath-
ing training.

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 Strategies for Children with Communication Problems 125

Contingency Management

Contingency management is important to language development and

reduction of selective mutism. Children with language problems can be
reinforced for greater articulation, fluency, comprehension, phonemic
awareness, and practice and effort, among other behaviors. Children
with selective mutism can be reinforced for more frequent and audible
speech, initiating conversations with others, and practice and effort,
among other behaviors. Many children with a communication disor-
ders and selective mutism will respond favorably to a specific type of
reward for completing language tasks and completing strategies to
reduce failure to speak. Other children, however, demand a more
nuanced approach. A child with Asperger’s syndrome, for example,
may respond well to praise from her mother when practicing fluency
and eye contact but may require more powerful tangible rewards to
boost speech with classmates.

Social Skills Training

Many children with communication disorders, such as children with

selective mutism or reluctance to speak, could also benefit from social
skills training (see Chapter 4). Social skills training may be particularly
useful for very young children or older children with Asperger’s disor-
der and communication disorders that has led to restricted social inter-
actions. As with children with selective mutism, social skills training for
youths with communication disorders or developmental delay can
follow a stage model that gradually addresses smaller skills such as eye
contact, larger skills such as responding to requests from others, and
broader skills such as initiating and maintaining conversations.

Cognitive Therapy

As mentioned in Chapter 4, cognitive therapy may be useful when a

child with selective mutism begins to speak and can express concerns
about how others will react to his or her speech. General principles of
cognitive therapy can also apply to some circumscribed cases of com-
munication disorder. Some children with communication disorder,
particularly those with stuttering, also have substantial concern about
how others respond to them as they speak. These cases may benefit

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 126 helping children with selective mutism and their parents

from some discussion about the child’s specific anxieties and the
(hopefully low) probability of negative events occurring after speech
(see specific questions and suggestions in Chapter 4). Keep in mind,
however, that you may have to address actual instances of peer ridicule
or alienation.

Final Comments and What Is Next

Strategies to address communication problems and selective mutism in

a given child can be administered together. General ideas were pre-
sented in this chapter, but I recognize that a child with both kinds of
problems will require a highly individualized and nuanced approach.
As mentioned, a multidisciplinary approach to these children is strongly
recommended. The next and final chapter addresses suggestions for
relapse prevention as well as associated intervention techniques for
selective mutism and a discussion of special issues that sometimes arise
in this population.

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