Selective Mutism School Based

Helping Children with
Selective Mutism and

Their Parents
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Helping Children with
Selective Mutism and
Their Parents
A Guide for School-Based Professionals
Christopher A. Kearney
1
2010
1
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Library of Congress Cataloging-in-Publication Data
Kearney, Christopher A.
Helping children with selective mutism and their parents :
a guide for school-based professionals / Christopher A. Kearney.
p. cm.
ISBN 978-0-19-539454-2 (pbk.)
1. Selective mutism. I. Title.
RJ506.M87K43 2010
362.82—dc22 2009040629
1 3 5 7 9 8 6 4 2
Printed in the United States of America

on acid-free paper
Contents
1 Selective Mutism and Reluctance to Speak:

Definition and Description 1
2 Assessing Cases of Selective Mutism and Reluctance to Speak 24
3 Exposure-Based Practice: Home Setting 52
4 Exposure-Based Practice: Community and School Settings 73
5 Contingency Management 96
6 Strategies for Children with Communication Problems 113
7 Relapse Prevention, Other Interventions, and Special Issues 127
Appendix 143
v
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1
Selective Mutism and Reluctance to
Speak: Definition and Description
Jenny refuses to speak around unfamiliar individuals, even at home.

The only people Jenny speaks to are her parents. In private, she
speaks to her parents in a clear, audible voice. When a stranger is
present, however, Jenny does not speak and hides behind her mother.
She uses nonverbal cues such as pointing and high-pitched noises to
get her parents’ attention in public situations. Jenny’s parents com-
municate for her when she does not speak.
Miguel comes from a bilingual household. He does not speak to

classmates or teachers at school and will not speak in other public
situations. He speaks often at home in a clear, audible voice.
In public social situations, his voice is soft and muffled. He has great-
est difficulty speaking when others approach him in social situations.
He becomes upset and will not maintain eye contact. Miguel also
seems somewhat angry and defiant in these situations.
Sunee attends school and performs very well on nonverbal tasks. She
does not speak at school, however. She refuses to answer or ask ques-
tions in class, read aloud, speak within a small group, or use the
bathroom at school. Sunee has difficulty making friends and spends
most of her time alone. Although she is talkative at home, she will
not speak when the family has visitors.
Zion has never spoken in school. He does speak at home, though not
particularly well, and avoids direct conversation with his stepfather.
When nonfamily members are in the home, Zion will speak only to
his mother. School has recently become very difficult as a result of
Zion’s refusal to speak and his grades are falling. He increasingly avoids
social interactions outside of his immediate family.
1
2 helping children with selective mutism and their parents
D o these cases sound familiar to you? As a school professional, you

have likely encountered children or perhaps some adolescents
who do not speak to others (selective mutism) or who are quite reluctant
to speak to others, especially in public situations. Youths who rarely
speak pose a vexing problem for school officials, many of whom are
rightly concerned about a child’s subsequent academic and social per-
formance. As a clinical child psychologist who has worked with this
population for years, as well as with educational professionals at various
schools, I know how difficult and odd some of these cases can be. In
this book, I hope to share my expertise to help you address this difficult
population. This chapter outlines the purpose of this book, describes
the characteristics of youths with selective mutism, and provides a
model for understanding selective mutism to guide assessment and
intervention. The chapter also covers children who are reluctant to
speak but who may not have full-blown selective mutism.
Purpose of This Book
The purpose of this book is to illuminate the characteristics of youths

with selective mutism and reluctance to speak and focus on methods
you can use to assess this population and help these children speak
more audibly and frequently. This book is written primarily for school
officials who address youths with aspects of selective mutism. This
includes school-based social workers, school psychologists, guidance
counselors, regular and specialized teachers, principals and deans,
school nurses, and other relevant personnel. The book may be useful as
well when you discuss a child’s mutism with psychologists, psychia-
trists, pediatricians, and other healthcare professionals. This book can
also serve as a resource when you collaborate with parents to resolve a
child’s selective mutism.
Types of Cases Covered in This Book
This book is best for moderate cases of selective mutism. This means
that the procedures described may be less necessary for children who
speak fairly well at school. Similarly, the procedures in this book may
be less useful for unremitting cases of selective mutism that have lasted
Selective Mutism and Reluctance to Speak 3
many years or that involve intense additional problems such as severe

learning disorders, depression or bipolar disorder, attention-deficit/
hyperactivity disorder (ADHD), conduct and aggressive problems,
substance abuse, pervasive developmental disorder, or psychotic disor-
der. In these cases, referral to psychological and psychiatric services may
be necessary (see box).
Referrals to Mental Health Professionals

For severe cases of selective mutism, which may include extensive
comorbid problems, I recommend referral to a qualified mental
health professional. A clinical child psychologist has specialized train-
ing with youths with severe behavior problems. A psychiatrist is a
medical doctor who can prescribe medication for severe behavior
problems. For many children with behavior problems that signifi-
cantly interfere with daily life, seeing a clinical child psychologist
and a psychiatrist is a good idea. Other mental health professionals
who may be helpful to families include social workers and marriage
and family therapists.
If you wish to refer a family to a mental health professional in your
area, then consult with local people knowledgeable about who
specializes in certain kinds of problems. Some mental health profes-
sionals, for example, have special training in substance abuse prob-
lems or depression. Others work closely with school officials to
help resolve problems such as learning disorders, attention-deficit/
hyperactivity disorder, or intense selective mutism. Ideally, a mental
health professional to whom you refer a family for mutism should
have knowledge of how to treat the problem and perhaps have access
to treatment manuals available for this population.
Consulting the psychology faculty at a local university is a good
start when looking for someone who best fits a family’s situation. If
you live in an area where this is not possible, contact your state asso-
ciations of psychologists and psychiatrists. In addition, talk to other
professionals at your school who work with certain therapists or who
have done so in the past. You may also consult the websites of
national associations of mental health professionals, such as apa.org,
abct.org, and psych.org.
This book is helpful if no legitimate reason exists for a child’s

mutism. If a child’s mutism results from bullying or another real threat
to self or property, then the threat must be addressed before using the
procedures in this book. Some children still have problems speaking
after removal of a threat, however, so the procedures in this book may
then apply. The focus of this book is on a child’s selective mutism. The
following section defines selective mutism and some terms used to
describe this population. Later sections discuss other characteristics of
these youths and present a model that serves as the basis for assessment
and intervention recommendations presented in subsequent chapters.
Selective Mutism: Diagnostic Features
You might be confused by the many terms used to refer to selective

mutism. The literature regarding youths with selective mutism is diverse
and scattered across disciplines such as education, psychology, psychia-
try, and pediatrics. Many different terms for selective mutism have been
used historically (see Table 1.1).
The current accepted term is selective mutism, a key diagnostic fea-
ture of which is “persistent failure to speak in specific social situations
where speech is expected, despite speaking in other situations” (American
Psychiatric Association [APA], 2000, p. 125). Children with selective
mutism such as Miguel most commonly fail to speak, or refuse to speak,
Table 1.1 Historical Terms Used for Selective Mutism
Speech phobia Ideogenic mutism

Speech shyness Partial mutism
Speech inhibition Psychogenic mutism
Speech avoidance Heinzian mutism
Suppressed speech Psychological mutism
Hearing mute Situation-specific mutism
Learned mutism Temporary mutism
Thymogenic mutism Functional mutism
Voluntary mutism Elective mutism
in social situations and, especially public situations such as schools,

restaurants, parks, shopping centers, and playgrounds. These children
are unlikely to speak to people they do not know well, such as strangers,
but often do not speak either to people they encounter daily, such as
teachers.
Such failure to speak is persistent, meaning it has lasted a long time
and seems quite resistant to change. In addition, lack of speech occurs
in situations where speaking is expected for most children––for
example, most children obviously speak at school. If speech fails to
occur only in situations where speech would not be expected, such as
attending and listening to a concert, then selective mutism does not
apply.
An important aspect of selective mutism is that a child will often speak
well in certain, usually comfortable, surroundings. Most children with
selective mutism such as Miguel speak clearly and audibly at home,
although some such as Zion do not. Most of the children we see and
children described in the literature speak well at home and with people
they know well, such as parents and siblings. Many parents say their
child is a “chatterbox” at home and that they are quite surprised when
the child fails to speak in public or at school (or when school personnel
tell them about this). Some children with selective mutism will even
speak to people they do not know well, such as school counselors, on
the telephone but not in person. Other children with selective mutism
will speak through doorways but not face to face with someone.
The fact that many children with selective mutism speak well at
home indicates two very important things. First, the problem is not
specifically due to a communication disorder such as a phonological
disorder, expressive language disorder, mixed receptive-expressive lan-
guage disorder, or stuttering. In most cases of selective mutism, the
child can speak adequately and clearly––the ability is there. However,
in some cases selective mutism may be comorbid with a communication
or developmental disorder. A child’s selective mutism may not be spe-
cifically due to stuttering, for example, but the two problems could
coexist and obviously influence each other. Consider Justin, a 5-year-
old boy with moderate stuttering who spoke to some degree in pre-
school but will not speak to anyone now in kindergarten. His failure to
speak and thus practice his articulation may delay his recovery from
stuttering, and his stuttering may contribute to his ongoing unwilling-
ness to speak.
A second issue surrounding a child’s ability to speak well at home is

that parents often do not believe their child has a problem. Many
parents attribute selective mutism to simple shyness that the child will even-
tually outgrow. Selective mutism is indeed linked in many cases to
intense shyness or social anxiety, but mutism represents a much more
intransigent and pervasive problem. Unfortunately, many parents of
children with selective mutism delay or never seek treatment. The aver-
age age of onset of selective mutism is 3–6 years, but parents do not
generally refer their child for treatment until age 6–8 years, if at all. The
good news is that children with selective mutism show clear signs of
the problem during elementary school when you and other school per-
sonnel and peers often interact with them. This is the best time for
intervention.
Selective mutism generally interferes with a child’s educational or
occupational achievement or social communication (APA, 2000).
Many children with selective mutism do not speak with peers at school,
although some have nonverbal friendships. Many of these children
cannot take standardized tests (verbal sections), perform academic tasks
that require verbal input, answer questions in class, or even ask to attend
the restroom (see the example of Sunee at the beginning of this chap-
ter). Such difficulties may not significantly interfere with academic
achievement in kindergarten or first grade, but may do so as academic
tasks become more complicated and autonomous in later grades. Recall
that Zion’s grades were beginning to suffer.
Selective mutism must last at least 1 month and cannot be limited
to the first month of attending school (APA, 2000). Many children are
naturally shy and reluctant to speak when transitioning to a new setting
such as kindergarten. Children with selective mutism, however, do not
speak in public situations for months or years at a time – some school
personnel say they have never heard a particular child in third or fourth
grade utter a single word! Selective mutism is thus a pervasive and long-
standing problem.
A final diagnostic feature of selective mutism is that failure to speak
is not due to “lack of knowledge of, or comfort with, the spoken lan-
guage required in the social situation” (APA, 2000, p. 127). A diagnosis
of selective mutism would not generally apply, for example, to new
immigrants or to youths whose parents are non-English speakers.
However, many children with selective mutism or reluctance to speak
do have parents who speak English as a second language. Recall Miguel
Table 1.2 Diagnostic Features of Selective Mutism
Persistent failure to speak in specific social situations in which speech is

expected, despite speaking in other situations
Interferes significantly with educational or occupational achievement or
social communication
Must last at least 1 month and is not limited to the first month of school
Disorder is not due to lack of knowledge of, or comfort with, spoken lan-
guage required in a social situation
Disorder is not better accounted for by a communication disorder and
does not occur exclusively during the course of a pervasive developmen-
tal disorder, schizophrenia, or other psychotic disorder
Adapted from the American Psychiatric Association (2000).
presented at the beginning of this chapter. I have seen many children

over the years whose parents primarily speak Spanish, Tagalog, Russian,
or another non-English language in the home. This could influence the
speaking performance of children when they are at school and are sur-
rounded by those who speak English. Chapter 7 provides more detailed
information about this type of case. For a complete list of diagnostic
features of selective mutism, see Table 1.2.
Selective Mutism: Associated Features
Children with selective mutism have other features that are not a formal
part of the diagnostic criteria for the disorder, but are important to
understand nonetheless. Several researchers have found that social anxi-
ety and social phobia (fear) are key aspects of many of these cases.
Children with selective mutism such as Sunee often avoid social situa-
tions that involve speaking to others, initiating conversations, answer-
ing the door or telephone, or responding to questions from people such
as teachers. Some children with selective mutism are also likely to avoid
evaluative situations, especially those involving some verbal perfor-
mance such as reading a story in class. Others show anxiety-based
behaviors such as clinging to parents, hiding, running away, crying,
freezing, and throwing tantrums when asked to speak in public.
Some children with selective mutism are also physically anxious

when faced with a situation in which they must speak. Examples include
muscle tension, shaking or trembling, sweating, hyperventilation,
accelerated heart rate, nausea, dizziness, and other panic-like symp-
toms. Unfortunately, some of these symptoms are difficult to detect
and many children with selective mutism obviously do not verbally
report having them. Other children with selective mutism do not dem-
onstrate any of these physical symptoms.
Many children with selective mutism also do not report specific
anxiety-based thoughts, perhaps because of their young age and refusal
to speak. Some children, however, may believe that negative conse-
quences will occur as a result of speaking. They may be concerned that
others will ridicule them, that they cannot articulate what they want to
say well, or that they will be ignored. As children with selective mutism
are coaxed to speak, these concerns may be expressed and addressed.
Some reports in the literature indicate that children successfully treated
for selective mutism described their experience as “the words were stuck
between my toes” or that speech was locked in some way. These
children may thus have some insight into their own behavior.
Many children with selective mutism have been described in the
literature as shy, timid, reserved, reticent, and inhibited. These person-
ality characteristics are similar to those of social anxiety. Some children
with selective mutism have also been described as socially withdrawn.
Symptoms of depression and selective mutism such as sadness and
reduced speech may also overlap and could be comorbid in some chil-
dren as well. Recall Zion, who increasingly avoided social interactions
outside of his immediate family. Such an increase in social withdrawal
may indicate some depression.
Researchers have also found that some cases of selective mutism
involve oppositional, manipulative, or willful behavior. Some children
may not be anxious to speak but deliberately refuse to speak. These chil-
dren may have received extensive reinforcement such as attention from
parents or others for not speaking or can avoid school and other obliga-
tions by refusing to speak. Other children seem particularly willful in
their refusal to speak. Consider Emma, a 5-year-old girl in kindergarten
who has never spoken in public, even during her preschool years, and
who throws tantrums and otherwise acts defiantly when encouraged to
speak in public. Intervention for children such as Emma may focus
heavily on managing rewards and other consequences for speaking and

not speaking (see Chapter 5).
Another common aspect of selective mutism is linkage to develop-
mental and communication problems. Recall that selective mutism
cannot be attributable only to developmental and communication
problems, but these problems sometimes coexist in a child. An example
from our clinic is April, a 5-year-old girl who rarely spoke, even at
home. In addition, her speech at home was marked by low audibility
and poor articulation. Nonverbal standardized tests (see Chapter 2)
indicated below average intellectual functioning, which may have con-
tributed to her poor speech. In many of these cases, especially in younger
kids, separating selective mutism from a developmental disorder can be
quite difficult. Chapters 2, 6, and 7 discuss this population in more
depth.
Researchers have also linked some cases of selective mutism to
trauma-based reactions. Youths who have experienced trauma often
display social withdrawal and less verbal expression. Zion’s refusal to
speak to his stepfather naturally raises a red flag, for example. I recom-
mend assessing children for a recent history of trauma as well as school-
based threats and other contextual factors that may lead to poor verbal
expression. In addition, keep in mind that some children’s refusal to
speak may be adaptive. A child who remains very quiet to avoid physi-
cal abuse, for example, would not be diagnosed with selective mutism.
Other kids will have difficulty speaking even after an abusive situation
is resolved and could still benefit from the procedures discussed in this
book.
Another common feature of children with selective mutism, regard-
less of subtype or associated features, is compensatory behavior, which
refers to nonverbal forms of expression to communicate with others, as
in Jenny’s case. Common examples include pointing, gesturing, whis-
tling, nodding or shaking the head, stomping the feet, whispering in a
parent’s ear, pulling on clothing, or writing words in the air with one’s
fingers. Other compensatory behaviors may involve vocalizations such
as grunts, odd or high-pitched noises, or slurred or incomplete expres-
sions such as “ah” for “yes” and “un” for “no.” Reducing or eliminating
compensatory behaviors is a key aspect of treatment for selective mutism
and usually involves extensive work with parents and teachers (see
Chapter 5).
Children may display selective mutism for several reasons, all of

which must be assessed (see Chapter 2). Common antecedents of selective
mutism, or what comes before a failure to speak, may include desires to
• decrease anxiety
• increase social or sensory feedback from others
• avoid having to display inefficient or underdeveloped speaking
skills.
These antecedents intersect to some degree with the social anxiety com-
ponent of selective mutism discussed earlier. Consider the case of Sarah,
a 7-year-old girl who fails to speak because she is concerned about how
others will respond to her voice. Sarah’s parents also report that their
daughter enjoys soliciting hugs and other forms of physical affection
from people she knows, perhaps by not speaking.
Common consequences of selective mutism, or what happens after a
child does not speak, usually involve parents, peers, and teachers who may
• complete tasks for a child or try to communicate for the child
• rearrange a setting to accommodate a child’s mutism
• allow whispers or other compensatory behaviors.
Consider the case of Colby, a 6-year-old boy who does not speak
in public. His parents order his food at restaurants, explain to school
personnel that he does not speak, and allow him to avoid birthday par-
ties and other social events where he might be asked to speak. In addi-
tion, Colby’s friends at school tell people that “Colby doesn’t talk” and
try to “translate” or otherwise communicate what Colby might need.
Colby’s teacher also allows him to point to pictures of things he needs,
such as having to attend the restroom.
Finally, some cases of selective mutism are so severe that a child
may refuse to attend school. School refusal behavior is not directly
addressed in this book, but you may wish to consult some resources in
this area. One resource is a self-directed book for parents of youths with
acute or mild attendance problems (Getting Your Child to Say “Yes” to
School: A Guide for Parents of Youth with School Refusal Behavior, Oxford
University Press, 2007). Another resource is a book designed for school-
based professionals for moderate cases of school refusal behavior
(Helping School Refusing Children and Their Parents: A Guide for School-
Based Professionals, Oxford University Press, 2008). A third resource is
a set of treatment manuals for psychologists and other clinicians who
Table 1.3 Associated Features of Selective Mutism
Social anxiety and social phobia (fear)

Physical symptoms of anxiety
Concern about negative consequences of speaking
Shy or sad or socially withdrawn
Oppositional, manipulative, or willful behavior
Developmental and communication problems
Trauma-based reactions
Compensatory behavior
Desire to decrease social anxiety, increase social or sensory feedback from
others, or avoid displaying inefficient or underdeveloped speaking
skills
Significant others who complete tasks for a child, rearrange settings to
accommodate a child’s mutism, or allow compensatory behaviors such
as whispering
School refusal behavior
address severe attendance problems [When Children Refuse School: A

Cognitive-Behavioral Therapy Approach, 2nd ed. (Therapist Guide and
Parent Workbook), Oxford University Press, 2007]. Full references for
these books and other supporting materials on selective mutism can be
found in the bibliography at the end of the book. For a full list of asso-
ciated features of selective mutism, see Table 1.3.
Selective Mutism: Epidemiology, Course, and Family

Factors
Selective mutism occurs in about 0.2–2.0% of children and adolescents

and is somewhat more common in girls than boys (about a 1.5:1 ratio).
As mentioned, the disorder typically begins during preschool years, but
treatment is often delayed. Selective mutism may have a chronic course
for some children and can produce significant problems with respect to
peer rejection, incomplete verbal academic tasks or standardized tests,
or inadequate language or social skills. An infamous example of some-

one previously diagnosed with selective mutism is Seung-Hui Cho, the
student responsible for the Virginia Tech massacre. Obviously children
with selective mutism will not generally become mass murderers, but
the social alienation and potentially poor academic performance that
could result from the disorder can be quite debilitating for a child.
Family functioning for children with selective mutism is not
dramatically different from children in the general population, although
I and other researchers have noted some issues that can interfere with
treatment. Some parents of children with selective mutism are quite
shy, meek, or reserved themselves and often have to be coaxed to par-
ticipate in treatment and help conduct exposures (see Chapter 5). Other
parents need an extensive rationale as to why their child needs treat-
ment, or perhaps an extended behavioral observation session of their
child at school, to convince them of the seriousness of the issue at hand
(see Chapter 2). Keep in mind as well that most parents have never
heard of selective mutism and need a detailed description of the disor-
der and its associated features.
Reluctance to Speak
Selective mutism, the primary focus of this book, is a very serious dis-
order. Some children, however, do speak to some degree in public situ-
ations, but only reluctantly, infrequently, at a barely audible level, or
only to certain people. These kids might be described as excessively shy
and may or may not have friends. Many of these children have intense
levels of social anxiety and may avoid some social situations but may
not meet formal diagnostic criteria for selective mutism. The problems
covered in this book may thus be seen along a continuum. Figure 1.1
outlines a sample spectrum of normal speaking, reluctance to speak,
and selective mutism in school.
You can see from Figure 1.1 that different levels of appropriate
speaking exist prior to full-blown selective mutism. Most children speak
normally to peers and teachers. Some children, however, are quite shy
but do speak to others in a low but audible voice. Greater reluctance
to speak occurs at the next two levels. Some children hesitate to speak
to others and limit their speech to a select group of people at school.
Some kids, for example, enjoy speaking to friends on the playground
X-------------------------X----------------------------X----------------------------------X---------------------------------X--------------------------------X--------------------------------X
Normal speaking Child speaks Child reluctantly speaks Child reluctantly speaks Child communicates to Child will not speak Child will not speak
to peers and to peers and to peers or teachers to peers or teachers peers or teachers only to anyone at school, to anyone at school,
teachers teachers using but not to both using but not to both by by speaking to a parent even with a parent even with a parent
low audible voice low audible voice whispering present, but will present, and will not
participate nonverbally participate nonverbally
in social and academic in social and academic
Selective Mutism and Reluctance to Speak

activities activities
Figure 1.1. Sample spectrum of normal speaking, reluctance to speak, and selective mutism at school.
13
but seem quite intimidated by teachers and other school personnel.

Other kids prefer talking to adults more than classmates. In either case,
communicating with a select group of people is difficult for a child.
The first level of this reluctance to speak to either peers or teachers
involves low audible speech, but the second level involves barely audible
whispering.
The next level of difficult speech involves children who will not
speak to peers or teachers at school, but will convey information via a
parent. Children at this level will often whisper what they want to say
in a parent’s ear and the parent will then convey the information to
others. Obviously this is an unwieldy practice, so most communication
occurs immediately before or after school. In some cases, a child will
also choose a peer or sibling who will serve the same function as the
parent when the parent is absent. The final two phases on the spectrum
in Figure 1.1 involve formal selective mutism. Many children with
selective mutism will not speak but will participate nonverbally in social
and academic activities as much as possible. Children with severe selec-
tive mutism, however, will not speak or even participate nonverbally in
these activities and may actively refuse to attend school.
Children with great reluctance to speak may not have formal selec-
tive mutism but could still benefit from the techniques discussed in this
book. The pace of your intervention could be a little faster for these
children than for those with formal selective mutism because some
speech is already evident. Many of the procedures discussed in this book
can be applied to youths who are reluctant to speak (see the later treat-
ment section and Chapters 3–7). In addition, a working model of selec-
tive mutism generally applies to youths who are reluctant to speak.
A Working Model of Selective Mutism and Reluctance

to Speak
Researchers are still developing a comprehensive model of selective

mutism, but available studies and treatment outcome evaluations do
allow for a working model that can be used to guide intervention. This
model focuses on key antecedents (what comes before) and consequences
(what comes after) of selective mutism or reluctance to speak (see Fig.
1.2). These antecedents and consequences were discussed earlier and
serve as the basis for the intervention techniques described in this book.
Decrease social anxiety,

Key antecedents of increase social or sensory
selective mutism or feedback from others, avoid
reluctance to speak
aversive directives
(oppositional), avoid displaying
inadequate social or speech
skills (communication
problems), contextual factors
such as trauma or depression
Selective mutism Refusal or failure to speak or

or reluctance to difficulty speaking in public
speak settings, despite speaking well
in other settings such as home;
problems have lasted at least
one month and interfere with
functioning; not specifically
due to developmental or
communication disorder
Completing tasks for a child,

Key consequences rearranging settings to
of selective mutism accommodate a child’s lack of
or reluctance to speech, allowing whispers or
speak
other compensatory behaviors,
peers speaking for the child or
informing others that the child
does not speak, allowing the
child to avoid social settings
Figure 1.2. Model of selective mutism and reluctance to speak.

As mentioned, selective mutism appears to be closely linked to

social anxiety in many cases. The primary treatment for social anxiety
in children involves exercises to manage physical aspects of anxiety,
cognitive therapy to manage problematic or irrational thoughts about
social and evaluative situations, and exposure-based practice to help
children build interactive skills and become more comfortable in social
and evaluative situations.
Successful treatment for many children with selective mutism is
based on these same principles and techniques. A possible exception is
cognitive therapy, or modifying problematic thoughts, which usually
requires a verbal component and greater intellectual development.
Cognitive therapy is thus not a central feature of this book. If a child
with selective mutism or reluctance to speak does improve, however,
then discussions about what they may fear when speaking may be pro-
ductive (see Chapter 4).
As mentioned, other kids with selective mutism are not necessarily
anxious but seem adamant about not speaking, perhaps in a deliberate
refusal or manipulative kind of way. Anxiety management approaches in
these cases may not be helpful. Instead, speech will likely need to be
brought forth by managing contingencies – this likely involves providing
incentives for speaking appropriately and disincentives for refusing to
speak appropriately. This contingency management approach demands a
highly coordinated effort between parents and school personnel.
Still other children with selective mutism have comorbid problems
or developmental delays that impact their ability to speak appropri-
ately. Anxiety and contingency management techniques for these chil-
dren may be helpful but not necessarily sufficient. These kids may
require phonics training and other academically-based language inter-
ventions to improve articulation, comprehension, and speaking and
cognitive ability. The chapters in this book are largely designed to
address these three major classes of youths with selective mutism or
reluctance to speak (anxiety-based: Chapters 3 and 4; oppositional:
Chapter 5; and communication problem: Chapter 6).
Introduction to Intervention Techniques Discussed in

this Book
The most common and empirically supported interventions for selec-

tive mutism are behavioral in nature and comprise the main basis of
Table 1.4 Key Intervention techniques for Selective Mutism
Exposure-based practice
Stimulus fading
Shaping and prompting
Self-modeling
Relaxation training and breathing retraining
Contingency management
Negative reinforcement/escape
Social skills training
Language training
Family therapy
Group therapy
Pharmacological intervention (medication)
this book. These interventions are designed to address the major sub-
types of selective mutism described previously: anxiety-based, opposi-
tional, and communication problem. Because many cases of selective
mutism can involve more than one of these key subtypes, I strongly
recommend that you read all the chapters. A brief description of the
intervention techniques that are presented in much greater detail in
Chapters 3–7 is next (Table 1.4).
Exposure-Based Practice
Exposure-based practice refers to a collection of techniques that require

a child to say words in gradually but increasingly difficult or anxiety-
provoking situations. Exposure-based practice is a mainstay of treat-
ment for children with social anxiety and selective mutism and is the
main focus of Chapters 3 and 4. The practice is most suited for kids
whose selective mutism has an anxiety component. Exposure-based
practice is not as helpful for children who have intense oppositional or
communication problems. Kids with oppositional or communication
problems may still have anxiety about speaking, however, so exposure-
based practice is a cornerstone of intervention for many with selective
mutism.
Exposure-based practice usually involves a hierarchy of speaking

situations. A hierarchy is a list of situations that range from least to
most anxiety-provoking (or least difficult to most difficult). A typical
hierarchy for a child with selective mutism might include speaking
to a school-based social worker in the child’s home, speaking to the
social worker and others in community situations, speaking to the social
worker and others in a school office setting, and speaking to the social
worker and others at school. Many smaller steps within each of these
larger steps are obviously necessary as well (see the later section on stim-
ulus fading).
Exposures may involve community situations such as convenience
stores, shopping malls, pet stores, and parks. School-related situations
may include classrooms, hallways, offices, cafeteria and gymnasia, play-
grounds, and special classes such as music. Expectations for speaking in
school can also involve peers, teachers, administrators, and other per-
sonnel. Hierarchies can also involve expectations for speaking that
range from mouthing words to whispering to barely audible speech to
low-volume speech to full-volume speech. The goal of exposure-based
practice is to gradually develop a child’s ability to speak frequently and
audibly in all public situations while at the same time helping a child
manage her anxiety. Exposure-based practice is often used in conjunc-
tion with other techniques that are briefly described next.
Relaxation Training and Breathing Retraining
As mentioned, youths with selective mutism may have uncomfortable

physical feelings of anxiety such as muscle tension and hyperventila-
tion or shortness of breath. To help a child manage these symptoms
in speaking situations, he may be taught to relax muscles or breathe
more correctly. Muscle relaxation training involves teaching a child to
tense and release different muscle groups when preparing to speak
before or to others. Breathing retraining involves teaching a child to
breathe in slowly through her nose and exhale slowly through her
mouth. Both techniques are portable and can be taught with little or
no verbalization from the child. These techniques are typically per-
formed as a child is exposed to increasingly more difficult speaking
situations in exposure-based practice. The goal is to replace anxious
physical feelings with greater relaxation when a child communicates
verbally with others.
Stimulus Fading
Stimulus fading involves systematically increasing the difficulty of an

exposure by fading in new stimuli such as verbal academic tasks, peers,
or teachers. Consider Juan, a 7-year-old boy who rarely speaks at school.
Juan might be initially asked to speak to someone he knows and speaks
to well, such as a school psychologist, in an empty classroom for 30
minutes a day. In this way, Juan’s speaking is associated with the class-
room and his anxiety can be limited by having no one around.
Certain stimuli can then be faded into the exposure to make it
more challenging. Juan could be asked to engage in a verbal academic
task such as reading aloud to the school psychologist. As he becomes
proficient at this, the psychologist may add a friend to the classroom
who sits several feet away or the psychologist may ask the teacher to sit
at a desk on the other side of the room. As Juan’s speech becomes pro-
ficient under these conditions, more tasks, peers, or other components
of the classroom can be added. Stimulus fading can be used as well in a
child’s home or in community settings. Stimulus fading is usually done
in conjunction with exposure-based practice and ongoing rewards and
prompts for speech.
Shaping and Prompting
Shaping refers to reinforcing successive approximations of a desired

response, in this case audible and frequent speech. School-based mental
health professionals may initially reward a child’s vocalizations such as
humming and then gradually shape these sounds into verbalizations.
The shaping process is usually accompanied by prompting or prodding
a child to use words to communicate, speak more articulately and
loudly, establish eye contact, and extend the duration of speech. The
child may be encouraged as well to express speech in common situa-
tions such as greeting or thanking someone. Shaping and prompting
are key elements of exposure-based practice as a child engages in increas-
ingly difficult speaking scenarios.
Self-Modeling
Self-modeling involves asking parents to audiotape or videotape a child

as he speaks clearly and well in a comfortable situation such as home.
The recording is then replayed in a low-frequency speaking situation

such as your office at school. Others may be present, such as family
members. The child is given substantial verbal praise or tangible induce-
ments during this process to reward the clarity, volume, and beauty of
her voice. The child is essentially viewing herself as a model for appro-
priate and audible speech. The process is also aimed at rewarding
speech, easing discomfort, and helping a child recognize that no nega-
tive consequences will result from speaking publicly.
Contingency Management
The techniques described so far focus largely on a child’s anxiety-based

symptoms. As mentioned, however, some children display more oppo-
sitional tendencies by refusing to speak in public situations. Contingency
management is a key aspect of intervention for these types of cases,
although the approach can also be used for anxious children during
exposure-based practices. Contingency management refers to establish-
ing rewards and disincentives for a child’s speech or a child’s refusal to
speak, respectively. These rewards and disincentives are typically pro-
vided by parents, teachers, and the person primarily responsible for
handling the child’s intervention.
Rewards and disincentives are mostly geared toward frequency and
audibility of speech, although they can also target compensatory or
other problematic behaviors such as tantrums or clinging. Jenny’s high-
pitched noises to try to communicate to others, for example, could be
ignored by significant others to extinguish the behavior. Contingencies
can be contrived, such as a sticker chart, or can be more natural.
An example of the latter would be asking a child to order a treat in an
ice cream parlor – appropriate speech leads to ice cream and refusal to
speak leads to no ice cream.
Negative Reinforcement/Escape
Another behavioral technique for cases of selective mutism that involve

oppositional tendencies is negative reinforcement. Negative reinforce-
ment refers to rewarding a behavior by removing aversive consequences.
In this approach, a child is required to sit in a low-frequency speaking
situation (such as your office) for an extended period of time until he
speaks one word, and is then allowed to leave. Speaking thus allows the
child the opportunity to escape a boring and potentially stressful situa-

tion (negative reinforcement). This process can last several hours, how-
ever, and there is no guarantee the child will speak. This approach is
described in greater detail in Chapter 5. The approach is not well-
tested, however, and can be burdensome and ineffective.
Language Training
Another key subtype of selective mutism involves kids with language or

communication problems. These children may benefit from phonics or
other language training that can be integrated into exposure-based
practice. Recall the case of April, the 5-year-old girl who rarely spoke,
even at home. Her speech at home was marked by low audibility and
poor articulation. April could benefit from using gestures to imitate
sounds and then practice other sounds for basic three-phoneme words
such as “dog.” This process could intersect with exposure-based prac-
tice by having April initially mouth the words and later progress to
whispering, barely audible speech, and normal voice volume. Language
and other types of academic training could also involve close collabora-
tion with a speech pathologist and specialized education teachers to
build articulate language and generalize speech.
Other Interventions
Other interventions have been utilized for children with selective

mutism and are included in this book. Social skills training refers to
building basic skills such as establishing and maintaining eye contact,
starting and maintaining conversations effectively, and introducing
oneself to peers (see Chapter 4). Such training may be useful for chil-
dren with selective mutism whose development of social skills and
friendships has been hampered by the disorder. Social skills training
can be extended as well to social-academic tasks such as asking or
answering a question in class, responding to instructions on a standard-
ized test, or participating in music or other specialty classes.
Family therapy regarding this population refers to educating family
members about selective mutism, exploring family patterns of commu-
nication, addressing enmeshed or overcontrolling parent–child relation-
ships, and reducing family member pressure on a child to speak. You
may not have the time or resources to conduct formal family therapy for
a particular case of selective mutism, but addressing family dynamics to

some extent in many of these cases is crucial for success. Addressing
these dynamics can often be done in the context of contingency man-
agement practices. Family interventions are discussed in greater detail
in Chapter 7.
Group therapy has not been extensively tested for children with
selective mutism but involves conducting many of the procedures
described here for several children at one time. Children in the group
could benefit by modeling the accomplishments of others or engaging
in exposures together. Children could also practice social skills on one
another. A key advantage of group therapy is its cost-effectiveness –
multiple children can be seen at one time. A potential downside, of
course, is that children may progress at different speeds. Finally, you
may not have enough children with selective mutism at your school to
constitute a group. Group therapy is discussed at greater length in
Chapter 7.
Finally, pharmacological intervention refers to the use of medication.
Some researchers have found that antidepressants and other medica-
tions can help some children with severe selective mutism. The medica-
tions may help reduce anxiety or depression that stifles speech, although
other mechanisms may be at work as well. Referral to a pediatrician or
psychiatrist may be necessary in some very difficult cases of selective
mutism (see the box on page 3). Try the procedures in this book before
seeking a solution involving the use of medication (see Chapter 7 for
more details).
Final Comments and What Is Next
Selective mutism and reluctance to speak are complex and difficult

problems that can lead to serious consequences for a child. The first
step in addressing a child with these issues is to fully understand the
forms and function of the behavior as well as contextual variables that
may contribute to the behavior. Assessment methods for this popula-
tion are discussed in Chapter 2, with a particular emphasis on key ques-
tions you can ask as well as other time-efficient methods of data
collection such as questionnaires and worksheets.
Chapters 3 and 4 outline recommended procedures for youths
whose selective mutism or reluctance to speak appears to be based on
anxiety. A heavy emphasis is placed on exposure-based practice, or having

a child practice speaking in various situations. Many techniques can be
utilized in conjunction with exposure-based practices, such as relaxation
training, self-modeling, and shaping and prompting. Chapter 3 focuses
on exposure-based practice at a child’s home. Chapter 4 focuses on
exposure-based practice in community settings and at your school.
Chapter 5 outlines recommended procedures for youths whose
selective mutism or reluctance to speak appears to be more oppositional
in nature. A heavy emphasis is placed on contingency management
practices using incentives for speaking and disincentives for refusing to
speak. Chapter 6 outlines recommended procedures for youths whose
selective mutism or reluctance to speak may relate to specific language
impairment or developmental delay. Emphasis is placed on integrating
phonics and other language training with techniques specific to selec-
tive mutism.
Chapter 7 covers relapse prevention for children with selective
mutism and reluctance to speak, including strategies for handling a
new school year. This chapter also includes a discussion of group, family,
pharmacological, and other treatments for these children. The chapter
concludes with a discussion of special issues regarding this population
such as bilingualism, difficult parents, comorbidity, and developmental
delay.
2
Assessing Cases of Selective Mutism
and Reluctance to Speak
Gabriella is an 8-year-old student in third grade who moved to

her current elementary school 2 years ago. She does not speak to
anyone in school but has several friends who speak for her. She also
points to pictures of things she wants or will tug on the teacher’s
clothing if necessary. Gabriella’s parents say their daughter speaks
well at home and is very quiet in public. She seems to be a good
student but adamantly refuses to participate in academic tasks that
involve speaking to peers or others. She often prefers to sit quietly
at her desk, keep her head down, and focus on her work.
Nash is a 5-year-old boy in kindergarten who speaks only in a

whisper in class. His classmates say “Nash doesn’t talk” and do try
to play with him, but Nash prefers to be by himself. Nash’s parents
say their son is quiet even at home but also say they can usually
understand what he is trying to convey. Other people, however, say
they can barely hear Nash speak, that he does not articulate well,
and that he will not attempt to speak again when people ask him
to repeat what he said. Nash also appears sad much of the time and
does not seem to enjoy school.
S chool officials are commonly faced with children such as Gabriella

and Nash. Chapter 1 discussed different aspects of selective mutism
and reluctance to speak and presented a working model for understand-
ing this population. Recall that many of these kids have some degree of
social anxiety, oppositional behavior, or communication problem.
Methods of assessing children such as Gabriella and Nash are described
in this chapter. Some of these assessment methods are less time-intensive
for school officials with little opportunity for conducting a detailed
24
Assessing Cases of Selective Mutism and Reluctance to Speak 25
assessment. Other methods are time-intensive and might be under the

purview of someone who can conduct a detailed assessment, such as a
school-based social worker or school psychologist. Some methods are
very specific to selective mutism and others are broader instruments to
assess global aspects of functioning such as intelligence or language
ability.
This chapter begins with interview questions that are specifically
geared toward core aspects of selective mutism. Later sections cover
measures such as questionnaires and worksheets that generally require
little time. These basic and less time-intensive methods must be part of
any assessment for a youth with selective mutism or reluctance to speak.
Later in the chapter, measures that relate to key associated features of
selective mutism (social anxiety, oppositional behavior, and communi-
cation problems) are discussed. These measures may be a bit more time-
intensive and include other questionnaires, formal testing, behavioral
observation, and review of records. A final section of the chapter
involves suggestions for collating your assessment data to develop an
intervention plan.
Interview Questions Specific to Selective Mutism and

Reluctance to Speak
One assessment method that you may wish to emphasize first with this
population is the interview. You may wish to interview the child,
parents, teachers, and others who regularly interact with the child. You
might be surprised at the suggestion to interview a child with selective
mutism—after all, what is he going to say? Many children with selec-
tive mutism, however, will respond nonverbally to yes or no questions
by nodding or shaking their head. This allows you to collect at least
some information about their nonspeaking and what maintains their
failure to speak. Other children such as Nash may not respond even at
this level, and I do not recommend pushing a child to answer if he does
not want to. In these latter cases, information will have to be gleaned
primarily from parents and teachers and possibly from peers and
others.
Ideally you should interview different parties separately, but time
pressures may force you to meet with parents and teachers together.
If only a group meeting is feasible, then try to interview the child separately.
Doing so may reduce the child’s anxiety by avoiding a large group and
help you obtain a good indication of how reluctant she is to speak.
Following are some key questions recommended for the interview
process. The questions are designed to help you decide whether a child
does indeed have selective mutism, what subtype of selective mutism a
child may have, and what associated features of selective mutism a child
may have.
Does the Child Meet Criteria for Selective Mutism?
A good way to start your interview is to ask questions that directly

match specific diagnostic criteria for selective mutism. Answers (Yes/
No) that support a diagnosis of selective mutism follow the questions:
• Does the child show a persistent failure to speak in public situations
where speaking is expected? (Y)
• Does the child speak well in other situations, especially at home? (Y)
• Does the child’s refusal to speak interfere significantly with
her educational or occupational achievement or social
communication? (Y)
• Has the child’s failure to speak lasted at least 1 month and not just
during the first month of school? (Y)
• Is the child’s failure to speak due to lack of knowledge of, or comfort
with, the spoken language required in a social situation? (N)
• Is the child’s failure to speak better accounted for by a
communication disorder? (N)
• Does the child’s failure to speak occur exclusively during the course
of a pervasive developmental disorder, schizophrenia, or other
psychotic disorder? (N)
Selective mutism is generally indicated if the answers to questions
1–4 are yes and the answers to questions 5–7 are no. Bear in mind,
however, that some gray areas may be present, especially with respect to
the presence of a communication disorder. Not all children with selec-
tive mutism neatly fit these diagnostic criteria. Keep in mind as well
that a child may not have formal selective mutism but may still be quite
reluctant to speak. A child may have some willingness to whisper in
class, as Nash does for example (see also Fig. 1.2 in Chapter 1). The
assessment methods presented in this chapter can still apply to a large
degree to children such as Nash who are reluctant to speak.
What Specific Settings Involve Failure to Speak?
Children with selective mutism will not speak in specific social situa-
tions where speaking is expected. These situations often include restau-
rants, malls, supermarkets, parks, other recreational settings, and school.
You should work to discover exactly which speaking situations involve
the greatest difficulty for a child. You should also detail at length the
specific settings at school that involve the greatest difficulty for a child.
You may wish to use Worksheet 2.1 in this regard to determine the
extent of a child’s selective mutism or reluctance to speak.
School-based situations involving failure to speak should be detailed
at length. Some children will speak a bit on the playground or other
highly social settings such as the cafeteria but never in class. Other kids
will speak to peers a bit but never to adults. Some kids will speak to a
favorite teacher, such as the music teacher, but to no one else. Many kids
with selective mutism, however, never speak to anyone at school in any
situation. Establishing a baseline of speaking behavior––knowing the
minimum amount of speech a child is willing to produce, and where, and
how loud––will help you determine the starting point for intervention.
What Circumstances Surround Failure to Speak?
Many of the questions described to this point surround the form of

nonspeaking behavior, such as whether and where it occurs. Of equal
importance is discovering factors that maintain a child’s refusal to
speak––in other words, what motivates the child to continue to refuse
to speak? What is the function of nonspeaking behavior for the child?
To help ascertain function, ask the following questions:
• Is the child’s refusal to speak due to a desire to decrease anxiety?
• Is the child’s refusal to speak due to a desire to increase social or
sensory (physical) feedback from others? If so, what type of
feedback?
• Is the child’s refusal to speak due to a desire to avoid aversive
directives from others?
• Does the child refuse to speak because of inefficient or
underdeveloped speaking skills?
Keep in mind that many parents and teachers have trouble answer-
ing these questions. As such, ask about a child’s behavior in situations
where he does speak well to see what patterns could reveal the function
Worksheet 2.1 Situations Involving Selective Mutism or

Reluctance to Speak
Does the child refuse/fail to speak or have great reluctance speaking in the
following situations?
Mutism Reluctance
to speak
Home Y/N Y/N

Answering the door or telephone _____ _____
Speaking to parents _____ _____
Speaking to siblings _____ _____
Speaking to visitors the child
knows well _____ _____
Speaking to visitors the child does not
know well _____ _____
Speaking to peers inside the home with
the parents present _____ _____
Community/public Y/N Y/N

Speaking to parents or siblings in
markets and similar places _____ _____
Speaking to peers at social events
or extracurricular activities _____ _____
Speaking to clerks or waiters _____ _____
School Y/N Y/N

Speaking to peers on the playground _____ _____
Speaking to peers in hallways and
related situations _____ _____
Speaking to peers in the classroom _____ _____
Speaking to peers at lunch/cafeteria _____ _____
Speaking to peers on the school bus _____ _____
Speaking to parents at school _____ _____
Speaking to teachers on the playground _____ _____

Speaking to teachers in the classroom _____ _____
Speaking to other staff
members at school _____ _____
Speaking during academic activities _____ _____
Speaking or reading before classmates _____ _____
of nonspeaking. For example, does the child often seek attention from
his parents at home? If so, refusal to speak in public may be designed to
gain attention. Does the child often refuse to do things such as chores
that she does not want to do? If so, refusal to speak in public may be
motivated by a desire to avoid directives from others. Are the child’s
social or speech skills at home not well developed? If so, the child may
be unwilling to display these rudimentary skills in public. Look for pat-
terns of behavior and how the child may be reinforced for nonspeaking.
Bear in mind that more than one issue, such as attention-seeking and
poor communication skills, may be pertinent.
You should also ask questions about contextual factors that may
influence a child’s refusal to speak. Recall that some children will not
speak following a traumatic event or ongoing difficulties, so questions
surrounding this possibility should be posed. Other children experi-
ence episodes of sadness or even depression. Ask whether recent changes
have occurred in a child’s life, such as parental divorce, that could lead
to decreased speaking. If a child experiences traumatic or difficult events
and did speak well prior to these events, then a diagnosis of selective
mutism would not likely apply. In these cases, helping the child adjust
to trauma or other changes in his life may be best.
Other contextual factors involve the parents, family, and school.
An important question to ask parents is whether English or another
language is primarily spoken in the home. Parental emphasis on Spanish
in the home, for example, could influence a child’s willingness to speak
English at school. Family dynamics could also be probed. Are family
members themselves meek or shy? Do family members communicate
well and solve problems effectively? Is there substantial conflict in the
home? Have any recent changes in the parents or family potentially
affected a child’s willingness to speak? School-related factors such as
possible threats from others should be explored as well.
Can the Child Be Encouraged to Speak Audibly in

Certain Public Situations?
Recall from Chapter 1 that normal speaking, reluctance to speak,

and selective mutism occur along a dimensional spectrum of severity
(Fig. 1.2). Try utilizing this spectrum as an assessment tool during your
evaluation of a child. Where on the spectrum does the child fall? How
severe is the child’s refusal to speak in different situations? Does the
child fluctuate in his type of speaking across different situations?
A child might whisper in a mall, for example, but remain completely
mute at school. Be sure to chart all instances of nonspeaking or reluc-
tance to speak.
Determining where a child falls on this spectrum will involve know-
ing whether a child can be encouraged to speak audibly in certain public
situations. Some children will whisper or even speak in certain situa-
tions if prompted by parents or others or if some substantial motivation
is present (e.g., toy, ice cream). Children with selective mutism who can
speak to some extent in public situations may have a better prognosis
than those who do not.
Knowing whether a child will speak in response to a prompt or
tangible reward such as a toy is also important for intervention pur-
poses. If a child is receptive to prompts, then utilizing this technique
heavily during intervention is suggested. Other children actually
become more closed and unwilling to speak if verbal praise or prompts
are given, however, so knowing this allows you to emphasize alternative
motivators such as tangible rewards. A child’s willingness or unwilling-
ness to respond to prompts will also help you determine how quickly or
slowly your intervention must proceed.
What Symptoms Surround a Child’s Failure to Speak?
Many children with selective mutism and reluctance to speak show

problems in addition to the core diagnostic criteria of the disorder (see
associated features in Chapter 1). Interview questions should surround
these related problems and may include the following:
• Does the child seem generally anxious or nervous? Does the child
have physical symptoms of anxiety such as trembling, sweating, or
crying? Does the child report being scared or anxious in different
situations?
• Does the child seem socially anxious? Does the child commonly
avoid situations such as birthday parties or soccer games that
involve social interaction or some type of evaluation?
• Has the child expressed concerns about speaking such as negative
reactions from others?
• Does the child have a history of separation anxiety from significant
others such as parents? Does the child often cling to parents, cry
when separation occurs or is anticipated, or refuse to attend school?
• Does the child seem depressed? Does the child show sad mood,
poor self-esteem, poor eating or sleeping habits, social withdrawal,
or tendencies to self-harm?
• Does the child show oppositional tendencies? Does the child often
show defiance or noncompliance, argue with parents, or throw
temper tantrums?
• Does the child have a history of poor communication such as
inarticulate speech, stuttering, or other expressive or receptive
language problems?
• What is the child’s general level of intellectual functioning?
• Can the child engage in basic adaptive self-care skills such as
dressing, washing, eating, and using the toilet appropriately and
independently?
• Does the child show compensatory behaviors such as whispering,
pointing, gesturing, high-pitched noises, grunts, incomplete words,
or other nonverbal methods of communication?
• Does the child have health problems that may specifically impact
his ability to speak?
Regarding the last question, I strongly recommend that a child
with selective mutism or reluctance to speak be referred to a pediatri-
cian for a full medical examination. Medical conditions are not com-
monly linked to selective mutism, but conditions such as asthma, pain,
or anatomical problems could influence the condition. If medication
becomes an option (see Chapter 7), then referral to a pediatrician or
psychiatrist will be necessary as well.
How Do Others Respond to a Child’s Failure to Speak?
A very important part of your assessment will be to discover how other

people respond to a child’s refusal or reluctance to speak. By others, I
mean parents, teachers, peers, siblings, relatives, and people who interact
or see the child on a regular basis. Recall the common consequences of

selective mutism covered in Chapter 1. Ask the following questions in
this regard:
• Do others commonly complete tasks for a child after he fails to
speak?
• Do others rearrange settings for a child to accommodate her
mutism?
• Do others allow whispering or other compensatory behaviors?
• Do peers help the child communicate to others at school or in other
places?
Many kids with selective mutism have grown accustomed to having
other people complete tasks for them, and many parents, teachers, and
others have grown accustomed to compensating for a child’s lack of
speech. This will have to change during intervention. In the meantime,
discover exactly what accommodations are commonly made for a child.
For example, parents may habitually order food for a child, allow the
child to avoid activities such as answering the door or telephone, ask a
peer or sibling to help the child communicate at school, or keep the
child away from birthday parties and other social events. Teachers may
habitually decline to call on a child in class, allow the child to point to
pictures or use hand gestures to communicate, or stop assigning work
to the child that requires verbal input. As mentioned, peers will also be
happy to tell others that “Nash doesn’t talk” and try to communicate
the child’s desires to others.
These interview questions will help give you a broad perspective of
a child’s selective mutism and reluctance to speak. If you desire a more
structured approach, the Anxiety Disorders Interview Schedule for
DSM-IV: Child and Parent Versions is available via Oxford University
Press. This is a structured diagnostic interview that emphasizes anxiety-
related disorders but has sections for externalizing problems such as
oppositional defiant disorder as well. The interview also contains a sec-
tion on selective mutism that mirrors DSM-IV criteria. Another inter-
view format for selective mutism is the Functional Diagnostic Protocol
(Schill, Kratochwill, & Gardner, 1996). This brief interview assesses for
conditions under which selective mutism occurs and what reinforcers
maintain mutism over time.
If you decide to use these interviews, you should still ask the ques-
tions posed in this chapter for a complete picture of a child’s mutism or
reluctance to speak. Interview questions should be supplemented as

well by measures specific to selective mutism and reluctance to speak.
These measures include questionnaires and worksheets and are described
next.
Measures Specific to Selective Mutism and Reluctance

to Speak
Some measures have been designed specifically for selective mutism

and can apply to youths who are reluctant to speak. A strong one from
the research literature is the Selective Mutism Questionnaire (SMQ),
a measure that contains three main factors: school, home/family, and
public/social (see Fig. 2.1). School items surround a child’s willingness
to speak to peers, teachers, and groups at school. Home/family items
surround a child’s willingness to speak to family members when others
are present or in unfamiliar situations, to extended family members and
family friends and babysitters, and on the telephone to parents and
siblings. Public/social items surround a child’s willingness to speak to
unfamiliar peers or family friends, medical personnel, store clerks and
waiters, and in clubs or teams outside of school. Parents rate each item
on a 0–3 scale of never, seldom, often, and always.
Questions 18–23 surround how much interference or distress is
associated with a child’s pattern of nonspeaking. These items are rated
as not at all, slightly, moderately, and extremely. Lower scores on the
SMQ generally reflect a lower frequency of speaking behavior. The
measure has strong psychometric properties (Bergman, Keller,
Piacentini, & Bergman, 2008). A supplemental measure is the School
Speech Questionnaire (SSQ), an eight-item instrument completed by
the teacher that surrounds school-based speaking behavior in different
situations (see Fig. 2.2).
The SMQ and SSQ are good measures of the severity of a child’s
selective mutism, but the scales do not supply information about a
child’s daily fluctuations in terms of speech, audibility, or anxiety.
In our work with youths with selective mutism, we utilize several daily
monitoring forms developed for children, parents, and teachers. These
forms were developed by a colleague of mine, Jennifer Vecchio, who has
investigated this population with me (see Vecchio & Kearney, 2005,
2007, 2009).
Please consider your child’s behavior in the last two weeks and rate how frequently
each statement is true for your child.
AT SCHOOL
1. When appropriate, my child talks to most peers at school.

Always Often Seldom Never
2. When appropriate, my child talks to selected peers (his/her friends) at school.
3. When my child is asked a question by his/her teacher, s/he answers.
4. When appropriate, my child asks his or her teacher questions.
5. When appropriate, my child speaks to most teachers or staff at school.
6. When appropriate, my child speaks in groups or in front of the class.
HOME/FAMILY
7. When appropriate, my child talks to family members living at home when other
people are present.
8. When appropriate, my child talks to family members 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 parents and siblings.
11. When appropriate, my child speaks with family friends who are well-known
to him/her.
12. My child speaks to at least one babysitter.
Always Often Seldom Never N/A
Figure 2.1. Selective Mutism Questionnaire (SMQ)©.

Created by and the property of R. Lindsey Bergman, Ph.D. Reprinted with
permission.
IN SOCIAL SITUATIONS (OUTSIDE OF SCHOOL)
13. When appropriate, my child speaks with other children who s/he doesn’t know.
14. When appropriate, my child speaks with family friends who s/he doesn’t know.
15. When appropriate, my child speaks with his or her doctor and/or dentist.
16. When appropriate, my child speaks to store clerks and/or waiters.
17. When appropriate, my child talks when in clubs, teams, or organized activities
outside of school.
Always Often Seldom Never N/A
Interference/Distress*
18. How much does not talking interfere with school for your child?
Not at all Slightly Moderately Extremely
19. How much does not talking interfere with family relationships?
20. How much does not talking interfere in social situations for your child?
21. Overall, how much does not talking interfere with life for your child?
22. Overall, how much does not talking bother your child?
23. Overall, how much does your child’s not talking bother you?
Figure 2.1. continued

*These items are not included in the total score and are for clinical
purposes only.
Name of Teacher Who Completed This Questionnaire: ________________________
When responding to the following items, please consider the behavior of your student,
__________________, and activities of the past month and rate how often each
statement is true.
1. When appropriate, this student talks to most peers at school.
2. When appropriate, this student talks to selected peers (his/her friends) at school.
3. When called on by his/her teacher, this student answers verbally.
4. When appropriate, this student asks you (the teacher) questions.
5. When appropriate, this student speaks to most teachers or staff at school.
6. When appropriate, this student speaks in groups or in front of the class.
7. When appropriate, this student participates non-verbally in class (i.e., points,

gestures, writes notes).
8. How much does not talking interfere with school for this student?
Figure 2.2. School Speech Questionnaire.*

*Reprinted with permission.
One set of forms requires children, parents, and teachers to rate the
degree of anxiety a child feels each day on a scale of 0–10 (see Worksheets
2.2 to 2.4). Recall that anxiety is a key feature of most cases of selective
mutism and reluctance to speak. Young children may be unable to grasp
the concept of anxiety or the rating system, so information from parents
and teachers can be emphasized. In other cases, young children may
understand related words such as nervous or scared and attempt to rate
these constructs. Some children also respond better to facial expressions
Worksheet 2.2 Child Daily Ratings of Anxiety
DIRECTIONS: Rate your anxiety (nervous, tense, scared, fearful) on

a 0–10 scale where 0 = none and 10 = extreme. Use any number from
0 to 10.
0 1 2 3 4 5 6 7 8 9 10
None Some Extreme
DATE ANXIETY
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
Worksheet 2.3 Parent Daily Ratings of Child Anxiety

DIRECTIONS: Rate your child’s anxiety (nervous, tense, scared, fearful)
on a 0–10 scale where 0 = none and 10 = extreme. Use any number from
0 to 10.
0 1 2 3 4 5 6 7 8 9 10
None Some Extreme
DATE ANXIETY
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
Worksheet 2.4 Teacher Daily Ratings of Student Anxiety
DIRECTIONS: Rate the student’s anxiety (nervous, tense, scared,

fearful) on a 0-10 scale where 0 = none and 10 = extreme. Use any
number from 0 to 10.
0 1 2 3 4 5 6 7 8 9 10
None Some Extreme
DATE ANXIETY
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
_____ _________
than to numerical scales to rate anxiety, which is perfectly acceptable.

Encourage children to supply independent ratings and encourage par-
ents and teachers not to influence their child’s ratings.
The other set of forms requires children, parents, and teachers to
record the number of words spoken, mouthed, or whispered that day
across several situations (see Worksheets 2.5 to 2.7). These situations
primarily include school, telephone, and public, but other situations
could be added as relevant. Each party also rates, on a 0-10 scale, how
audible the child’s speech was for words produced that day, if any. On
this scale, 0 reflects the fact that no one could hear the child and 10
reflects the fact that everyone could hear the child. The scale also
requires each party to record to whom the child spoke that day.
These forms can be quite useful for monitoring daily fluctuations and
progress in a child’s audibility and frequency of speech. Young children
can complete the forms with help, though in many cases the most useful
data will come from parents and teachers. You may wish to chart or graph
a child’s daily progress in speaking, especially as you engage in the inter-
vention procedures listed in the next several chapters. These forms could
also be used as you conduct behavioral observations of a child (see later
section). Feel free to photocopy these worksheets as needed for your case
or redesign them to better fit your setting and case.
Measures of Behaviors Most Commonly Associated with

Selective Mutism
An important part of your assessment of a child with selective mutism

or reluctance to speak is to utilize measures of behaviors most com-
monly associated with these problems. A full description of all possible
relevant measures is beyond the scope of this chapter, but the following
sections provide an overview of common, useful, and practical instru-
ments with solid psychometric properties. References for these mea-
sures are in the bibliography at the end of the book.
Measures of General and Social Anxiety and

Depression
General and social anxiety clearly relate to many cases of selective

mutism. Depression can be related to these cases as well. Measures of
Worksheet 2.5 Child Daily Ratings of Behaviors

DIRECTIONS: Record the numbers of words you spoke, whispered, or mouthed today
in the following situations. Rate how loud your speech was on a 0 to 10 scale where 0 =
no one could hear you and 10 = everyone could hear you. Use any number from 0 to 10.
0 1 2 3 4 5 6 7 8 9 10
No one Some Everyone
SCHOOL
No. words spoken No. words whispered No. words mouthed Audibility rating
_______________ _________________ ________________ _____________
TELEPHONE
______________ _________________ ________________ _____________
PUBLIC
______________ _________________ ________________ _____________
DIRECTIONS: Record the people to whom you spoke, whispered, or mouthed today in
the following situations, by answering yes or no. Yes indicates that you communicated
with the person and no means you did not. Please circle Yes or No.
SCHOOL
Mouthed Teacher Yes No Classmate Yes No Other Person Yes No
Whispered Teacher Yes No Classmate Yes No Other Person Yes No
Spoken Teacher Yes No Classmate Yes No Other Person Yes No
TELEPHONE
Whispered Family member Yes No Friend Yes No Teacher Yes No
Which family member (s)_______________________________
Spoken Family member Yes No Friend Yes No Teacher Yes No
Which family member (s)_______________________________
IN PUBLIC
Mouthed Family Yes No Friend Yes No Teacher Yes No Other Person Yes No
Whispered Family Yes No Friend Yes No Teacher Yes No Other Person Yes No
Spoken Family Yes No Friend Yes No Teacher Yes No Other Person Yes No
Worksheet 2.6 Parent Daily Ratings of Child Behaviors

DIRECTIONS: Record the numbers of words your child spoke, whispered, or mouthed
today in the following situations. Rate how loud your child’s speech was on a 0-10 scale
where 0 = not at all audible and 10 = completely audible. Use any number from 0 to 10.
0 1 2 3 4 5 6 7 8 9 10
Not Audible Moderately Completely
Audible Audible
IN PUBLIC
No. words mouthed No. words whispered No. words spoken Audibility rating
_______________ ________________ ______________ _____________
ON THE TELEPHONE
_______________ ________________ ______________ _____________
AT HOME
_______________ ________________ ______________ _____________
DIRECTIONS: Record the people to whom your child spoke, whispered, or mouthed
today in the following situations, by answering yes or no. Please circle Yes or No.
IN PUBLIC
Mouthed Family Yes No Friend Yes No Teacher Yes No Other Person Yes No
Whispered Family Yes No Friend Yes No Teacher Yes No Other Person Yes No
Spoken Family Yes No Friend Yes No Teacher Yes No Other Person Yes No
TELEPHONE
Whispered Family member Yes No Friend Yes No Teacher Yes No
Spoken Family member Yes No Friend Yes No Teacher Yes No
AT HOME
Mouthed Family member Yes No Friend Yes No Other Person Yes No
Whispered Family member Yes No Friend Yes No Other Person Yes No
Spoken Family member Yes No Friend Yes No Other Person Yes No
Did your child mouth, whisper, or speak to someone to whom he or she does not
normally speak? Yes No
If yes, please indicate who and describe the amount and audibility of the words
communicated ______________________________________________
Worksheet 2.7 Teacher Daily Ratings of Student Behaviors

DIRECTIONS: Record the numbers of words the student spoke, whispered, or mouthed
today in school. Rate how loud the student’s speech was on a 0-10 scale where 0 = not at
all audible and 10 = completely audible. Use any number from 0 to 10.
0 1 2 3 4 5 6 7 8 9 10
Not Audible Moderately Completely
Audible Audible
________________ ________________ ______________ ______________
DIRECTIONS: Record to whom the student spoke, whispered, or mouthed today in the
following situations, by answering yes or no. Please circle Yes or No.
IN THE CLASSROOM
Mouthed Classmate Yes No Friend Yes No Teacher Yes No
Whispered Classmate Yes No Friend Yes No Teacher Yes No
Spoken Classmate Yes No Friend Yes No Teacher Yes No
DURING RECESS
AT LUNCH
DURING SPECIALS
Did the student speak directly to his or her teacher in the classroom? Yes No
If yes, please indicate how many other students were present ____________ (none, entire
class, etc.).
internalizing problems such as these are often assessed via child self-
report measures. I have found that youths with selective mutism are
generally willing to complete these measures, though younger children
may need someone to read the items to them. Five psychometrically
strong and practical child self-report measures of these constructs
follow:
• Children’s Depression Inventory is a 27-item scale that measures
negative mood, interpersonal problems, ineffectiveness, anhedonia,
and negative self-esteem.
• Multidimensional Scale for Children is a 39-item scale that measures
harm avoidance and physical anxiety, separation/panic, and social
anxiety.
• Screen for Child Anxiety-Related Disorders is a 41-item scale that
measures somatic/panic symptoms, general anxiety, separation
anxiety, social anxiety, and school-related fear.
• Social Anxiety Scale for Children-Revised and Social Anxiety Scale for
Adolescents are 26-item scales of social anxiety that measure fear of
negative evaluation from peers, social avoidance and distress specific
to new situations, and generalized social avoidance and distress.
• Social Phobia and Anxiety Inventory for Children is a 26-item scale of
social anxiety that contains items surrounding assertiveness, general
conversation, physical and cognitive symptoms, avoidance, and
public performance.
Measures of Oppositional Behavior
Oppositional behavior can also be a feature of selective mutism and

reluctance to speak. Most measures of oppositional behavior involve
parent- and teacher-based questionnaires and checklists that cover
internalizing and externalizing behavior problems. The following have
excellent psychometric strength and practicality:
• Child Behavior Checklist and Teacher’s Report Form are 113-item
measures of several factors of misbehavior: anxious/depressed,
withdrawn/depressed, somatic complaints, social problems, thought
problems, attention problems, rule-breaking behavior, and
aggressive behavior (this scale also has an adolescent self-report
version for 11-18-year-olds, the Youth Self-Report).
• Conners Ratings Scales (Parent and Teacher Versions-Revised) are
80-item (long version) or 27-item (short version) measures of
several factors of misbehavior: oppositional, cognitive problems/

inattention, hyperactivity, anxious-shy, perfectionism, social
problems, and psychosomatic (for long version).
• Child Symptom Inventory-4 (Parent Checklist: 97 items and Teacher
Checklist: 77 items) screens for the following problems: attention
deficit/hyperactivity disorder, oppositional defiant disorder, conduct
disorder, generalized anxiety disorder, social phobia, separation
anxiety disorder, obsessive–compulsive disorder, specific phobia,
major depressive disorder, dysthymic disorder, schizophrenia,
pervasive developmental disorder, and motor and vocal tics.
Measures of Communication Problems
Recall that some children with selective mutism or reluctance to speak

have communication or developmental problems. If you suspect this to
be so for a particular child, you should conduct an assessment of the child’s
intellectual/achievement and speech/language abilities. Intellectual/
achievement and speech/language assessments for youths with selective
mutism and reluctance to speak are obviously going to be a challenge.
Many tests have nonverbal scales, however, that allow you to glean
some information about a child’s cognitive and language ability. A full
description of all relevant measures is beyond the scope of this chapter,
so I encourage you to access current textbooks on nonverbal assessment
to keep abreast of ongoing developments in this area. Some common,
psychometrically strong and useful tests for children with selective
mutism and reluctance to speak are described in the following para-
graphs. The intelligence/achievement tests listed here are available
through major testing companies.
The most common intelligence tests for children and adolescents are
the Wechsler Preschool and Primary Scale of Intelligence and Wechsler
Intelligence Scale for Children. Most children with selective mutism and
reluctance to speak will obviously fare poorly on the verbal tasks of these
tests, so I recommend utilizing the performance subtests to secure at least
a basic understanding of the child’s intellectual capability. Performance
or otherwise nonverbal subtests of these measures generally surround
perceptual reasoning, working memory, and processing speed.
Other measures can also help comprise an intellectual/achievement
assessment of a child with selective mutism because some tasks do not
require verbal input. For children with selective mutism, nonverbal
aspects of these tests must be emphasized. For children who are reluc-
tant to speak but may speak to some degree, some verbal aspects of the
tests may be possible. The following instruments may be helpful:
• Kaufman Assessment Battery for Children-II measures general
cognitive ability and achievement; the nonverbal scale of the
measure allows students to respond using gestures.
• Peabody Individual Achievement Test-Revised measures reading,
mathematics, and spelling that requires only a pointing response for
most multiple-choice items.
• Raven’s Progressive Matrices measure abstract reasoning via multiple-
choice tests that require identifying a missing segment of a matrix.
• Test of Nonverbal Intelligence-3 measures intelligence, aptitude,
abstract reasoning, and problem solving in a nonverbal format that
requires only pointing, nodding, or gesturing.
• Wide Range Achievement Test-Expanded measures reading
comprehension and mathematics and contains a nonverbal
reasoning component.
Speech and language assessment is obviously challenging for youths
with selective mutism and reluctance to speak. Some researchers rec-
ommend the use of written narratives (McInnes et al., 2004), and the
nonverbal aspects of the following tests may be helpful as well:
• Children’s Communication Checklist-2 is a parent-completed measure
of a child’s nonverbal communication, speech, syntax, coherence,
semantics, use of context, and other language-based abilities.
• Clinical Evaluation of Language Fundamentals-4 measures a wide
range of expressive and receptive language skills as well as
phonological awareness and other abilities.
• Lindamood Auditory Conceptualization Test-3 measures the ability to
perceive and conceptualize speech sounds using a visual medium.
• Peabody Picture Vocabulary Test-III measures receptive vocabulary by
requiring the student to point to correct responses.
• Preschool Language Scale-4 measures auditory comprehension,
expressive communication, and other language abilities in young
children up to age 6 years, 11 months.
• Test of Auditory Comprehension of Language-3 measures
vocabulary, grammar, and syntax by asking a child to point to
correct answers.
• Token Test for Children-2 measures receptive language dysfunction
by having the child manipulate tokens in a prescribed way.
• Utah Test of Language Development-4 measures receptive and

expressive language skill.
Behavioral Observations
Because your time is very limited (school officials are among the most
time-burdened people I know!), I have tried so far to suggest assessment
methods that either (1) require as little time as possible, such as inter-
view questions, questionnaires, or worksheets, or (2) can be conducted
within the parameters of a normal working environment for school-
based social workers and psychologists, such as formal testing. Another
form of assessment that will be quite valuable for evaluating kids with
selective mutism is behavioral observation. Behavioral observation
involves watching a child and her parents in a natural setting, such as a
home or playground, to obtain information about forms and function
of behavior. This assessment method can be time-intensive because,
ideally, we want to watch a child long enough to fully understand the
mutism problem and what maintains the problem. In other words, we
want a good sample of behavior.
Observing a child with selective mutism or reluctance to speak does
not necessarily have to be complicated given what is usually a limited
amount of behavior to watch. If possible, you should observe the child
at home, in two or three public situations, and in various situations at
school. Conducting behavioral observations at a child’s home and in
public situations obviously requires much of your time and energy, but
the information will go a long way toward deciding how and where to
target your intervention approach. You may see, for example, that a
child physically withdraws or shrinks when someone tries to speak to
him—this may indicate some social anxiety. Or you may observe a child
throw a temper tantrum or scowl when verbally addressed, praised, or
asked to do something—this may indicate some oppositional behavior.
If you can secure parental consent and conduct a behavioral obser-
vation of a child at home, then watch for the following:
• Whether and how the child interacts with people she knows well,
such as parents, siblings, and relatives who often visit the home (e.g.,
during games, mealtime, preparations for school).
• Whether other family members, especially older siblings, tend to
dominate conversations within the home, thus providing little room
for the child to speak.
• Family communications and dynamics such as conflict.

• What language is primarily spoken in the home.
• Whether the child is expected to answer the telephone or door and
if the child avoids such activities.
• Whether the child appears to have any communication problem or
developmental delay when speaking or otherwise engaging in
adaptive behaviors.
• Whether the child is disturbed by your presence in the home.
If you can conduct behavioral observations of a child in public situ-
ations, then watch for the following:
• The child’s interactions with parents and other family members.
• The child’s interactions with strangers such as waiters or clerks.
• Compensatory behaviors.
• How parents and others respond when a child fails to speak (e.g.,
accommodations, reprimands, ignoring).
• Whether and how parents expect or command a child to speak.
If you can conduct behavioral observations of a child at school,
which is strongly recommended, then watch for the following:
• Parent–child interactions before, during, and after school.
• Teacher–child interactions in class and unstructured settings such as
the playground.
• Peer–child interactions in class and unstructured settings such as the
playground, including if and how peers help convey information to
others for the child.
• Compensatory behaviors.
• Whether the child’s level of speaking behavior differs across
situations (e.g., playground versus classroom).
• Whether the child is willing to speak to a parent to convey
information to people at school.
• Specific social or evaluative situations avoided by the child.
• Threats or other problems that may lead to a legitimate reluctance
to speak.
• The child’s performance in academic, social, music/art, and athletic
tasks.
• Behavior that may indicate anxiety, oppositional behavior, or
communication problems.
• School refusal behavior.
You may be in a situation where extensive behavioral observations

such as these are not feasible. If so, then I recommend observing key
behaviors in parents and a child as you interview them in your office.
Children who are nervous or upset in this situation may have consider-
able social anxiety. Other children cling tightly to parents and may have
considerable separation anxiety or attention-seeking behavior. Still
other children show oppositional behavior because they wish to main-
tain the “status quo” of not speaking in school. I also recommend
observing how much a child can be coaxed to speak in various situa-
tions at school. This information will help you determine at what point
intervention can begin.
No “cookbook” strategy exists to indicate exactly what observed
behaviors reveal a particular function of selective mutism. You must use
your best judgment and supplement your observations with informa-
tion from other methods described in this chapter. Still, I strongly rec-
ommend that you watch for aspects of social anxiety, oppositional
behavior, communication problems, attention-seeking behavior, com-
pensatory behaviors, and other key features of selective mutism
described in this chapter and in Chapter 1.
Reviewing Records
I recommend reviewing a child’s attendance, academic, and other

school-based records to note whether selective mutism has resulted in
additional problems. As mentioned, selective mutism can be severe
enough to lead to school refusal behavior, can interfere with academic
functioning if verbal participation is required, and can preclude attempts
at formal testing. Most children with selective mutism are fairly young,
however, so discussions with parents and teachers as well as behavioral
observations may have already covered these areas.
Putting the Assessment Information Together
This chapter has discussed many different ways to collect information

about a child with selective mutism or reluctance to speak. Putting
all of this information together, however, can be a bit of a challenge.
Once you have conducted as thorough an assessment as possible, look

for patterns of behavior among your data. For example, are parent
reports and your observations of behavior consistent? Does the child’s
failure to speak occur in most situations, as might be expected for a case
of selective mutism?
As you search for patterns in your data, form an opinion about
what maintains a child’s selective mutism. Concentrate on the main
reasons for selective mutism described in this chapter and in Chapter 1.
Consider the possibility as well, especially in more chronic cases, that a
child refuses to speak for more than one reason (e.g., anxiety and a
communication problem). As you form this opinion, talk again to par-
ents, teachers, and knowledgeable others about your hypothesis and see
if they agree.
You may find at this point that the picture of a child’s selective
mutism is unclear. This may indicate that people cannot supply you
with good information because they are not sure what is happening.
Recall as well that some parents may not believe their child has a prob-
lem. In other cases, parents disagree with one another or parents and
children disagree about the forms and function of selective mutism. In
these cases, you will have to consider the preponderance of evidence in
one direction or another. In addition, your own behavioral observa-
tions will become more critical in these kinds of cases.
Once the assessment process is as complete as possible, meet with a
child’s parents and fully explain your thinking. Provide specific exam-
ples of how a child’s behavior is maintained over time as well as evi-
dence of social anxiety, oppositional behavior, communication
problems, or other factors that seem to influence the child’s unwilling-
ness to speak. Encourage parents to challenge your findings, but pro-
vide as much evidence for your opinion as possible.
Finally, provide parents with a rationale for the intervention you
decide to choose. If a child’s selective mutism is anxiety-based, then
point out how an anxiety management strategy might be helpful (see
Chapters 3 and 4). If a child’s selective mutism seems related to oppo-
sitional behavior, then point out how incentives and disincentives may
be useful (see Chapter 5). If a child’s selective mutism seems related to
communication or developmental problems, then point out how a
school-based academic program may be helpful (see Chapter 6). If a
child’s selective mutism or reluctance to speak seems related to other
special circumstances such as trauma, depression, or family issues, then
discuss these at length and propose an appropriate remediation plan.

Ask parents to commit to whatever strategy you outline and fully answer
their questions.
Assessing a child’s forms and function of selective mutism can be ardu-

ous, but it is extremely important. In fact, the assessment process should
continue throughout your intervention and even beyond. Indeed,
extensive monitoring of a child’s frequency and audibility of speech
should remain intact indefinitely in cases of selective mutism because
slips and relapse can happen (see Chapter 7). This chapter provided
you with a general framework and some tools for assessing youths with
selective mutism and reluctance to speak, but you must use an approach
that is feasible within your particular setting. Even so, focusing on the
daily “nuts and bolts” of a child’s behavior is critical.
The next two chapters (Chapters 3 and 4) are devoted to exposure-
based practice for children whose selective mutism or reluctance to
speak seems related to social anxiety, which is the case for most of these
children. Chapter 3 focuses on home-based intervention procedures
and includes discussions of hierarchy development, relaxation and
breathing training, specific exposures, and shaping and prompting.
Chapter 4 focuses on community- and school-based intervention pro-
cedures and includes further discussions of exposure-based practice,
stimulus fading, self-modeling, social skills training, and cognitive
work, among other topics.
3
Exposure-Based Practice:
Home Setting
Chase is a 7-year-old boy who rarely speaks at school and even

then only whispers quietly to others. His parents are surprised by
this behavior because Chase speaks well at home with his older
brothers. Chase is now in second grade and still cannot answer
questions in class or ask the teacher for help. His grades are average
but could be higher if he participated more in academic activities
such as the class spelling bee and multiplication teams. He also
struggles in music because some verbal repetition of rhythmic
patterns is required. Chase clearly seems anxious in these situations,
avoiding eye contact and trembling, and an assessment has revealed
substantial nervousness before others he does not know well.
Ling is a 9-year-old girl in fourth grade who is quite reluctant to

interact with others. She moved to this school from South Korea
2 years ago and remains extremely shy and reclusive around others.
Ling does speak English well but often keeps her head down in
class and rarely speaks, though she does run around with classmates
on the playground. Ling’s parents say their daughter seems fine at
home and is “appropriately” quiet in public places. Ling will speak
on the telephone to people from school but not in person. Her
teacher says that Ling seems “petrified” at school, sometimes tearful
in class, and is usually the first to leave. An assessment revealed
substantial social and evaluative anxiety on Ling’s part.
R ecall from Chapters 1 and 2 that social anxiety is a key feature

of many cases of selective mutism and reluctance to speak. Chase
and Ling appear to have aspects of social anxiety such as avoidance,
52
Exposure-Based Practice: Home Setting 53
trembling, and tearfulness. A key task for you when addressing these
kinds of cases will be to help a child lower anxiety to a manageable
level, become more comfortable in speaking situations, and speak more
audibly and frequently in these situations. Speaking situations primar-
ily involve home, community, and school settings. The key interven-
tion to accomplish these goals will be exposure-based practice, in which
a child is required to say words in gradually but increasingly difficult or
anxiety-provoking situations.
This chapter focuses on exposure-based practice and other tech-
niques in home situations. Chapter 4 discusses exposure-based practice
and other techniques in community and school settings. Although you
may not be able to conduct intervention in a child’s home or in com-
munity settings, doing so may improve the prognosis for a particular
child. Speaking at school is usually the most difficult task for many
children with selective mutism. Developing rapport and a history of
speaking at home and in public settings often ease the intervention
process at school.
If you feel a school-based intervention is the only available option
to you, then you will have to emphasize the procedures described in
Chapter 4. You may wish to review this chapter, however, because of its
coverage of anxiety, rapport building, and key aspects of intervention in
this population. At a minimum, the procedures mentioned in this
chapter can be conveyed to parents so that they can practice them at
home. The following section provides an overview of anxiety, exposure-
based practice, and consultation with parents and the child.
Overview of Anxiety
To best implement the interventions discussed in this chapter and the

next chapter, it is necessary to understand the different aspects of anxi-
ety and how exposure-based practice is designed to work. Anxiety refers
to worry, uneasiness, discomfort, nervousness, dread, or apprehensive-
ness about something; in this case speaking before others in a clear and
audible voice. Children may show anxiety or distress in different ways,
such as crying, withdrawal, clinging, tantrums, irritability, restlessness,
and trembling.
Anxiety is composed of three main parts. One part of anxiety is

physical feelings of distress such as aches, trembling, shaking, “butterflies”
in the stomach, and shortness of breath or hyperventilation (breathing
too quickly). Recall that Chase seemed to have some physical aspects of
anxiety and that Ling was tearful in class. A second part of anxiety is
uncomfortable thoughts or worries a child may have, especially about
something bad happening. Anxious children are often apprehensive,
and children with selective mutism may have concerns that others will
react negatively in some way to their voice or to what they say.
A third part of anxiety is a behavioral component, or what a child
does when anxious. Many anxious children avoid situations or withdraw
from people so they can reduce or eliminate anxious feelings. Chase
withdrew from participation in the class spelling bee, for example.
Children with selective mutism often avoid speaking to others or attend-
ing events that require extensive social interaction. Such avoidance is
often designed to reduce anxious feelings––think of someone who is
terrified of the dentist and then cancels a scheduled appointment and
feels great relief. Such relief rewards the avoidant behavior, which is
likely to be repeated in the future. Some children with selective mutism
may not speak in order to reduce the physical aspects of anxiety.
Recall from Chapter 1 that many children with selective mutism dis-
play the first and third aspects of anxiety––physical feelings of distress and
avoidance of speaking. Some may have uncomfortable thoughts or wor-
ries about speaking, but young children, especially those with selective
mutism, typically do not express these thoughts. Some of these thoughts
may become apparent as a child begins to speak more frequently, so
addressing these thoughts later in the intervention process may be a good
idea (more information on this is provided later in this chapter).
Recall also that social anxiety or failure to speak on the part of a
child with selective mutism must not be the result of a legitimate threat
at home, school, or elsewhere. Children who are silent to avoid mal-
treatment, who are intimidated by peers at school, or who are bullied
or otherwise threatened by classmates will not respond well to the expo-
sure-based techniques described in this chapter or the next chapter.
Instead, the threat must be removed prior to your intervention. Some
children will continue to have difficulty after a threat is removed, so
exposure-based practice may then be more appropriate. The following
is an overview of exposure-based practice.
Overview of Exposure-Based Practice
Recall from Chapter 1 that exposure-based practice refers to a collec-

tion of techniques that requires a child to say words in gradually but
increasingly difficult or anxiety-provoking situations. Exposure-based
practice is designed to help a child replace anxious feelings in a specific
situation with more relaxed feelings. In addition, exposure-based prac-
tice is designed to increase a child’s self-efficacy by gradually building
her ability to speak clearly and audibly in different situations. Once a
child becomes comfortable speaking in one situation, this ability can be
generalized to another, more difficult situation. This process continues
until the child can speak well in all situations.
Exposure-based practice occurs along a hierarchy of situations that
range from least to most anxiety-provoking in nature (or least to most
difficult). Most children with selective mutism can speak fairly well at
home, with low anxiety, so intervention often begins here. A school-
based mental health professional may begin by speaking with the child
at home and then gradually extend this process to other situations such
as community settings. The process can continue over time to include
various school-related situations as well. Exposure-based practice can
also involve a hierarchy whereby a child mouths words, then whispers
words, then speaks words softly, and then speaks words with full volume
in these situations.
Exposure-based practice is sometimes combined with methods to
help a child reduce physical aspects of anxiety. Recall from Chapter 1
that relaxation training and breathing retraining may be used to help
children manage physical aspects of their anxiety. Some children
respond to these relaxation exercises quite well and others do not, but
the techniques are portable and are easily learned in a nonverbal manner.
A child may practice the relaxation techniques as he is exposed to each
speaking item on the hierarchy.
Over time, exposure-based practice should help a child decrease
social anxiety and increase her ability to speak more frequently and
audibly in various situations. Exposure-based practice thus helps you
address two main components of anxiety: the physical feelings of dis-
tress and the avoidance of speaking. As mentioned, cognitive or think-
ing aspects of anxiety can be addressed later in the process of
exposure-based practice.
Consultation with Parents and the Child
Conduct a detailed consultation with the parents and the child (if
possible) regarding your assessment findings, a description of anxiety,
and a rationale for exposure-based practice. When discussing your
assessment findings, concentrate on behavioral patterns you have found
in the data (see Chapter 2). If you have determined that a child’s selec-
tive mutism relates closely to social anxiety, then focus on which aspects
of questionnaires, worksheets, observations, or other assessment data
support your claim.
You may wish to discuss particular anxiety sequences that seem most
relevant to a child. Concentrate on multiple, specific, and recent exam-
ples from the child’s behavior. Consider Reginald’s case, for example:
Reginald is an 8-year-old boy who has many concerns about

attending school and speaking to others at school. His mother
says Reginald seems irritable and shaky in the morning before
school and reportedly has stomachaches and feels sick on some
days. She drives her son to the playground before school, at which
time Reginald clings to her and cries softly. Reginald does enter
class after some reluctance but will not speak to teachers or peers
at school. He appears nervous in class, and an assessment reveals
several aspects of social anxiety, especially around people Reginald
does not know well. He has asked his mother to place him in a
home schooling program.
Reginald’s sequence of anxiety appears to begin with physical feel-

ings such as shakiness, stomachaches, and irritability. For many chil-
dren, these physical feelings are quite uncomfortable and naturally lead
to behaviors designed to reduce them. For Reginald, clinging to his
mother, subtle school refusal behavior, the desire to be home-schooled,
and of course failure to speak in class represent behavioral aspects of his
anxiety (see Fig. 3.1). Reginald may have cognitive aspects of anxiety as
well, such as those listed in Figure 3.1, but again you may not be able
to access these at this early point in the intervention.
A child’s anxiety sequence can be illustrated and presented to par-
ents and the child for review. You should encourage the child and par-
ents to disagree with you if their observations differ radically from yours.
If necessary, collect additional information from family members to
modify your view of the child’s anxiety sequence. Most importantly,
Physical component Shakiness

of Reginald’s and stomach
distress pain;
irritability;
feeling sick
Possible cognitive I don’t want

component of to go to
Reginald’s distress school; I
don’t want to
talk to people
there; I hate
being in class
Behavioral Reluctant to
component of go to school;
Reginald’s distress not speaking;
crying; wants
home
schooling
Figure 3.1. Illustration of Reginald’s sequence of anxiety.
be sure all relevant family members fully understand the sequence you
outlined because the sequence will serve as the rationale for the inter-
vention you will propose. Specifically, you will recommend to family
members that each component of the child’s anxiety––particularly
physical and behavioral components––be addressed so the child can
speak fully in all situations. Use this sequence to convince family mem-
bers to address each aspect of anxiety and encourage family members to
commit to a plan of action.
You should also convey to family members the need to practice all
interventions described in this chapter. The analogy I commonly give
to children and parents is that managing anxiety involves learning a

new skill. Ask the parents to give you an example of a skill the child has
recently learned, such as riding a bicycle or playing a song on the piano
(the child may also communicate a recently acquired skill via writing or
whispering to parents). Ask the family members to describe the learn-
ing process, which surely required some adult help at the beginning as
well as some pratfalls. With practice, however, the child was able to
complete the skill more independently. The same is true for anxiety
management. Initially, speaking to others and managing upsetting feel-
ings will be difficult. With practice, however, speaking to others will
become much easier.
Once everyone is on the same page, outline the expected course
and timeline of your intervention. The general course of intervention
will include hierarchy development (discussed next), relaxation train-
ing and breathing retraining, and home-based exposures. Home-based
exposures involve requiring the child to interact with you in his home
at various levels such as whispering, using soft voice, and using full
volume voice. Later exposures will involve community- and school-
based settings (Chapter 4).
The timeline of your intervention is hard to predict––some cases
are resolved in just a few weeks, some take several months, and some
require very intense intervention for an extended period of time.
Explain to parents and the child that the intervention will require sub-
stantial effort on their part but that frequent practice generally leads to
quicker results. The intervention will likely last at least several weeks
and possibly several months. We have noticed in many of our cases,
however, that once a child begins speaking clearly in one situation,
speech quickly generalizes to other situations. Of course, your case will
be affected by many different variables such as parent motivation, how
often you can visit the home, other behavior problems in the child, and
teacher willingness to help implement the exposure-based procedures
(see the special issues section in Chapter 7).
Developing a Hierarchy
A key first step in exposure-based practice is developing a hierarchy. A

hierarchy is a list of items that range from least to most anxiety-provoking
or least to most difficult for a child to speak audibly. Hierarchies are
important for structuring the exposure-based process and provide you,

parents, teachers, and the child with a “roadmap” for how treatment
will progress and what the end stage will look like. Hierarchies typically
begin with relatively easy tasks such as asking a child to speak to some-
one in his bedroom or in another area of the home. As the intervention
continues, greater expectations are gradually placed on the child to
speak in more difficult situations. As mentioned, hierarchies can also
involve types of speech, such as mouthing words, whispering, speaking
softly, and speaking with full volume.
Let us consider Austin’s case and then develop a sample hierarchy.
Austin is a 6-year-old boy in first grade who has never spoken
in school. He spoke rarely in an academic preschool but his
parents simply considered their son to be shy. Austin speaks well
at home with his older brother and younger sister but relies on
his parents to communicate for him in public places. Austin will
speak softly to others on the telephone but only for 30 seconds or
so. Austin’s teacher says that Austin does interact to some extent
with classmates on the playground but that he stays by himself in
class. An assessment by the school psychologist revealed normal
intelligence and achievement functioning for Austin but also a
diagnosis of selective mutism. Some anxiety features were also
noted. For example, Austin seems to shake and lowers his head
when others try to speak to him.
Austin would seem to be a good candidate for exposure-based prac-

tice because his selective mutism appears to contain elements of social
anxiety. Developing a hierarchy for Austin should involve input from
his parents and teachers and possibly from Austin himself. Items on the
hierarchy should start in situations where Austin is relatively comfort-
able and will speak to others, such as home. A sample hierarchy for
Austin is shown in Figure 3.2.
You can see that Austin’s least difficult items are at the bottom of
the hierarchy and his most difficult items are at the top of the hierarchy.
This is only a sample. You will have to design your own hierarchy for
the child you are addressing, which may or may not include these steps.
In addition, some of these sample steps must be subdivided for some
children. A child may have great difficulty making the transition from
(1) speaking to a school official in a public place and (2) speaking to the
official at school. In this case, smaller steps may need to be added, such
Anxiety Avoidance
Speaking situations Rating Rating
1. Reading aloud to all classmates and the teacher or

engaging in show-and-tell 10 10
2. Speaking to the teacher in the classroom, such as asking
or answering a question or requesting help 9 9
3. Speaking to peers in the classroom during small group
activities or during free time as appropriate 8 9
4. Speaking to a school official in Austin’s classroom with all
classmates present plus the teacher 8 8
5. Speaking to a school official in Austin’s classroom with ten
6. Speaking to a school official in Austin’s classroom with
five classmates present plus the teacher 7 7
two friends and the teacher sitting at his or her desk 6 6
two friends on the other side of the room 6 5
9. Speaking to a school official in Austin’s empty classroom 4 4
10. Speaking to a school official in his or her school office 3 4
11. Speaking in a public place to a clerk or waiter, such as
ordering food or asking for directions or time 4 3
12. Speaking in a public place to a school official without
family members present 3 3
13. Speaking in a public place to a school official with
family members present 3 2
14. Speaking at home in person with a school official 2 2
15. Speaking at home on the telephone with a school official 1 1
Figure 3.2. Sample hierarchy for Austin’s speaking behavior.
as speaking to the school official in the school parking lot or school

entrance prior to speaking in the office.
Items from the hierarchy should come naturally from your assess-
ment, but work closely with parents and teachers to finalize and fine-
tune the hierarchy. Ask parents, teachers, and the child to supply ratings
of anxiety and avoidance to each hierarchy item if possible (see Fig. 3.2).
On a 0– 10 scale, where 0 = none and 10 = an extreme amount, try to
glean average ratings of the child’s anxiety and degree of avoidance for
each hierarchy item. Doing so will help you organize and prioritize the
items. If this is not possible or workable, then simply consult with
parents and teachers to generally organize the hierarchy items from
least to most difficult. In some cases, you may have to develop a sample
hierarchy yourself for a particular child and present it to the parents for
review. If so, the hierarchy presented for Austin could serve as a basic
template.
Austin’s hierarchy could also contain speaking steps within each item.
These steps could involve aspects of speech that range from mouthing
to whispering to soft speech to full-volume speech. Consider, for example,
the item surrounding speaking to you at the child’s home. In this case,
initial speaking could simply involve mouthing words in an effort to
communicate. Subsequent sessions with the child could involve asking
him to gently whisper in your ear or, at a minimum, to speak to some-
one else in an effort to communicate with you. Greater expectations
are then placed on the child for each session. Austin may eventually be
required to whisper softly in your ear, perhaps even just a word or two,
and later whisper more words or two or three sentences. After that,
Austin would be expected to speak softly to you and eventually speak
frequently and audibly as he does with his parents and siblings. An
example of this mini-hierarchy for this item is illustrated in Figure 3.3.
Be sure that all parties agree to the hierarchy before proceeding.
Parents and teachers should be fully aware of what the hierarchy
looks like and agree to provide support for the exposure-based practice
More difficult
1. Speaking all words audibly and clearly to the school official ↑
2. Speaking most words audibly and clearly to the school official ↑
3. Speaking 1 or 2 words audibly and clearly to the school official ↑
4. Speaking all words softly to the school official ↑
5. Speaking most words softly to the school official ↑
6. Speaking 1 or 2 words softly to the school official ↑
7. Whispering all words to the school official ↑
8. Whispering most words to the school official ↑
9. Whispering 1 or 2 words to the school official ↑
10. Whispering to others in the presence of the school official ↑
11. Communicating vocally but not verbally, such as grunting, ↑
making high-pitched sounds, or using incomplete words such ↑
as “eh” for yes and “un” for no ↑
12. Communicating nonverbally but mouthing words or phrases ↑
such as “hello” or “please” ↑
13. Communicating nonverbally or without mouthing words or ↑
phrases (e.g., writing words in the air, pointing, gesturing) ↑
14. Communicating by writing or drawing on paper ↑
Less difficult
Figure 3.3. Sample minihierarchy for Austin’s speaking behavior to

a school official at home.
to come. Children can also be made aware of the hierarchy, though

their input and understanding is not as necessary. Also keep in mind
that the hierarchy is fluid, meaning it could change as the intervention
proceeds. You may find that you will need to (1) add steps to the hier-
archy, such as those smaller steps described previously, (2) change the
hierarchy based on how the child is responding and whether family-
based changes or other changes occur, and (3) skip steps if the child is
progressing well. Regarding the latter, some children respond quickly
to exposure-based practice and may not require extensive practice of
some steps on the hierarchy.
Once the hierarchy has been developed and sanctioned by every-
one, a good next task is to teach the child to relax. Methods of relax-
ation training and breathing retraining are described next. These
relaxation exercises are also a good way for you to help establish rapport
with a child with selective mutism. The techniques can be taught with-
out the need for verbalizations on the child’s part and allow you and the
child to get to know each other a bit better.
Breathing Retraining and Relaxation Training
Recall that many children with selective mutism and reluctance to

speak have physical aspects of anxiety that need to be reduced. These
physical feelings often trigger distressing thoughts and avoidance behav-
iors such as failure to speak. Therefore, helping a child control her
physical feelings of anxiety is important. Different methods of helping
a child control physical feelings are available, but only the most feasible,
portable, and time-efficient are presented here. Two methods in par-
ticular involve managing one’s breathing and engaging in progressive
muscle relaxation.
Breathing
A simple way to help children reduce physical feelings of distress is to

teach them to breathe correctly. Many children experience shortness of
breath, breathe shallowly, or hyperventilate when upset. Doing so actu-
ally makes the feeling of anxiety worse, so helping a child regulate
breathing is important. Have the child sit before you in a comfortable
position. Then ask the child to breathe in slowly through the nose (with
mouth closed) and breathe out slowly through the mouth. As the child does
so, encourage him to breathe deeply into the diaphragm (between the
abdomen and chest and just below the rib cage). The child may need to
push two fingers into the diaphragm to experience the sensation of a
full, deep breath. The child can then breathe slowly out of his mouth.
Parents may even join the process to help their child practice at home.
For younger children such as Austin, you may wish to create an
image during the breathing technique. Austin could imagine blowing
up a tire or pretend he is a large, floating balloon. As Austin breathes in,
he can imagine filling up with fuel and energy. As he breathes out, he
can imagine losing fuel or energy (or tension). The child must come to
understand the difference between feeling tense when the lungs are full
of air and feeling more relaxed after breathing out. The following
breathing script adapted from Kearney and Albano (2007) may be
helpful:
Pretend you are a hot air balloon. When you breathe in, you are filling
the balloon with air so it can go anywhere you want. Breathe in
through your nose like this (show for your child). Breathe slowly and
deeply––try to breathe in a lot of air! Now breathe out slowly through
your mouth like air leaving a balloon. Count slowly in your head as
you breathe out…1…2…3…4…5. Let’s try this again (practice at
least three times).
Key advantages of the breathing method are its ease, brevity, and
portability. The child can use this method in different stressful situa-
tions and usually without drawing the attention of others. I recom-
mend that a child practice this breathing method at least three times
per day for a few minutes at a time. In addition, the child should prac-
tice in the morning before school and during particularly stressful times
at school. Some children benefit as well by practicing this technique
whenever they are around other people and an expectation for poten-
tially speaking is present. For example, a child could use the breathing
technique prior to and during a church service.
Muscle Relaxation
Another method of helping a child reduce physical feelings of anxiety

is progressive muscle relaxation (PMR). Youths such as Austin are
usually quite tense in different areas of their body, especially in the

shoulders, face, and stomach. Different methods of muscle relaxation
are available, but a preferred one is a tension-release method in which
a child physically tenses, holds, and then releases a specific muscle
group. For example, a child may ball his hand into a fist, squeeze as
tightly as possible and hold the tension for 10 seconds, and then sud-
denly release the grip (try it). When this is done two or three times in a
row, people generally report feelings of warmth in the muscle as well as
relaxation.
Muscle relaxation via tension-release can be done in different ways.
When I work with children, I use a relaxation script that covers most
areas of the body. I first ask the child to sit in a comfortable position
and close her eyes. I then read the script slowly and ask the child to
participate. You may wish to use the following script adapted from
Ollendick and Cerny (1981) with a child:
(Speaking slowly and in a low voice) Okay, sit down, try to relax, and
close your eyes. Try to make your body droopy and floppy, as if you are
a wet towel. Take your right hand and squeeze it as hard as you can.
Hold it tight! (Wait 5 to 10 seconds.) Now let go quickly. Good job.
Let’s do that again. Take your right hand and squeeze it as hard as you
can. Hold it. (Wait 5 to 10 seconds.) Now let go quickly. See how that
feels. Nice and warm and loose. Now take your left hand and squeeze it
as hard as you can. Hold it tight! (Wait 5 to 10 seconds.) Now let go
quickly. Good job. Let’s do that again. Take your left hand and squeeze
it as hard as you can. Hold it. (Wait 5 to 10 seconds.) Now let go
quickly. See how that feels. Nice and warm and loose.
Now shrug your shoulders hard and push them up to your ears.
Make your shoulders really tight. Hold them there. (Wait 5 to 10
seconds.) Now let go quickly. Great. Let’s do that again. Shrug
your shoulders hard and push them up to your ears. Make your
shoulders really tight. Hold them there. (Wait 5 to 10 seconds.)
Now let go quickly. Great job.
Now scrunch up your face as much as you can. Make your face
seem really small and tight. Now hold it there. (Wait 5 to 10
seconds.) Now let your face go droopy. Good. Let’s do that again.
Scrunch up your face as much as you can. Make your face seem
really small and tight. Now hold it there. (Wait 5 to 10 seconds.)
Now let your face go droopy. Good job.
Now I want you to bite down real hard with your teeth. Make your
jaw really tight. Hold it there. (Wait 5 to 10 seconds.) Now open
your jaw. How does that feel? Good. Let’s try that again. Bite down
real hard with your teeth. Make your jaw really tight. Hold it there.
(Wait 5 to 10 seconds.) Now open your jaw. Try to make it as loose
as you can. Good practicing!
Let’s go to your stomach now. Bring in your stomach as much as

you can––make it real tight! Press it against your backbone. Now
hold it there. (Wait 5 to 10 seconds.) Now let go quickly. That feels
better. Let’s try that again. Bring in your stomach as much as you
can––make it real tight! Press it against your backbone. Now hold it
there. (Wait 5 to 10 seconds.) Now let go quickly. Great job.
Okay, one more. Push your feet onto the floor real hard so your legs
feel really tight. Push hard! Now hold it. (Wait 5 to 10 seconds.)
Now relax your legs. Shake them a little. Let’s try that again. Push
your feet onto the floor real hard so your legs feel really tight. Push
hard! Now hold it. (Wait 5 to 10 seconds.) Now relax your legs.
Shake them a little. Good practicing!
Now try to make your whole body really droopy––pretend you are
a wet towel! Relax your whole body and see how nice that feels. You
did a great job relaxing. Okay, open your eyes.
You may wish to audiotape this script so a child can play it back
when practicing. I recommend that a child practice this script at least
twice per day in the beginning of your intervention and then once or
twice per day as he becomes more adept and independent. In addition,
the child could practice the method during times of the day when she
feels most distressed. Austin could practice relaxation as he speaks with
you at school or in his home. The idea is to replace anxious feelings with
more relaxed ones so the child may feel more comfortable speaking.
Other Recommendations Regarding

Relaxation Training
Because of time constraints, you may wish to teach a child relaxation

techniques immediately after developing the anxiety hierarchy (see
earlier section). In addition, you may wish to teach breathing and
muscle relaxation at one time so the child can use one or both immedi-
ately. Some children prefer one approach over the other, which is fine.
The important thing is that a child practice and use the techniques as
soon as possible.
In situations where time is highly constrained, using breathing and
partial muscle relaxation may be preferred. In partial muscle relaxation,
you or the child chooses one or two areas of the child’s body that are
particularly tense and the child practices the tension-release method
only on those areas. Austin, for example, may say his shoulders and stom-
ach are tensest when asked to speak. To save time, therefore, you could
concentrate your efforts on these two areas only.
If time is very short, then you could recommend commercially
available breathing and relaxation tapes. In addition, you could help a
child practice relaxation techniques during times you know he is par-
ticularly distressed at school. Helping a child relax in your office imme-
diately before class, for example, might be feasible. You may also need
to solicit the help of teachers who can take an anxious child aside and
help her practice relaxing.
Home Visits and Exposure-Based Practice
Now that you have developed a hierarchy and helped a child with the
relaxation training exercises, the real heart of the exposure-based prac-
tice begins. Most of your early exposures with a child will be conducted
within the child’s home, but there may be some preliminary exposures
you could do to ease this process. As mentioned, some children with
selective mutism or reluctance to speak will communicate to others as
long as they do not have to endure face-to-face contact. Your assess-
ment should indicate what these situations are, but common examples
include the following:
• Speaking on the telephone.
• Speaking to someone with a door or other obstruction in between.
• Speaking to someone from a far distance, such as across a
parking lot.
• Emailing or otherwise sending a video of yourself speaking to
someone.
• Communicating in nonverbal ways such as writing an email or
texting.
Recall that the first item on Austin’s hierarchy was speaking at home
on the telephone to a school official (you). The school official could
arrange times to speak to Austin on the telephone, preferably during
times when he is most relaxed, such as on the weekend or right after
dinner. The conversation could be kept to light topics such as current
school events, pets, dinner, and play activities. These conversations do
not have to last long––perhaps a few minutes or so. Intermittent praise
and gratitude should be provided to the child to reward the speaking
behavior.
Such exposures can be quite helpful for establishing rapport and
setting the stage for the next set of home-based exposures. These
conversations or communications can serve as a springboard for
conversation within the home. For example, you may ask the child to
show you his dogs that he described at length on the telephone. The
child could point, nod, or shake his head to yes–no questions, and
comply to requests to interact with the dogs in some way. Again, the
major goal here is to replace anxiety about speaking with a greater com-
fort level.
The first stage of face-to-face (in vivo) exposure-based practice is
best conducted within a child’s home where he feels most comfortable
and has a history of speaking well to others, albeit to those the child
knows well. Arrange with the parents a suitable time to spend 60–120
minutes at their home. Inform the parents that you will be interacting
with the child in his bedroom or another area of the house in which the
child and the parents feel most comfortable.
Try to arrange regular home visits as well––preferably once or twice
a week if possible. Some children and parents prefer a Saturday morn-
ing or other time of the week when they are not so rushed, so consider
their input on this issue. The child should be fully informed by you or
by his parents that you will be visiting and talking and playing with
him – no surprises. Parents should also convey the expectation to the
child that he is to interact with you at least nonverbally while you are
there. If the child refuses to do so, then specific contingencies should be
given (see Chapter 5).
I fully understand the difficulties, extensive resources, logistical and
safety issues, and administrative obstacles that may be associated with
home visits. I do strongly recommend home visits but understand that,
for some locales and circumstances, this is simply not feasible. If this is
the case, then emphasizing exposure-based practice in public or just
school-based situations (Chapter 4) may be necessary. If you can con-

duct home visits, then the following sections apply.
Initial Home Visits
Your initial set of home visits should be relatively unstructured and

carefree for the child. I recommend simply playing with the child either
by imitating what he is doing (e.g., building something out of blocks)
or by inviting him to play a game or draw together. In our experience,
most children are willing to do this, but some kids may require more
time and patience. Gently prompt the child to show you something he
is doing and encourage him to use nonverbal ways of communicating
such as pointing or gesturing. These nonverbal methods of communi-
cating will eventually be faded, but they are allowable for now. Try to
establish good eye contact with the child as well and smile at him.
Refer again to the sample mini-hierarchy developed earlier for
Austin (Fig. 3.3). Initial home visits may concentrate on the lower items
on this hierarchy: communicating by writing or drawing on paper,
communicating nonverbally, and communicating vocally but not ver-
bally. You can begin to encourage the child, as you play with him, to
communicate to you by writing words in the air, pointing, gesturing, or
via other nonverbal means. The child may already be doing this on his
own, so smiling and offering praise is a good idea. You can also encour-
age the child to communicate to you by using his mouth to form words
such as “hello,” “please,” and “bye.” You may wish to model this for the
child.
You should reward any vocal communications the child may
present such as grunting, high-pitched noises, or incomplete words.
These vocalizations will be extinguished later in your intervention, but
the sounds do give you the opportunity to praise the child’s voice and
his attempt to communicate at a rudimentary level. Tactics that often
work for my cases include using substantial humor to make kids laugh
out loud and asking kids to hum a favorite song. A child who engages
in regular vocalizations such as these at this level may verbalize quickly
in later sessions.
As you interact with the child, pay close attention to how he
responds to your presence. Does he seem tense and uncomfortable or
relaxed and nonchalant? If the child seems tense, offer to do the breath-
ing and muscle relaxation exercises you taught him earlier (if applicable).
Do not push the child to do so, but I have found that most kids are
willing to do the exercises. Gently praise the child for engaging in the
exercises and smile often. Be sure to thank the child for allowing you to
play with him and do the exercises together. Remember that the initial
home visits, perhaps two or three or so, are simply designed to help the
child acclimate to your presence in the home. You will hopefully become
someone the child is comfortable being around, especially because you
are being associated with a comfortable setting (child’s house or bed-
room). Remember that the purpose of exposure-based practice is to
replace tense or anxious feelings about communicating with more
relaxed feelings.
You may find during these initial home visits that feedback to the
parents is necessary as well. You may have to ask the parents, for exam-
ple, to avoid hovering around you and the child, quell siblings or other
noisy distractions in the home, or supply materials for play or drawing.
If parents do wish to observe from a distance, this is fine because it
allows you to serve as a good model for their later behavior with the
child (see Chapter 5). In particular, you will model how to talk to the
child without criticism or lecturing, how to gently encourage speech,
and how to praise speech appropriately.
As mentioned, you may need to devote two or three home visits
simply to interacting nonverbally with a child, but this timeline is not
set in stone. Some children, especially those simply reluctant to speak,
will acclimate to your presence quickly and may even speak to you in
the first session at home. Other children require more early home visits
to become comfortable with you, and that is fine. As noted earlier,
intervention for some children with selective mutism can last several
months.
Intermediate Home Visits
As the child appears to be more comfortable with your presence in the

home, you can begin to gradually increase expectations for speech.
Refer again to Figure 3.3 and items 4–10 on the hierarchy – these items
will constitute the bulk of your intermediate home visits. The main
goals of these visits are to help the child begin to whisper words and
phrases and then speak softly to you. This is where shaping and prompt-
ing, initially discussed in Chapter 1, become important. Recall that
shaping refers to reinforcing successive approximations of a desired
response, in this case more audible speech. Prompting refers to gently

prodding a child to use words to communicate, speak more articulately
and loudly, establish eye contact, and extend the duration of speech.
As you play and otherwise interact with the child, see if she will
respond to subtle prompts to whisper words. Such whispering can ini-
tially be low-key and indirect, such as asking the child to whisper some-
thing in a parent’s ear that the parent then conveys to you. This is
acceptable for now. Be sure to thank the child for communicating to
you and respond by speaking directly to her. If possible, have the child
extend the amount of information conveyed to a parent to simulate an
actual conversation. Be animated in your responses, such as laughing,
smiling, and otherwise injecting humor into the “conversation.”
Once the child is comfortable with this process, then shaping and
prompting can be used to help the child utilize speech directly toward
you. This part might be a little tricky. Be sure to tell the child that you
expect her to begin whispering to you directly but that she may choose
which words or phrases to use. The child may also be allowed to whis-
per softly in your ear, whisper with her head turned to the side, or
whisper to the floor. As this process continues and the child’s comfort
level grows, then you can gradually build eye contact, smiling, and
other social nuances.
One thing we commonly do to elicit whispers is to deliberately make
mistakes during games played with the child. Think of a game that
requires a roll of the dice and movement of a game piece, for example.
If you roll a “5” on the dice, you could move your piece the incorrect
number of spaces (e.g., 1 or 9 spaces––something obvious). Most young
children are quite attentive to the rules of the game and will become
annoyed by this kind of error. If the child is trying to nonverbally
convey a sense of unfair play, then “play dumb” and encourage the child
to say what she wants to. At this point, remind the child to use words
and that it is necessary to at least whisper to you what it is she wants to
say. Some children will pout or throw something, but ignore inappro-
priate behavior and simply continue playing the game as if nothing
happened. Following are some additional tactics you can use to try to
solicit whispers or beginning speech:
• Ask a child how a game is played. Many children are quite adept at
a certain game and are eager to share the rules, so take advantage of
this. Asking yes–no questions and receiving a verbal “yes” or “no”
response at this point is acceptable.
• Concentrate on topics of conversation a child is most willing and

eager to discuss, especially pets, siblings, and favorite foods, toys,
activities, and television shows.
• Have the child say what reward she would like for interacting with
you. You might bring stickers or candy and ask the child to indicate
which one she would like, contingent on verbal speech. The child at
this point cannot be allowed to simply point but must, at a
minimum, whisper in your ear which item she wants. Failure to do
so means no reward is given, and the child can be encouraged to try
harder during the next visit.
• Use puppets; ask the child to speak to the puppet rather than to you
directly, and have the “puppet” praise the child for speaking. You
will need to eventually fade the stimulus (puppet) in favor of having
the child speak directly to you.
• Alter your proximity and eye contact. Some children find it easier
to speak initially if your face is turned from them, if your eyes are
lowered, or if you sit on the other side of the room. You may also
choose to speak to the child only when looking at something else,
such as when you roll dice or flip a spinner for a game. Eye contact
can be gradually increased as the sessions continue.
• Make mistakes in your knowledge that the child may wish to try to
correct. For example, you could give the wrong name for the child’s
sibling or dog, say the child’s incorrect favorite color or game, or say
it is raining when actually it is sunny.
• To help increase audibility, blame the child’s inability to convey
speech adequately on your inability to hear her due to some
environmental stimulus such as an airplane flying overhead or
siblings making noise in another room. This allows you to absolve
the child of blame but, at the same time, prompt speech again at a
higher volume level.
Later Home Visits
Later home visits involve items at the top of a mini-hierarchy (see again
Fig. 3.3). These visits involve requiring the child to speak clearly and
audibly to you, beginning with one word, then several words, and then
all words. The goal of these later home visits is to reach a point where
you and the child can have positive, extensive, and clearly audible con-
versations. In addition, the child should be quite comfortable with
these conversations. Being able to converse freely with a child at this
point will be a strong lead-in to the more difficult exposures to come in

public and school settings.
Your conversations with a very young child––a 5-year-old for
example––will necessarily be quite brief. If the child can describe some
things to you, such as a picture she drew, that is fine. The conversation
could primarily involve the child speaking to you, but the conversation
should not be dominated by your speaking. Continue to practice the
relaxation and breathing exercises if applicable and reward the child
often––via praise or tangible rewards––for speaking to you. Continue
as well to model for the parents how speech is encouraged and prompted
(see also Chapter 5).
Later home visits should set the stage for community- and school-
based exposures (Chapter 4). During these visits you should remind the
child and the parents of the next steps on their hierarchy, such as going
to malls and restaurants and talking to people at school. Remind the
child and parents that this will be a gradual process and that practice is
required to learn new skills (e.g., anxiety management, social interac-
tions, using an audible voice). Be sure as well to express confidence that
the child can do these things given her progress and work during your
home visits.
This chapter focused on many of the initial intervention steps you may
need to address a child with selective mutism or reluctance to speak.
Chapter 4 covers various procedures to help a child speak in more chal-
lenging situations outside the home. These challenging situations
involve community-based settings such as malls and restaurants as well
as school-based settings such as the playground and classroom. As you
navigate these situations with a child, other supportive techniques will
be implemented. These include self-modeling, stimulus fading, and
social skills training, among others.
4
Exposure-Based Practice:
Community and School Settings
Avery is a 7-year-old girl who has been in second grade for

3 months but will not speak in school. She has attended her current
elementary school since the beginning of first grade but does not
speak to peers or teachers. Her parents say Avery seems like a shy
and normal child who speaks clearly and well at home. Avery’s
comments in public places, however, are limited and people usually
say they cannot hear what Avery says even when she does attempt
speech. Avery’s parents have resisted intervention in the past but
now recognize that their daughter’s failure to speak is affecting her
academic and social performance. An assessment indicated some
social and evaluative anxiety on Avery’s part. She does interact
nonverbally with children on the playground, but their games have
become more complicated and dependent on speech. Avery has
thus grown more socially withdrawn in the past several weeks.
R ecall from Chapter 3 that a key aspect of intervention for children

such as Avery with anxiety-based selective mutism or reluctance to
speak is exposure-based practice. Exposure-based practice refers to a
collection of techniques that requires a child to say words in gradually
but increasingly difficult or anxiety-provoking situations. Exposure-
based practice is often accompanied by relaxation training, hierarchy
development, and shaping and prompting to increase the frequency
and audibility of speech (Chapters 1 and 3).
This chapter focuses much more on exposure-based practice in
community and school situations. If you were able to conduct home
visits and exposures there (Chapter 3), then hopefully you have estab-
lished a good rapport and a speaking foundation with the child. If not,
then you may need to begin exposure-based practice at the community
73
setting level. Community settings include places such as malls, restau-

rants, parks, church events, and entertainment facilities.
If you were able to conduct home-based exposures, then the proce-
dures described in this chapter are a natural next step. If you were not
able to conduct home-based exposures, then I recommend establishing
good rapport with a child by meeting with him frequently in your office
or in a community setting where he feels comfortable. Some of the
procedures described in Chapter 3 can be modified and replicated in
your office, such as relaxation training, hierarchy development, and
telephone and play-based exposures. The goal of these office-based
interactions is to have the child become comfortable speaking with you,
learn how to relax, and replace anxiety in speaking situations with
greater comfort while increasing frequency and audibility of speech.
These interactions will hopefully set the stage as well for the community-
based exposures to follow.
This chapter outlines hierarchy development for community- and
school-based exposures, exposure-based practice in these settings, and
accompanying techniques such as self-modeling and stimulus fading.
Intervention strategies that can be used in conjunction with exposure-
based practice are also discussed. These strategies include social
skills training and cognitive intervention. Let us proceed next with
hierarchy development using Avery as our primary example through-
out the chapter.
Hierarchy Development
Recall that a hierarchy involves a list of speaking-related situations that

range from least to most anxiety-provoking or least to most difficult in
nature. Various hierarchies can be developed during exposure-based
practice, and hierarchies can include levels of speaking such as mouth-
ing, whispering, speaking softly, and speaking in a normal tone. Recall
from Chapter 3 that we designed a hierarchy for Austin that included
various situations and a mini-hierarchy that more specifically focused
on different expectations for speaking within the home.
We can use a similar approach for Avery. We want to focus on com-
munity and school settings, so it makes most sense to have two hierar-
chies. The first hierarchy can include public situations (see Fig. 4.1).
Avery’s parents indicated from their assessment that their daughter
Exposure-Based Practice: Community and School Settings 75
Anxiety Avoidance
Speaking situations* Rating Rating
1. Asking a stranger in a public place for the time or for directions 10 10

2. Using 2 or 3 sentences to order food from a waiter or clerk 9 9
3. Answering a question during Sunday School class 8 9
4. Speaking to several potential friends (unknown peers) at
soccer practice or a birthday party or other social event 8 8
5. Speaking to one potential friend (unknown peer) at soccer
practice or a birthday party or other social event 7 8
6. Greeting others (known and unknown) at church 7 7
7. Speaking to potential friends (unknown peers) at a park 6 6
8. Using one word to order ice cream from a clerk 6 5
9. Speaking to friends at soccer practice or a birthday party
or other social event 4 4
10. Speaking to parents and siblings at the mall 4 3
11. Speaking to parents and siblings at church 3 3
12. Speaking to neighborhood friends at a park 3 2
13. Speaking to neighborhood friends in your driveway 2 2
14. Speaking to parents in a public place such as a market 2 2
15. Answering the door or telephone at home 1 1
*Items may be divided as necessary into levels of voice volume such as mouthing
words, whispering, speaking softly, and speaking in a normal tone; items may be
reordered as necessary; items may be added or divided as necessary.
Figure 4.1. Sample hierarchy for Avery’s speaking behavior in

community settings.
commonly fails to speak in places they frequently visit. These include

restaurants, parks, malls, birthday parties, church, and other places
where Avery might be expected to interact with parents, siblings, peers,
family friends, or clerks. These public situations, and various levels of
speech within these situations, may comprise a good hierarchy.
You can see from Figure 4.1 that lower-level items generally involve
potentially easier tasks such as speaking within one’s home on the tele-
phone, speaking to parents and siblings in some public settings, and
speaking to neighborhood friends the child knows well in familiar situ-
ations such as their driveway or a nearby park. Middle items surround
forays into speaking with others using limited speech or in situations
such as church in which the child is slightly less comfortable. Higher
items surround more difficult tasks such as using more words (sen-
tences), speaking to people more independently, and speaking to people
the child does not know. Any item may be divided as necessary—Avery,
for example, might initially use just one sentence to order food from a
waiter instead of two or three sentences. This is perfectly acceptable as
long as she eventually completes the full hierarchy item (i.e., two or
three sentences).
The second hierarchy can include school situations and may rely
heavily on the hierarchy developed in Chapter 3 for Austin, with some
embellishments (see Fig. 4.2). Note that the classroom-based exposures
at the middle and top of the list (items 1–9) are the same—these hier-
archy steps are often essential when addressing kids with selective
mutism or reluctance to speak. The hierarchy steps near the lower part
of the list (items 10-15) are new and specific to Avery.
Many children with selective mutism are more willing to initially
speak to you in relatively quiet and familiar surroundings such as your
office or other settings outside the classroom. I strongly recommend
beginning your exposures away from the classroom, which has likely been
associated with significant anxiety for a child. Instead, begin exposures in
situations that generally cause the child less anxiety, such as the play-
ground, and especially areas in which no one is around. Once a child is
comfortable in these situations, you can ease him into the classroom and
gradually add others as he speaks. The sample hierarchy in Figure 4.2 is
Anxiety Avoidance
Speaking situations Rating Rating
1. Reading aloud to all classmates and the teacher or engaging

in show-and-tell 10 10
2. Speaking to the teacher in the classroom, such as asking or
answering a question or requesting help 9 9
3. Speaking to peers in the classroom during small group
activities or during free time as appropriate 8 9
4. Speaking to a school official in Avery’s classroom with all
5. Speaking to a school official in Avery’s classroom with
ten classmates present plus the teacher 7 8
five classmates present plus the teacher 7 7
two friends and the teacher sitting at his or her desk 6 6
two friends on the other side of the room 6 5
9. Speaking to a school official in Avery’s empty classroom 4 4
10. Speaking to a school official in the cafeteria with others present 4 3
11. Speaking to a school official in an empty school cafeteria 3 3
12. Speaking to a school official in the library with others present 3 2
13. Speaking to a school official in an empty school library 2 2
14. Speaking to a school official in his or her school office 3 4
15. Speaking to a school official on the playground at school 1 1
Figure 4.2. Sample hierarchy for Avery’s speaking behavior in

school settings.
a general one that could contain many more items specific to the needs
of a child, so feel free to add items as necessary and in conjunction with
your assessment findings.
Keep in mind that some kids will need to engage in nonverbal
interactions with peers and teachers before any verbalizing is possible.
Some children, for example, prefer to complete class projects with peers,
point or gesture to answer a teacher’s question, or write on the black-
board or complete some other task before the entire class before speaking
can be prompted. Other children have already done these things, albeit
nonverbally, and so exposures for speaking can occur sooner. Avery did
interact with her peers nonverbally but was starting to show some social
withdrawal. Prompting Avery to reengage her peers at least nonverbally
for now might be a good idea.
Note that the hierarchies in Figures 4.1 and 4.2 contain anxiety
and avoidance ratings that can come from one or more sources. If a
child can rank these items for you, then consider these rankings with
others received from parents, teachers, and yourself. If the child cannot
rank these items, which is often the case for younger children, then rely
on others’ reports or rank the items yourself based on assessment data.
In some cases, you will need to develop the hierarchy yourself and pres-
ent it to parents for review. In other cases, you may have little assess-
ment data on which to rely and may use the hierarchies presented here
as a general template for intervention.
Recall as well that mini-hierarchies can be designed to address voice
volume. Each step on the hierarchies in Figures 4.1 and 4.2 could
include smaller, subdivided steps that focus on mouthing words, whis-
pering, speaking softly, and speaking with normal voice volume.
Hierarchies are fluid entities, meaning frequent changes usually occur
during exposure-based practice. Some children become stuck on one
step and need considerable practice, and other children zip through
multiple hierarchy items in a short time. Be flexible in your approach
as you engage in exposure-based practice and understand that the
expected timeline could shift unexpectedly.
Exposure-Based Practice in Community Settings
Exposure-based practice in community settings can hopefully flow nat-

urally from home-based exposures discussed in Chapter 3. That is,
community exposures will involve your supervision and interaction

with the child, ongoing rapport development, prompts for speaking in
progressively more difficult situations, and continued practice of relax-
ation and breathing exercises. You should review with parents and the
child the rationale for exposure-based practice in community settings.
Again, the goal is to help the child feel more comfortable in these
settings and gradually increase the frequency and audibility of his
speech in less difficult and then more difficult situations. In addition,
the community-based exposures are to serve as practice for more diffi-
cult school-based exposures later on.
Initial Community-Based Exposures
Your first set of community exposures should be in fairly close proxim-

ity to the child’s house. The child at this point should be comfortable
speaking to you within his home, so a good first step is to have him talk
to you outside of his home. Examples include the backyard, courtyard,
driveway, or even a few steps from the front door. Most children will be
able to make this transition fairly easily, though you may need to
prompt some additional speech and volume and use some of the tactics
discussed in Chapter 3 (e.g., alter your proximity and eye contact, make
mistakes in your knowledge, blame the inability to hear the child on
environmental stimuli). Keep the conversations light, perhaps asking
the child to describe the neighborhood and what he commonly does
and with whom he interacts (e.g., neighborhood friends).
In conjunction with these conversations, have the child practice
answering the door or telephone, which is sometimes an easier step on
the hierarchy. The child should be familiar with you at this point, so
you can call him on the telephone for chats and practice coming to the
door, ringing the doorbell, greeting him, and providing him with feed-
back about what he can say, his volume level, and other relevant behav-
iors such as eye contact. Be sure to practice these tasks until the child
becomes proficient and seems at ease. Have the child practice relaxation
and breathing exercises (Chapter 3) as appropriate to reduce anxious
arousal.
Your next step in the community-based exposure process will be to
systematically approach each item on the child’s hierarchy. Refer again
to Figure 4.1. Initial steps on the hierarchy usually involve asking a
child to speak to people he knows well such as parents, but in situations
where he does not commonly speak such as a local market. The expo-
sures to follow will be somewhat structured, meaning you will conduct
the exposure with the parents, child, and relevant others such as friends
or other peers. Sometimes this requires effort with respect to schedul-
ing, so take advantage of normally occurring events. If parents shop for
groceries on Saturday afternoon, for example, then this would be a
good time for a naturally occurring exposure session.
Note that hierarchy item number 14 for Avery is “speaking to par-
ents in a public place such as a market.” For this exposure, explain to
parents and the child what is expected from everyone. You, at least one
parent, and the child will go to the market and shop for groceries (choose
a place that is well-known to the child). During the shopping experi-
ence, the child is expected to say at least one word to her parent—the
word can be any she chooses and can initially involve a whisper or
barely audible expression. The child must say the word to her parent
during the normal shopping time—no special time extensions should be
given. Speaking success should be met with praise and tangible rewards
and failure to speak should be met with admonishment and loss of
privilege (see Chapter 5). The child should be prompted for speech and
reminded of this obligation several times during the exposure. The
child can also practice relaxation and breathing exercises as needed.
This exposure may require several practices, many of which the
parents can accomplish on their own as homework assignments during
the week. You need not be present for all exposures. Once the child has
met the criterion for speaking one word, then expectations for speaking
in this setting should increase. The child should eventually be expected,
for example, to say a few audible words and later a few sentences to his
parents in the market. Be sure that parents carefully track the number
of words spoken (see forms in Chapter 2) and that consequences are
administered consistently (see Chapter 5).
Intermediate Community-Based Exposures
The next set of exposures on the child’s hierarchy can occur in similar
fashion. Avery’s next set of exposures involve talking to familiar neigh-
borhood friends near her house and at a park near her house. Some kids
want less formal supervision (i.e., less hovering) during these exposures,
so you or the parents can stand several feet away to monitor the child’s
progress. In some cases, you may find it beneficial to inform the friends
about what you are trying to do and encourage them to prompt the
child for speech. Again, expectations for speech can be initially low
(e.g., one word, whisper) but must progress to at least two or three
sentences of audible speech before moving to the next hierarchy item.
Your demeanor (and the demeanor of the parents) during these
exposures should be nonchalant, neutral, and matter-of-fact. Some kids
will balk at increasingly difficult exposures at this time, so use subtle
phrases such as “You can do it,” “You know what you need to do,” or
“You need to use your words.” Do not attend to disruptive, noncompli-
ant, or defiant behaviors. Instead, consequences for failing or refusing
to speak should be established previously, should be known to the child,
and should do your talking for you (or the parents) (see Chapter 5).
Do not criticize, lecture, berate, or adopt a negative tone with the child.
In addition, be patient and pleasant during these exposures, repeatedly
prompting the child to fulfill his speaking obligation for that day. I have
found that many kids with selective mutism eventually “wear down”
after an hour or two and fulfill their obligation during the exposure.
Middle items on Avery’s hierarchy also involve speaking to people
she knows well (parents, siblings, friends) in a wider array of settings
(church, mall, soccer practice, birthday party). The goal is to have the
child practice speaking in various situations to achieve a sense of self-
efficacy, manage anxiety appropriately, and receive praise and feedback
for speaking. Split the hierarchy items into two or three smaller steps if
necessary and continue to ask the child to describe how anxious she
feels. Continue to help the child practice relaxation and breathing tech-
niques to lower arousal.
These lower and middle items set the stage for the much more
difficult community-based exposures to come. Make sure the child is
proficient at these levels before proceeding. As mentioned earlier, the
timeline for these exposures may be several weeks or months, though
some children progress well and quickly. Trying to progress too quickly,
however, without adequate practice at this intermediate level, will
damage the chances for success in the even more difficult exposures
discussed next.
Later Community-Based Exposures
Higher items on the community-based exposure hierarchy generally

involve greater independence, discussions with less familiar people, and
speaking before a larger number of people. Refer again to Avery’s hier-

archy in Figure 4.1. As you engage in these more difficult exposures, try
to make them as natural as possible. That is, the exposures can be less
contrived (such as the market) and blended more into situations the
child normally encounters during the week. Family members who reg-
ularly attend church, for example, often meet and greet people before
and after the service. Such interactions could also serve as subtle expo-
sures for the child.
Consider an example of a naturally occurring exposure with a natu-
ral consequence for speaking that involves taking a child to an ice cream
parlor. In this situation, the child is required to use one word to convey
to the clerk the type of ice cream he wants. The child could, for example,
say “cone” or “bowl” or “chocolate” or any other general descriptor—
adults at this stage are allowed to fill in the rest of the description for
the child as he points to what he wants. The important point to convey to
the child is that speaking will result in ice cream and that no speaking will
result in no ice cream. Parents must then refrain from giving ice cream
to a child who fails to speak, so this type of exposure is recommended
only if you are confident the parents can comply with your instruc-
tions. This type of exposure often requires some repetition. I have found
that most clerks are quite patient and willing to prompt a child for
speech, so sending a child up to the counter for several attempts at
speaking is often feasible.
Other difficult steps on the hierarchy include speaking to or greet-
ing other people less known to the child, such as potential friends at a
park or birthday party or to adults at church. Give the child suggestions
ahead of time regarding what words or statements he can make to
others. Some kids need only say “hello” and “hi” during initial expo-
sures or answer yes–no questions audibly. A child should always be
prepared for different social situations by having options for what he
can say to others (see also the social skills training section later in this
chapter).
The highest or most difficult items on Avery’s hierarchy (Fig. 4.1)
involve more proactive speaking, such as approaching others or volun-
teering to speak. A good exposure for Avery is answering a question
during Sunday school class because this may help facilitate later expo-
sures in her regular classroom setting. I strongly recommend conducting
exposures at this point that will at least partly mimic what will occur next
in school-based situations. Examples include initiating speech with
others, speaking with sentences and not simply single words, and speak-
ing before larger numbers of people.
A common exposure I often end with at the community level
requires the child to approach strangers to ask for the time or for direc-
tions. Obviously this is done only under your supervision or parental
supervision. The exposure requires the child to excuse himself, establish
eye contact, clearly and audibly ask for time or for directions, and thank
the person for their information. I have found that most strangers are
willing to accommodate a child’s request, although you and parents
must always judge the safety of the situation (I prefer a college campus).
In addition, I have found that a child’s success in each of these steps
greatly facilitates school-based exposures, which are described next.
Exposure-Based Practice in School Settings
The final step of exposure-based practice is often the most difficult and
involves school settings. Hopefully you have been able to conduct
home- and community-based exposures to help facilitate school-based
interventions, but I recognize you may not have been able to because of
administrative, logistical, legal, safety, or other constraints. If your
intervention can begin only at the school level, then I still recommend
teaching the child to engage in muscle relaxation and proper breathing
(Chapter 3) and constructing a hierarchy of speaking-related situations
at school.
Another technique that may serve as a good preamble to exposure-
based practice at school, especially if this is where you must begin the
intervention, is self-modeling. Recall from Chapter 1 that self-modeling
involves asking parents to audiotape or videotape a child as he speaks
clearly and well in a comfortable situation such as the home. The
recording is then replayed in a low-frequency speaking situation such as
your office at school. As you play the recording, give the child substan-
tial verbal praise or tangible incentives to reward the clarity, volume,
and beauty of her voice. The child is essentially viewing herself as a
model for appropriate and audible speech. The process is also aimed at
rewarding speech, easing discomfort, and helping a child recognize that
no negative consequences will result from speaking publicly.
Some children are initially resistant to self-modeling, so you may
need to include parents, allow a child to sit several feet away, ignore
tantrums or other misbehavior, or avoid eye contact with the child.

Repetitive self-modeling should ease a child’s resistance with time and
allow you to develop better rapport. You may wish to continue self-
modeling during the hard work of school-based exposures. Self-
modeling may be a good technique, for example, when first interacting
with the child in his classroom. The following sections discuss school-
based exposures at different levels.
Initial School-Based Exposures
Initial school-based exposures can follow naturally from later community-

based exposures that required a child to speak before or to others in
some context outside the home. I recognize, however, that school-based
exposures may be the first exposures you are able to conduct with a
child. In either case, I recommend conducting initial school-based
exposures that are somewhat removed from the child’s classroom, which
is usually the most difficult place to increase speech. You may need to
enlist the help of parents who can initially serve as a mediator between
you and the child.
Refer again to Figure 4.2 and the school-based hierarchy for Avery.
You can see that the initial exposures involve discussions with you in an
area that is hopefully less anxiety-provoking for the child, such as your
office or the school playground. Other examples include the school bus
loading area, the school bus itself, a courtyard, or even an area near the
school campus if necessary. Exposures in these settings should generally
match what was done at home and in community settings—help the
child relax, discuss simple and fun topics, and prompt and reward
speech and audibility.
I strongly recommend conducting these exposures when few if any
other children are around. You could, for example, conduct the expo-
sure after school, during the morning when the playground is empty, or
on weekends or very early in the morning. Remember that a child may
need several sessions and many prompts before adequate speaking
occurs. Do not progress to the next step until a child is quite proficient
at speaking with you in a given setting.
Once a child can speak to you well in these settings, which are rela-
tively external to the main school complex of classrooms, the next set of
exposures can occur within the heart of the school (but still outside the
classroom). Examples include the school library, gymnasium, cafeteria,
or even hallways. As the child engages in these exposures, she will con-
tinue to attend class and be allowed to interact with classmates and
peers nonverbally. The child should be reminded, however, that she is
expected to eventually speak well and independently in class and to
people there.
This can be the point in the school-based exposure process at which
stimulus fading can begin. Recall from Chapter 1 that stimulus fading
refers to systematically increasing the difficulty of an exposure by fading
in new stimuli such as verbal academic tasks, peers, or teachers. Your
initial exposures can include situations outside and inside the main
school complex and with you and the child alone. Once the child can
speak to you well in these situations, then other stimuli can be added to
make the exposure more challenging.
If you have shaped and prompted good speech at the playground,
for example, then you can begin exposures there when just a few other
children are around. These children may be off in the distance playing
but later can move closer to you and the child. Over time, playground
exposures can systematically include more children and greater proxim-
ity. Young children will be naturally curious about your attempts to
help a child speak and will often offer to “help.” Take advantage of this
as appropriate. For example, you could ask the peers to stand 20 feet
away, then 10 feet away, and then 3 feet away as you conduct your
exposures. You can also vary what the peers are doing, to whom they are
speaking, and what they can say to the child. You may also have to
adopt firm rules about what the peers are allowed to do when you are
in the middle of an exposure.
Stimulus fading can occur during your exposures within the main
school complex as well (see Fig. 4.2). For example, you could ask a
child to speak with you in the school cafeteria when just a few other
people are around and gradually progress to busier times. You could
also begin exposures in an empty hallway and gradually work your way
up to times of the day when there is more foot traffic. A child could
initially speak to you as well in the library and later read to you while
other kids or teachers are present.
Keep in mind that you should also increase the length of your
exposures as the child progresses. A child may be able to read to you in
the library for only a minute or so at first, but this can gradually be
increased to 2, 5, and 10 or more minutes. The idea is that you are
always “pushing the envelope” with the child, always prompting more
speech, more audible speech, and speech that occurs in a normal social
context with others around. Always see if the child is willing to give you
just a bit more, but recognize as well when a child seems tired, frus-
trated, unmotivated, or upset about continuing. You may also choose
to conduct two or three “mini-exposures” throughout the day.
All of these initial school-based exposures set the stage for what
might be your toughest battle: the classroom. School-based exposures
in the classroom should progress in two main stages. The first stage
involves developing speech in a fairly empty classroom or one that has
only a few people in it. The second stage involves developing speech in
a full classroom, especially within the context of expected academic
activities such as reading aloud to classmates. The first stage is referred
to here as intermediate school-based exposures and the second stage is
referred to here as later school-based exposures.
Intermediate School-Based Exposures
Your first exposures with a child within the classroom can generally
follow some items listed on the hierarchy in Figure 4.2. Avery’s school-
based social worker, for example, initially brought Avery into her class-
room during a recess period when no one was there. She asked Avery to
show her where her desk was, identify pictures on the wall that were
drawn by her, and point out favorite books and class projects. She also
asked Avery to practice again the relaxation and breathing techniques
discussed in Chapter 3. The idea here was to lower Avery’s anticipatory
anxiety about speaking in her classroom, associate her classroom with
greater relaxation and less pressure, and continue to develop rapport.
The first two or three sessions within the classroom can be nonverbal
and relaxed.
Intermediate school-based exposures will largely involve interact-
ing with the child in the empty classroom and then gradually fading in
more stimuli. So, your first few sessions are simply an extension of what
you did earlier – have the child converse with you, read to you, talk
about favorite class activities or peers, and answer your questions.
Be sure to specifically praise the child for speaking in his classroom,
something Avery and many of these kids have never done before. Keep
in mind that this step can be quite difficult, so patience and ongoing
practice may be necessary. Initial sessions within the classroom can be
short and then perhaps extend to an entire recess period.
Your next set of exposures involves stimulus fading. Note Figure 4.2,
items 4–8, as an example. Avery was asked to speak to the social worker
in her classroom as two classmates sat on the opposite side of the room.
Let the child choose which classmates, hopefully good friends, initially
sit in the classroom. The peers should be specifically instructed to
remain quiet during your work with the child – they can read silently,
complete school work, or play on the computer, for example. You can
generally ignore the peers as you interact with the child, but you should
praise the child for speaking to you with others present. You can also
make the exposures more challenging by asking the peers to gradually
sit closer to you and the child.
Two caveats here. One, some kids prefer that the teacher be the first
person to be in the room as they speak, and this is perfectly acceptable
as long as the teacher is willing. Two, if peers are employed during the
exposure, spontaneous social interactions could occur later. For exam-
ple, the peers may be excited that the child spoke and tell others, may
try to converse with the child once the exposure is done, or may com-
pliment the child on his voice. These are not necessarily bad things, but
some kids with selective mutism are uncomfortable about the added
attention. You may find it necessary to include instructions to the
teacher and peers about what they should (and should not) do follow-
ing exposure sessions.
Once Avery became comfortable with this scenario and was speak-
ing appropriately to the social worker, more stimuli were faded into the
situation. Avery’s next step was to speak when the teacher and two
friends were in the classroom, then speak with the teacher and 5 class-
mates present, then speak with the teacher and 10 classmates present,
and then speak with the teacher and all classmates present. The latter
exposure can be conducted any time class is in session. In this scenario,
you simply work with the child in a corner of the room as she reads or
otherwise interacts verbally with you. If the child responds well to
spontaneous reinforcement from others, then point out how her voice
and speech create positive reactions and that nothing bad is happening
(see also the cognitive intervention section later in the chapter).
Later School-Based Exposures
Your last set of school-based exposures should mimic academic and

social activities that children are expected to engage in during class time.
Note that Avery’s hierarchy items in this regard included speaking to

peers in the classroom during small group activities and during free
time, asking and answering questions in class and otherwise speaking
clearly to the teacher, and reading aloud to classmates or engaging in
center-of-attention tasks such as show-and-tell.
Later school-based exposures sometimes progress very quickly
because some kids generalize speech to other situations with ease. Other
kids demand a more measured, structured, careful, and time-consuming
approach. Allow a child to choose a classroom-based activity during
which he would like to speak first. Some kids choose interactions with
a teacher and other kids choose group activities with peers because they
can blend in better and not necessarily be the center of attention. Either
option, or another suitable and equivalent one, is fine. Your exposures
during these activities can be less formal and direct – you may wish, for
example, to stand several feet away and prompt speech or give feedback
as necessary. You may also wish to further engage peers who can prompt
and reward a child’s speech.
For these exposures the child should have some good ideas about
what she can say to teachers and others (see next section on social skills
training). You may wish to role play with a child some statements she
can make to peers, questions she can ask others in class, and appropri-
ate methods of responding to requests and statements from others. You
can also help a child practice speaking before others by subtly remind-
ing them to lift her head, maintain eye contact, and speak audibly. You
may wish as well to surreptitiously monitor a child’s conversations with
peers and others during recess time, lunchtime, and in special classes
such as music and physical education.
The final steps to school-based exposure should involve regular prac-
tice speaking to peers and teachers throughout the school, perhaps gen-
eralizing to school staff members, custodians, and other school personnel.
The idea is to help a child reach a point where speaking to others is a
natural and reinforcing event, not one that continually has to be prompted
and reinforced. Pay close attention as well to the child’s academic and
social status, especially the child’s ability to make and keep friends. The
child should be emphasizing verbal interactions and not compensatory
behaviors by the end of your exposure program (see Chapter 5). Finally,
you may need to engage in relapse prevention strategies that are covered
in greater detail in Chapter 7. Following is a description of interventions
that may be employed in conjunction with exposure-based practice.
Social Skills Training
Many kids with selective mutism or reluctance to speak have not spoken
to other kids, at least in public settings, either most of their life or for a
long time. Once a child is speaking with other kids following your
exposure-based practice, it may be necessary to help expand his social
skills to some degree. Some children with selective mutism may already
have good social skills, so this step may not be necessary in all cases.
Other children with selective mutism either do not have good social
skills or simply do not have much practice using their good social skills
with others (recall Avery’s recent withdrawal from others). Once a child
is speaking regularly, you should be able to determine which scenario
applies.
If you feel a child could benefit from some training in social skills,
refer to the basic template for doing so described next. Social skills train-
ing largely involves learning a new skill, so the rationale for exposure-
based practice also applies here—that a child will need to practice how
to interact with others, initially with some help and later more inde-
pendently. The goal is to help a child speak well to others, but in an
effective way to form and keep friendships.
A social skills training approach largely consists of modeling, prac-
tice, and feedback in a repetitive cycle. Modeling in this case refers to
having a child watch socially skilled peers engage in key behaviors such
as establishing eye contact and conversing. The best models for a par-
ticular child are those close to the child’s age and may include siblings,
relatives, neighbors, classmates, or other peers. Ideally, these children
should be those the child knows fairly well and with whom the child is
comfortable. These models should be socially skilled and not overly shy
and must be willing and able to carry out whatever social practices you
ask them to do.
A basic modeling scenario is to have the child with whom you are
working observe two children (models) having a conversation. The
models can talk about whatever they want as long as they are polite to
one another and make good eye contact with each other. The conversa-
tion should be brief, perhaps less than a minute, and could even be
videotaped to show the child afterward. Ask the child to pay close atten-
tion to whatever skill you decide to focus on first, such as eye contact.
If necessary, ask the models to repeat their conversation a couple of
times as the child watches.
An important next step is practice. Once a child sees how others

perform a certain skill, she is asked to practice the skill herself. This
early practice can come with some help in the form of a very brief ses-
sion. The child may be asked to have a short conversation with one of
the peers for perhaps 10 seconds or so. Instruct the child that what she
says is not as important as establishing eye contact and making sure her
voice volume is sufficient. Practicing social skills is also a way to reinforce
skills learned for speaking frequently and audibly to others. Social skills
training can thus be partly an extension of exposure-based practice.
The other important part of social skills training is feedback.
Feedback refers to information given to a child about how a skill is
performed. As your student models and practices different social skills,
feedback from you, teachers, parents, and others will be important to
correct major flaws or help the child understand what needs some
minor adjustment. Feedback should also include much praise for the child’s
efforts and successes.
Some children who have emerged successfully from selective
mutism will need to practice many different social skills. Important
social skills and a brief summary of ideas when addressing these skills
are listed in Table 4.1. Social skills can also be practiced in situations in
which the child learned to speak better, such as ordering food in a res-
taurant. Social skills training may also involve helping a child recognize
and label his emotions and the emotions of others and to take the per-
spective of others.
Social problem solving has also been used by some researchers to
specifically assist children with selective mutism. O’Reilly and his col-
leagues (2008) treated selective mutism in two sisters aged 5 and 7
years. Their intervention involved collaboration between a therapist
and teacher. The teacher provided the therapist with a lesson plan for
class that day as well as five questions the teacher would ask (from the
study, for example: “If I had 12 bananas and a monkey ate 7, how many
bananas would I have left?”). The therapist then role played the lesson
and suitable answers with the children as well as social rules such as
speaking clearly in class. The children evaluated their responses and
noted how others responded to them, such as the teacher expressing
praise. Practice over 21 observation sessions resulted in substantially
more audible responses to teacher questions. The study was helpful in
showing that elements of exposure-based practice and social skills train-
ing could be blended to increase appropriate speech in the classroom.
Table 4.1 Suggestions Regarding Important Social Skills in

Children
Accepting invitations from others for play or other social interaction

→ Maintain eye contact and smile, ask what others are doing, say
“thank you,” and begin to play
Accepting praise and compliments from others
→ Maintain eye contact and smile, say “thank you,” perhaps offer a
compliment to the other person in return
Answering the door or telephone
→ Clearly say “hello” or “how can I help you?,” maintain good
distance, take a message
Asking others for help or information
→ Know exactly what information is needed, ask appropriately
(“Excuse me”), be clear in asking for help
Being assertive in saying “no” or when asking for something
→ Make eye contact, be brief in saying no, state your intention clearly
and with good voice volume
Calling someone on the telephone or inviting someone for a fun activity
→ Speak clearly and articulately, know ahead of time what the topic
is, use manners
Controlling impulses and anger instead of acting on them quickly
→ Count silently to 10, relax the body, exit the situation appropri-
ately, talk to someone
Cooperating with others in a game or project
→ Use manners, take turns, engage in small conversation, thank
others for playing
Dealing with being sad or anxious
→ Relax the body, think about difficult thoughts, understand that the
feeling is temporary, talk to someone
Dealing with embarrassing or stressful situations such as teasing
→ Ignore the provocation, walk away, go to a safe area, talk to some-
one if the teasing is severe
Delaying gratification, such as completing schoolwork before playing or
television
→ Schedule a time to do homework, focus on the future reward of
doing the work first, praise yourself for waiting
Eating appropriately around others

→ Chew food slowly, speak when your mouth is empty of food, relax
your body, listen to others
Giving affection
→ Know the right situation to give affection, know what kinds of
affection are acceptable and to whom, keep affection small in
scope, mix affection with compliments
Greeting others appropriately
→ Say “hello” and smile, keep your head up, speak articulately and
with good voice volume
Identifying emotions in yourself and others, such as happiness, sadness,
fear/anxiety, and anger
→ Watch your body posture and facial expressions, listen to
statements made by a person, study the context of the situation
(what is happening around the people involved)
Initiating and maintaining conversations with others
→ Think about the topic on which you want to focus, make eye
contact, speak clearly, ask questions
Introducing yourself or other people
→ Use an appropriate greeting, select a good time, use a full sentence,
follow-up with questions
Joining activities with peers
→ Introduce yourself, ask others if they want another person to join,
speak clearly and with confidence
Keeping your head up when speaking to others
→ Maintain eye contact with the person, smile, maintain the
conversation, ask questions
Listening to others appropriately
→ Nod your head occasionally, maintain eye contact, smile, do not
interrupt
Maintaining eye contact with others during a conversation
→ Keep your head up, watch the facial expression of the person
talking, smile
Maintaining personal hygiene and grooming
→ Wash and brush your teeth appropriately, dress nicely, use
deodorant, comb your hair, fix your clothes
Continued
Table 4.1 cont’d
Ordering a meal in a food establishment

→ Keep your head up, maintain eye contact, speak articulately and
with good voice volume, listen attentively to the person taking the
order
Performing athletically before others
→ Stay involved with the group activity, try doing your best, talk to
others, have fun
Refraining from interrupting or inappropriately touching other people
→ Maintain eye contact, wait for the other person to stop talking,
maintain appropriate distance (2 to 3 feet) from the person talking
Refraining from rude behaviors such as yelling, insults, sarcasm, or
hitting
→ Watch your own behavior closely, use manners, listen carefully,
control anger
Resisting group pressure to do something inappropriate
→ Think about whether someone is asking you to do something
inappropriate, say “no” clearly, give a reason for saying no, walk
away from the situation, avoid tempting situations
Resolving conflicts with others
→ Negotiate solutions to problems without force, listen carefully to
others’ opinions, think about all sides of the problem, develop a
solution agreeable to everyone
Sharing feelings appropriately
→ Discuss feelings when you are not angry, use manners, speak
articulately and listen carefully to others’ reactions
Speaking articulately
→ Speak slowly and pronounce each syllable clearly, maintain eye
contact, watch others’ reactions, speak with good voice volume
Speaking in a clear and audible tone of voice
→ Speak slowly, listen to yourself to see if your voice volume is strong,
maintain eye contact, watch others’ reactions
Speaking or reading before others
→ Speak slowly and articulately, speak with good voice volume, relax
your body, practice beforehand, be well prepared
Taking the perspective of other people

→ Actively observe and listen to others, think about what others may
be thinking and feeling in a certain situation, ask others what they
were thinking and feeling
Taking turns when playing a game
→ Wait patiently, smile, thank others for playing and for your turn, be
gracious in winning or losing
Using manners
→ Make eye contact, use “please,” “thank you,” and “excuse me”
appropriately in complete sentences, watch others’ reactions
Writing before others
→ Relax your body and fingers, write slowly and carefully, focus on
the task at hand
Addressing Problematic Thoughts about Speaking
As mentioned in earlier chapters, some children with selective mutism

or reluctance to speak may have maladaptive thoughts or worries about
speaking before others. Most young children will not or cannot say
what bothers them about speaking, so pressing the issue with them is
unnecessary and can even be counterproductive. Other children, how-
ever, will discuss their concerns about speaking once speech is developed,
especially with you. If this is the case, then there are some steps you can
take to address the child’s worries.
Your first step would be to ask the child several questions. Some of
these questions are general and some are specific:
• What do you think about when you speak to someone?
• Do you think bad things will happen when you speak to someone?
• How does your body feel when you speak to someone? Do you
worry about blushing or feeling nervous? Do you think about how
your body feels when speaking to someone?
• Do you worry someone will laugh at you, tease you, or make fun of
you if you speak to them?
• Do you worry you will look foolish or dumb if you speak to
someone?
• Do you worry you will be ignored by others if you speak to them?
• Do you worry others will make you do things you do not want to
do if you speak to them?
• Are you afraid to speak to others because you do not know what
to say?
These are sample questions. You may have to ask more specific
questions or other questions depending on the circumstances surround-
ing the child you are addressing. If a child is worried that bad things
will happen if she speaks, such as being ridiculed by others, first make
sure this is not actually happening. If a child is ridiculed for speaking or
some other negative consequence is occurring, then this situation must
be resolved first. I have found that most peers and classmates are gener-
ally quite supportive of a young child who is speaking to them for the
first time, but it is possible some adverse event has occurred. Consultations
with teachers and peers will be important in this process to resolve prob-
lematic circumstances that prevent a child from speaking.
Once you have discovered the primary worry a child has about
speaking, and found that no legitimate reason exists for the worry, then
work with the child to allay the concern. There are several general
methods for doing so, especially for younger children:
• Discuss with the child the likelihood that someone will laugh at
them for speaking and concentrate on the number of times
(hopefully near zero) that this has actually happened. Use this latter
number to help predict the poor likelihood of this happening in the
future.
• Discuss with the child what should be done if indeed he is ridiculed
for speaking; the child should certainly inform the teacher, avoid
socially isolated situations, and play with supportive peers.
• Talk to the child about how he cannot know ahead of time what
will happen when he speaks to others; he should not try to guess
how people will react.
• Talk to the child about how embarrassment is a temporary and
manageable condition; any discomfort he has about speaking will
be short-lived (will go away soon) and can be handled.
• Talk to the child about the fact that speaking does not always mean
you will have to do something you do not want to do, such as
chores.
• Remind the child that practice speaking to others will help her
become a better talker and that other people will generally respond
positively (e.g., smile, return compliments); help the child think
about topics for discussions with peers such as movies, school

projects, family activities, and pets.
If you are addressing a child with substantial concerns about speak-
ing, and the child is willing to discuss these concerns with you, keep in
mind that these methods will need to be conducted on a regular basis.
Try to involve parents and others as well in this process so the child
receives accurate information about the consequences of speaking.
Parents and others should also continue to praise the child for speaking
in public situations and occasionally remind the child that speaking led
to positive outcomes (e.g., receiving food, smiles from others) and not
negative outcomes (e.g., no one laughed or screamed at the child after
she spoke).
Exposure-based practice is typically an essential aspect of intervention

for children with selective mutism or reluctance to speak, especially
children with substantial general or social anxiety. Recall from earlier
chapters that some children with selective mutism have oppositional
tendencies as well, perhaps refusing to speak in public and school situa-
tions. A primary focus of Chapter 5 is contingency management, or
establishing incentives and disincentives for speaking and refusing to
speak, respectively. A contingency management approach is useful for
addressing oppositional tendencies and is helpful for rewarding youths
who follow through on exposure-based practice. Contingency manage-
ment can also be used to help parents create greater structure in the home
and to reduce compensatory behaviors common to this population.
5
Brody is a 6-year-old boy with selective mutism who actively refuses

to speak in any situation outside his home. Brody’s parents claim
their son speaks fine at home but does seem particularly defiant
about speaking in public. They tried to cajole their son to speak
publicly when he was a preschooler but several temper tantrums
largely ended their attempts. Brody communicates by writing words
in the air, pointing, growling, gesturing, or making odd facial
expressions. When someone asks him to speak, which is rare, Brody
issues a defiant look and shakes his head. Brody’s kindergarten
teacher let her students communicate nonverbally, but Brody’s
first-grade teacher has begun to insist that Brody read in class. This
resulted in several disruptive behaviors from Brody. An assessment
revealed little social anxiety for Brody, and he does play with friends
on the playground. His level of oppositional behavior, however, is
moderate to high.
R ecall from earlier chapters that some children with selective mutism,
such as Brody, display oppositional characteristics regarding speak-
ing in public. Some children seem defiant about not speaking, show
disruptive behaviors to avoid having to speak, force others such as par-
ents to acquiesce to their demands, insist on using compensatory behav-
iors such as pointing to communicate, and appear to be particularly
willful, stubborn, or manipulative in their behavior. Children such as
Brody may have elements of social anxiety, but their unwillingness to
speak clearly has some oppositional components.
A key aspect of intervention for children such as Brody with
selective mutism or reluctance to speak is contingency management.
96
Contingency Management 97
Recall that contingency management refers to establishing rewards and

disincentives for a child’s speech or refusal to speak, respectively. These
rewards and disincentives are typically provided by parents, teachers,
and the person primarily responsible for handling a child’s interven-
tion. However, peers, siblings, and others may be involved as well.
Rewards and disincentives are mostly geared toward increasing the
frequency and audibility of speech but are often targeted toward reduc-
ing compensatory or other problematic behaviors such as tantrums,
clinging, or classroom disruption. Rewards and disincentives may be
contrived or more natural in nature, as will be discussed.
Contingency management is especially useful when a child displays
oppositional components to his selective mutism, but the method
applies to other conditions as well. Contingency management is a valu-
able strategy for addressing compensatory behaviors such as Brody’s
pointing, gesturing, or writing words in the air. In addition, many chil-
dren with anxiety-based selective mutism or reluctance to speak have
initial difficulty responding to exposure-based practice and prompts to
speak. Extensive use of rewards and disincentives are sometimes neces-
sary to prod the exposure-based process.
This chapter focuses on contingency management practices for
each of these conditions (oppositional behavior, compensatory behav-
ior, linkage to exposure-based practice). This chapter also provides a
description of the negative reinforcement/escape intervention tactic
introduced in Chapter 1. The interventions discussed in this chapter
have been shown to be effective for children with selective mutism and
reluctance to speak, but keep in mind that contingency management is
often used in conjunction with exposure-based practices. As such, I strongly
recommend that you review Chapters 3 and 4, especially if the child
you are addressing has even a small degree of general or social anxiety.
If you feel the child you are addressing clearly has oppositional
characteristics and you are beginning your reading here, then be sure
you have properly consulted with relevant family members and devel-
oped sufficient rapport with parents, teachers, and the child if possible.
As mentioned previously, establish rapport with a child by meeting
with him frequently in your office or in a community setting in which
the child feels comfortable. Let us proceed next with steps for contin-
gency management using Brody as our primary example throughout
the chapter.
Consultation with Parents and the Child
As mentioned in Chapter 3 regarding exposure-based practice, I strongly

recommend that you have a detailed consultation with parents and the
child (if possible) regarding your assessment findings, a description of
oppositional behavior, and a rationale for contingency management.
When discussing assessment findings, concentrate on behavioral pat-
terns you have found in the data (see Chapter 2). If you have deter-
mined that a child’s selective mutism relates closely to oppositional
behavior, then focus on which aspects of questionnaires, worksheets,
observations, or other assessment data support your claim.
You may wish to discuss particular aspects of the child’s behavior
that seem most relevant to your choice of contingency management.
Concentrate on multiple, specific, and recent examples from the child’s
behavior. One characteristic common to some children with selective
mutism or reluctance to speak is a pattern of manipulative or attention-
seeking behavior. A child who defiantly refuses to speak is also likely to
behave similarly in other situations. The child may refuse to complete
chores, go to bed on time, or even attend school. In addition, the child
may throw tantrums, refuse to move, or cry to gain attention in various
situations. A pattern of oppositional or attention-seeking behavior such
as this is good evidence that the child might benefit from contingency
management.
Keep in mind, however, that some children with selective mutism
are defiant only about speaking in public and may be rather compliant
to other adult requests. Some children listen well to parents and teach-
ers but are quite adamant about not speaking in public. Contingency
management in this case may thus concentrate more on speaking and
less on a widespread pattern of oppositional behavior.
Brody’s sequence of selective mutism and oppositional behavior is
a common one and is illustrated in Figure 5.1. When asked to speak,
Brody engages in several defiant behaviors such as shaking his head,
throwing tantrums, and becoming disruptive in class. The key aspect
of this sequence is what occurs next—how do parents, teachers, and
others respond to the child’s refusal to speak? Acquiescence to a child’s
demands to refrain from speech is a common response in this popula-
tion. Recall that Brody’s parents largely abandoned their attempts to get
Brody to speak in public and that Brody’s kindergarten teacher allowed
him to use nonverbal means to express himself. In addition, adults in
Brody’s main Defiant look,

behaviors when asked shaking head,
to speak tantrums,
compensatory
behaviors,
disruptiveness
Parent and teacher Acquiescence,

responses to Brody’s responding to
refusal and allowing
compensatory
behaviors,
calling on
Brody less in
public or class
Long-term Ingrained
consequences of selective
child/parent/teacher mutism,
behaviors defiance in
other areas,
poor social
skills
Figure 5.1. Illustration of Brody’s sequence of oppositional

behavior and selective mutism.
Brody’s life have likely come to rely on his compensatory behaviors to

communicate – some parents become quite adept at “translating” a
child’s facial expressions, grunts, and odd sounds for others. In addi-
tion, teachers will sometimes call on a child less in class to compensate
for his lack of speech.
All of these parent and teacher behaviors serve to reinforce the

child’s refusal to speak. A child such as Brody is heavily invested in the
status quo because he can avert obligations to talk or participate more
in class. As such, selective mutism or reluctance to speak becomes more
ingrained over time. The fact that such defiance is rewarded also means
a child may extend disruptive behavior and other misbehaviors to other
situations such as refusing to complete homework. In addition, refusal
to speak for an extended period of time, or using defiance to manipu-
late communication, may lead to poor social skill development and
lack of friendships (see Fig. 5.2).
A child’s sequence of selective mutism and oppositional behavior
can be illustrated and presented to parents and the child for review.
Encourage the child and parents to disagree with you if their observa-
tions differ radically from yours. If necessary, collect additional infor-
mation from family members to modify your view of the child’s
sequence of oppositional behavior. Most importantly, be sure all rele-
vant family members fully understand the sequence you outlined
because the sequence will serve as the rationale for the intervention you
propose. Specifically, you will recommend to family members that key
reinforcers of the child’s behavior—especially acquiescence to compen-
satory behaviors and refusal to speak—must be addressed so that a child
is encouraged to speak fully in all situations.
Use this sequence to convince family members and teachers to
address each aspect of oppositional behavior, and their own behavior,
and encourage family members and teachers to commit to a plan of
action. Parents and teachers must understand that the bulk of the work of
contingency management falls on them. Recall from Chapter 3 that anxi-
ety management is a new skill that parents and children need to learn.
The same principle applies here—parents and teachers and relevant
others must be willing to change their method of responding to a child’s
behavior and continue to practice all interventions described in this
chapter. I do recommend informing the child of the upcoming process,
but do not allow the child to have much input into the structure of
the process.
Once everyone is on the same page, outline the expected course
and timeline of your intervention. The general course of intervention
will include identifying key rewards and disincentives, linking these
rewards and disincentives to expectations to speak, linking rewards
and disincentives to compensatory behaviors, and other parent-based
practices such as commands and daily routines. As mentioned in

Chapter 3, the timeline of your intervention is hard to predict, but
children with defiant behavior sometimes require extended effort and a
longer timeline. Be prepared for a potentially difficult process and be
sure that parent and teacher motivation during the process is main-
tained. The first step of contingency management is discussed next.
Identifying Rewards and Disincentives
The first step of the contingency management process will be to talk to

parents and teachers and possibly others about what rewards and disin-
centives are most salient for a child. Some of this information may have
already been culled from your assessment or you may know the child
well and have some idea. Keep in mind, however, that some children
are motivated by one thing at home and quite another thing at school.
Children with selective mutism, for example, may enjoy attention from
parents but not teachers.
Some children, especially those with substantial attention-seeking
behavior, are motivated by praise and time with parents and possibly
teachers. These children enjoy compliments, one-on-one conversations
(albeit one-sided sometimes), and running errands or taking walks with
adults, for example. Other children, however, are much more moti-
vated by tangible rewards such as toys, candy, access to television or
computer time, or even money (though I do not recommend paying a
child for speech). Tangible rewards can be contrived, such as a sticker
chart, or more natural, such as an extension of bedtime for speaking
appropriately.
You will also want to discover what disincentives are particularly
salient for a child. Examples include loss of privileges, early bedtime,
failure to earn stickers or toys, or fines. Another important disincentive
will be to ignore compensatory behaviors. Parents, teachers, and others
such as classmates will eventually have to ignore Brody’s pointing, ges-
turing, and other nonverbal means to communicate. This is the basis
for extinction. Once a child learns that nonverbal behavior is ineffec-
tive and ignored, the frequency of the behavior should decrease.
I do not recommend harsh disincentives for refusal to speak. These
cases do not require physical punishment, loss of privileges for days on
end, or outlandish responses such as canceling a birthday or holiday.
Instead, the best rewards and disincentives are those that can be applied
daily, that are most salient for a child, and that can be administered well
and consistently by parents, teachers, and others. Keep in mind that the
strength and type of a reward or disincentive may need to change as
your intervention progresses. More difficult expectations for speaking,
for example, may require more powerful incentives.
Contingency Management for Defiant Behaviors and

Selective Mutism: Parents
I find it helpful if specific rewards and disincentives are linked to spe-

cific expectations for speech in different situations. I do not recom-
mend a general approach of waiting to reward a child when he speaks
because speech may be too infrequent. Nor do I recommend rewarding
a child only at the end of the day for words spoken earlier. Rewards for
speaking should be immediate and linked to clear expectations for
speech. Let us discuss Brody as an example.
Brody speaks well at home, so we can reasonably expect him to
speak frequently and audibly in public situations. We next have to
decide whether we want initial contingencies for speaking to be admin-
istered only in public (nonschool) situations, only at school, or in public
(nonschool) and school situations. I recommend beginning with situa-
tions in which the child is most likely to speak and with situations in
which an adult is most likely to administer consequences appropriately
and consistently. Brody seems most defiant about speaking in school,
but his parents have a history of acquiescing to his nonverbal behavior
in public (nonschool) situations. Options here include working with
the parents to educate them about the need to properly administer con-
sequences, go with them and Brody to public situations to model how
contingencies should be given and provide feedback, or begin the con-
tingency management approach at school. In this situation, which is a
common one for this population, I recommend that you attend public
situations with the parents and child to facilitate contingency manage-
ment and serve as an appropriate model.
Begin the process with a specific situation, a specific requirement
for speech, and a specific reward and disincentive for fulfilling or not
fulfilling the speaking requirement, respectively. Be sure to fully inform
the child of all expectations and consequences. Brody was initially
required to go to the supermarket with his parents and say one audible
word to the person who was giving free samples of juice. Brody was
instructed to approach the clerk, smile, and say “please.” If he did so, he
was allowed to stay up an extra 30 minutes past his bedtime, a particu-
larly salient reward for him. If he failed to do so, then he was required
to go to bed 30 minutes earlier than usual.
You should be sure to budget extra time in these initial situations
for multiple attempts. Brody, for example, was allowed to approach the
clerk as often as he wanted to attempt speech. Children such as Brody
tend to be more defiant about speaking, so anxiety may not be a key
factor. Still, initial attempts may be difficult, so patience is particularly
virtuous here. Other children may need contingencies linked initially
to mouthing or whispering words, which is fine as long as later expecta-
tions involve audible speech.
Parent and other adult responses in these situations are very impor-
tant. Parents should adopt a neutral tone and matter-of-fact attitude
without significant emotional content. Some physical distance, such as
standing a few feet away, may be important as well. Some encourage-
ment is acceptable, such as saying “You can do it, go ahead,” but par-
ents should confidently convey an attitude that the child needs to finish
his speaking assignment independently. Parents should also be encour-
aged to let the preassigned contingencies speak for them. They need not
remind a child in the store about what will happen if he does not speak,
but simply administer consequences later. Immediate consequences,
such as praising a child for speech or gently admonishing him for fail-
ure to speak (e.g., “You’ll need to do better next time”), are often help-
ful as well.
Brody initially refused to speak, but his parents were able to gently
admonish him (they shook their head) and issue the early bedtime that
night. Brody was reminded at that time why he was going to bed early
and encouraged to try harder next time. I recommend that the child
engage in the same situation as soon as possible, such as the next day.
Most children with selective mutism that I work with eventually yield
to ongoing requirements for at least minimal speech, as Brody eventu-
ally did.
Once a child has successfully completed his first speaking require-
ment, then expectations for speech are raised. Brody, for example, was
then expected to say two words to the person bagging groceries for his
mother (“Thank you”). I have found that subsequent requirements for
speaking are successfully met a little more quickly with each step, but
consequences sometimes need to be changed to fit the situation. Parents
may need to increase the power of their rewards and disincentives as a

child is expected to speak more frequently, speak more audibly, and
speak in a wider array of situations and people. Contingency manage-
ment steps could follow the hierarchies outlined in Chapters 3 and 4.
I also encourage parents to adopt routines that make it likely a child
will encounter others and speak to others appropriately. Examples
include accepting a telephone call from you or other family members,
introducing oneself to another child at a park, or taking a child to recre-
ational activities that require some social interaction. Other situations
just naturally “pop up” during the day that could be used to help a child
speak more frequently and audibly. Parents may bump into someone
they know at a supermarket, for example, and ask their child to say hello.
Or the telephone could ring and parents may ask the child to answer.
These represent impromptu tasks that were not previously planned
but provide opportunities for rewards. A child need not be punished
for failing to speak in these situations, but could be given substantial
rewards for “going the extra mile.” Recall from Chapter 4 that settings
such as ice cream parlors could be used to take advantage of natural
reinforcers. In this situation, a child is asked to order ice cream with
family members. All those that audibly ask for ice cream receive the
dessert and those that fail to speak receive no ice cream. Again, multiple
attempts to speak should be allowed and parents should be reasonably
sure the child is capable of the necessary communication.
Contingency management in public (nonschool) situations can
follow the same step-by-step process discussed in Chapters 3 and 4 for
exposure-based practice. Here, the focus is on administering rewards
and disincentives for speaking and failure to speak, respectively.
Contingency management in community situations often precedes
school-based intervention, but I also recommend that a child continue
to practice speaking in community situations even as school-based tasks
are set. This is especially important because a child’s behavior in school
will be partly consequated at home.
Contingency Management for Defiant Behaviors and

Selective Mutism: Teachers
Contingency management for selective mutism at school must involve

close cooperation and communication among you, parents, teachers,
and relevant others. I strongly recommend a contingency management

program that involves all of the following components:
• Specific daily expectations for speech in the classroom.
• Specific rewards and disincentives for meeting or failing to meet
these expectations.
• A daily report card sent home to parents who can also provide
consequences at home.
• Ongoing teacher prompts to the child to communicate, including
calling on the child.
• Creating a milieu at school involving others who constantly
encourage the child to speak.
• Managing disruptive behaviors in the classroom, especially
misbehaviors in response to requests to speak.
Specific daily expectations for speech in the classroom can mirror
the gradual process we have covered in Chapters 3 and 4 and the begin-
ning of this chapter. Brody, for example, might be expected to audibly
state one word to his teacher during the course of a school day. Try to
give the child great leeway as to when, where, and how this occurs (we
will shape this more as time goes on). Brody can choose what word he
wants to say, choose when he wants to say the word to the teacher, and
choose a setting such as recess when no one is around. His success in
doing so should be met with an immediate reward from the teacher,
such as praise and extra computer time in the classroom, as well as a
later reward at night from his parents (e.g., later bedtime). The oppo-
site holds true as well, of course—Brody’s failure to meet the expecta-
tion should be met with an immediate (e.g., loss of recess) and later
(e.g., earlier bedtime) disincentive.
The close connection between school- and home-based conse-
quences strengthens the contingency management process, conveys to a
child the seriousness of the task, and helps teachers and parents form a
united front. This connection should be solidified by a report card sent
home by the teacher to the parents each day. A sample is provided in
Figure 5.2. I recommend asking the teacher to indicate whether the child
successfully fulfilled his speaking obligation for that day, rate a child’s
level of anxiety and disruptive behavior on a 0-10 scale, and stipulate any
disruptive behaviors or other relevant comments for parents. You can
arrange appropriate responses to each item with parents, with a particu-
lar focus on whether the child successfully completed his speaking task.
Daily Report Card
Date: __________
Speaking task for the day: _______________________________________________
The child successfully completed his or her speaking task today (circle one): YES NO
Level of distress shown by the child today (use 0–10 scale): _____
X--------X---------X--------X---------X---------X---------X---------X---------X---------X--------X
0 1 2 3 4 5 6 7 8 9 10
None A little Some Stronger A lot The worst
Level of disruptive behavior shown by the child today (use 0–10 scale): _____
X--------X---------X--------X---------X---------X---------X---------X---------X---------X--------X
0 1 2 3 4 5 6 7 8 9 10
None A little Some Stronger A lot The worst
Behavior problems in school today
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Homework today or other comments
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Figure 5.2. Sample Daily Report Card.
Teachers should also be asked to modify instructional methods they

may have employed to compensate for a child’s lack of audible speech.
Some teachers eventually call on a child less in class, allow a child to
avoid group projects, ask a child to sit in an isolated section of the class-
room to work, and give incomplete grades for reading and other tasks
that require verbalizations. These practices should change, but in a
gradual fashion as a child speaks more. A child who is just speaking her
first word to the teacher, for example, need not be required to read
before the class. However, she could be reintegrated with peers, asked
to participate in group projects even in a nonverbal fashion, and called
on in class more to do things such as write on the blackboard. Reducing
isolation is helpful to facilitate increased speech later on. Teachers will
be asked to help extinguish compensatory behaviors as well (see later
section).
As a child successfully speaks more in class, others can join the
process to encourage more spontaneous speech. Peers and classmates
could be asked to praise a child’s speech, prompt speech throughout the
day, and refrain from informing others that a child “does not speak.”
A classmate could initiate a conversation at lunchtime, for example.
The idea is to take a basic and natural life scene and shape it into a
learning and rewarding situation for the child with selective mutism. In
addition, specialized teachers (e.g., physical education, art, music),
office staff, and other adults at school could do the same to create a
general milieu where the default expectation for a child is audible
speech. A teacher could pull a child aside and ask how his day is
going, for example. You will have to take care not to overwhelm a child
with this approach. Instead, bring others into the process only when
you see the child is more willing to speak to the teacher and a few
classmates.
Teacher-based contingency management could apply as well to dis-
ruptive behavior a child may show in the classroom following requests
to speak. Recall that Brody was somewhat disruptive in class when
asked to speak, sometimes throwing something, stomping his foot, or
walking out of the classroom. Specific consequences must be provided
for such behavior, above and beyond those established for failure to
speak when asked. Consequences for disruptive behavior should be
particularly strong and set apart from those used for speaking. In this
way, the child understands that his misbehavior reached a specific,
unacceptable level that triggers a harsh response.
You may find that establishing a 504 plan is useful for children with
selective mutism, particularly if disruptive behavior accompanies their
failure to speak. A 504 plan would allow you to implement special cir-
cumstances to help address the child’s behavior, including those dis-
cussed in this book as well as tactics such as modifying the workload,
having a child sit near the teacher, and medication (see Chapter 7).
A 504 plan might also assist with relapse prevention (see Chapter 7)
because ongoing strategies must be practiced to ensure that a child con-
tinues speaking frequently and audibly at school.
Contingency management in later stages could be extended as well
to other disruptive behaviors that a child may show. Some children
with selective mutism and defiance about speaking also refuse to com-
plete homework or chores or even come to school (especially once
expectations for speech are implemented). Some of Brody’s associated
behaviors—such as disruptive classroom behavior or public tantrums—
could be linked to specific contingencies. Associated behavior problems
are thus reduced and parents can extend their contingency manage-
ment practice so that the practice becomes a regular family style.
Extending the contingency management process will help reduce
chances of relapse toward mutism as well (see also Chapter 7).
Contingency management often demands a broad approach so that
rewards and disincentives are administered by multiple adults (parents
and teachers) for various levels of misbehavior.
Extinguishing Compensatory Behaviors
As mentioned earlier, a key aspect of contingency management for

selective mutism is to extinguish compensatory behaviors such as
Brody’s pointing, gesturing, and writing words in the air. Compensatory
behaviors are generally allowed at the beginning of intervention to
ensure a child understands the expectations for speaking and the result-
ing consequences. A child may be allowed to nod or shake her head, for
example, when asked if she understands what must be done and said in
a given situation. As your intervention matures, however, a child should
be expected to “use words” to express simple responses such as yes or no
and later to converse more broadly.
Recall that Brody was initially expected to say “please” to the person
providing juice in the supermarket. One likely manipulation of this
situation on the child’s part will be to convey information without
speaking. Brody may try to point to the juice, smile, or otherwise charm
his way into the treat using nonverbal means. This often works for
young children. In this situation, Brody’s parents should tell their son
ahead of time that such behaviors are not allowed and that he must “use
his words.” In addition, try to convey to clerks and others that the child
is learning to use his words and should not receive the treat unless he
speaks clearly. Most people graciously comply and even encourage the
child to speak.
Extinction of compensatory behavior should occur on a daily basis
and become a regular parental response. Encourage parents to tell a
child to use his words, ignore nonverbal expressions such as pointing,
“play dumb” by claiming they do not know what the child wants with-
out speaking, or gently admonish the child. I recommend simply ignor-
ing compensatory behaviors. As your intervention progresses, teachers
and other school officials should adopt this practice as well. Doing so
may create some initial awkwardness and hardship such as a failed class-
room reading assignment, but ongoing practice should eventually
extinguish most of the nonverbal behaviors.
You may find it necessary as well to work closely with a child’s peers
and classmates at school. Ask them to encourage the child to use his
words, give the child much praise when he does speak, and stop telling
other people that the child does not speak. Educate children about the
need to help the child speak more frequently and audibly and to con-
tinue to ask him to play, converse, and participate in class or group
projects. The idea here is to create a general milieu at school that always
works toward encouraging active speech and discouraging compensa-
tory behavior.
Prodding Exposure-Based Practice
Chapters 3 and 4 discussed exposure-based practice and mentioned

that rewards and disincentives could be applied to facilitate the process.
Children must always be rewarded for engaging in a successful exposure
session and should be rewarded more if they happen to speak more
than what was originally required. I encourage you to model this pro-
cess for parents as you engage in various sessions with a child. A child
may be rewarded with simple things such as stickers but also more
natural stimuli such as praise and smiles. Parents should also help the
exposure process by providing disincentives if the child refuses to engage
with you verbally or nonverbally as required. Compensatory behaviors
should be ignored as well as your intervention progresses.
Negative Reinforcement/Escape
Another behavioral technique for cases of selective mutism that involve

oppositional tendencies is negative reinforcement/escape. Recall that
negative reinforcement refers to rewarding a behavior by removing
aversive consequences. With respect to selective mutism, a child is
required to sit in a low-frequency speaking situation (such as your
office) for an extended period of time until he speaks one word, and is
then allowed to leave. Speaking thus allows the child the opportunity
to escape a boring and potentially stressful situation (negative reinforce-
ment). This process can last several hours, however, and there is no
guarantee the child will speak. A twist on negative reinforcement/escape
is to require a child to say one word in a new situation and, if she fails
to do so, send her to her bedroom for an extended period of time until
she complies.
Negative reinforcement/escape is not a well-tested approach and
can obviously be burdensome and ineffective. The greatest risk of the
approach is that a child will successfully “wait out” the process and exit
without ever having spoken. In this situation, the child is actually rein-
forced for not speaking. This would complicate future attempts at this
or other intervention procedures as well because the child was able to
force adult acquiescence to a rather lengthy and arduous attempt to get
her to speak. Some children we have addressed in my clinic are quite
intransigent and would not have much difficulty waiting out a 4-hour
period of time, for example. You may wish to use this procedure only
if you are completely confident it would work. Otherwise I would rec-
ommend the general contingency management procedures discussed
earlier.
Other Contingency Management-Related Techniques
During the course of contingency management you may wish to help

parents address their children more effectively and reduce chaos. Two
general strategies may be most beneficial. One strategy is to help par-
ents restructure the way they issue commands to a child, whether it be
to speak, complete chores, do something to get ready for school, or
finish some other task. Some parents fall into the habit of bribing,
negotiating, berating, lecturing, criticizing, and interrupting to get a
child to comply with their requests. Other parents use sarcasm or phrase
commands in the form of a question such as “Will you please put your
jacket on?” I recommend that parents replace these habits with the fol-
lowing practices for issuing commands:
• Tell your child exactly what you want him or her to do (e.g., “Pick
up all clothes from the floor” instead of “Clean your room”).
• Give short, direct commands.
• Make direct eye contact when speaking to your child or giving him
a command.
• Be sure your child can actually physically do what you are asking
him to do.
• Do a task with your child (e.g., clean the bedroom with him).
• Reward good listening and discourage poor listening.
A second general parenting strategy that may be helpful is to struc-
ture the morning routine, especially on school days. Some families are
quite chaotic and could benefit from this, and parents of children with
selective mutism may find such structure consistent with what you
asked them to do earlier (i.e., establish specific situations and conse-
quences for speaking). Toward this end, work with parents to establish
a morning routine that begins with the child rising about 90-120 min-
utes prior to the start of school. Specific timelines should be given for
all morning preparation behaviors such as dressing, eating breakfast,
and brushing teeth. Provide extra time for each task—if a child should
be able to eat breakfast in 15 minutes, for example, allow 20 minutes.
Specific rewards and disincentives, which may parallel those discussed
earlier regarding speech, may be applied for compliance or noncompli-
ance to the morning routine.
The goal of these command and routine strategies is to provide
parents with skills they can use to respond appropriately to their child’s
behavior and manage misbehavior. Families that communicate well
and solve problems will be better equipped to address a child with
selective mutism or reluctance to speak. Communication and problem-
solving skills will go a long way toward preventing relapse as well.
Contingency management is a key aspect of addressing youths

with selective mutism with oppositional characteristics and is a good
supplement to exposure-based practice. Indeed, a combination of con-

tingency management and exposure-based practice is a good interven-
tion strategy for most youths with selective mutism. Other children of
this population, however, have great difficulty speaking, which may be
due to communication deficits or developmental delay in addition to
selective mutism. This latter population is discussed in greater detail in
the next chapter.
6
Strategies for Children with
Communication Problems
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
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
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.
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.
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.
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
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
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
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
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
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
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
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.
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
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.
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.
7
Relapse Prevention, Other
Interventions, and Special Issues
Carson is an 8-year-old girl who was diagnosed with selective

mutism at the beginning of third grade. She did not speak to others
at school and seemed particularly anxious about being around her
classmates and peers. Carson was more comfortable addressing her
teacher and other adults at her school. The school psychologist
and counselor at Carson’s school worked with her throughout the
school year to develop greater ease about speaking in different
situations, enhance her social skills, and teach her some anxiety
management techniques. With parental support and help at home,
Carson was able to gradually speak more to others at school and
play with friends at recess. Her ability to speak before others had
reached a point at which she could read a story aloud in class.
Carson had made several friends and was able to participate verbally
in group projects.
C hildren such as Carson make the months of intervention seem

worth all the effort. Intervention for children with selective mutism
or reluctance to speak can be a grinding, slow, and methodical process.
As such, we certainly want to maintain the gains we have made! Many
children with selective mutism, especially those of the severe type,
remain relatively shy in their demeanor, which is fine. The danger,
however, is that these children may be prone to regress to old habits of
relying on compensatory behavior, initiating conversation and play less
often, and withdrawing from social and verbal activities. Parents
and even teachers can also regress to old habits of rewarding inappro-
priate compensatory and other behaviors and neglecting the ongoing
development of robust speech and social skills. The initial part of this
127
chapter addresses relapse prevention, or methods you should consider

to ensure that a child’s speaking and social behavior remain healthy.
This chapter also contains a summary of intervention techniques
that could be used in conjunction with the behavioral strategies empha-
sized in this book. These include group and family therapy, medication,
and an Internet-based intervention. In addition, a separate section
addresses special issues that often arise with this population as well as
suggestions for handling them. These issues include bilingualism,
difficult parents, comorbidity, and mental retardation or other develop-
mental delay.
Relapse Prevention
We want to maintain gains for children such as Carson, so active strat-

egies to prevent relapse must be implemented. A first step when consid-
ering whether a child is regressing in her behavior is to determine
whether such regression is a slip or an actual instance of relapse. A slip
represents some minor backsliding toward failure or refusal to speak,
such as declining to answer a teacher’s question on a particular day,
withdrawing from peers during lunch, or trying to communicate by
pointing instead of using words. Slips occur frequently, especially after
breaks from school, and should not be made too much of unless the
problem worsens. Slips can usually be addressed quickly by practicing
anew the strategies used to help a child speak more frequently and
audibly (see Chapters 3–6).
Parents, teachers, and others sometimes become discouraged when
slips happen, thinking they are back to “square one.” Everyone should
remember, however, that a child with selective mutism or reluctance to
speak is likely to be a shy child by nature and that this nature will not
dramatically change. The occurrence of slips means that parents, teach-
ers, and others must intensify intervention efforts and communicate
well with each other. Use of ongoing scheduled and spontaneous expo-
sures, including calling on a child in class and providing feedback about
her withdrawn behavior, is important. Parents and teachers should con-
tinue the daily report card system (Chapter 5), maintain and modify
contingencies for speaking and failure to speak, and have the child
practice anxiety management techniques, social skills, and other rele-
vant aspects of the intervention.
Relapse Prevention, Other Interventions, and Special Issues 129
Slips can accumulate or intensify, however, and possibly lead to

relapse. Relapse represents more intense backsliding toward the original
problem. If Carson failed to speak one day at school, then this would
be a slip. This slip could be addressed by prompting Carson to read a
passage to her class or encouraging her to approach someone to play
with at recess. If Carson did not respond to these prompts or other
techniques and her situation deteriorated over a period of a month or
so, then this may be a moderate relapse. Relapses can be moderate or
severe, but in either case it is a situation we want to actively prevent.
The following sections present suggestions for doing so.
Reminders following Intervention
When a child has begun speaking more frequently and audibly in vari-
ous situations, parents and school officials can certainly feel good about
the successful work they have accomplished. The temptation at this
point, however, is to assume that the child will naturally continue to
speak well on her own with little help from others – this is a big mistake.
Relapse prevention must begin the moment you successfully complete
the last stage of your intervention.
I recommend that you, parents, and relevant teachers construct a
list of reminders or techniques that were most useful for helping the
child speak more frequently and audibly in different situations. Often
this means focusing on two to four techniques or ideas that were
particularly salient for that child. Examples include ongoing exposures
in various community and school situations, practicing anxiety man-
agement techniques, administering potent rewards and disincentives,
and continuing a child’s speech and language development program.
Parents, teachers, the child, and relevant others should keep this list of
reminders and refer to it when a slip occurs.
I also strongly recommend that a child’s anxiety level and number
of words spoken per day continue to be monitored and recorded daily
for at least several months after the formal end of intervention. Note
the forms introduced in Chapter 2. The idea here is that a child should
know that her willingness to speak in public situations is constantly
monitored and addressed. Ongoing monitoring will also provide useful
information about whether a child is regressing to old habits of non-
speaking behavior.
Practicing Techniques from the Intervention
Many parents and teachers continue to practice techniques to prod fre-

quent and audible speech for a child, but others do not. Some parents
and teachers naturally relax once a child has shown that she can speak
in different and previously difficult situations. Parents and teachers
become preoccupied with many other distractions and may thus
become less focused on the intense intervention techniques needed to
address selective mutism. Adults may tend to take for granted a child’s
willingness to speak.
Parents and teachers must understand that continued practice and con-
stant vigilance from the end of intervention are the best ways to prevent
future problems. Parents should continue practicing techniques useful for
encouraging speech, such as natural exposures and contingency manage-
ment. Similarly, teachers should continue to monitor a child’s anxiety
and level of speech each day and implement activities that must include
the child’s verbal input. Peers can also be encouraged to continue to
initiate conversations with and extend play invitations to the child.
You, the parents, and the teachers should remain in close contact
with one another for at least several months following the formal end
of intervention. Close communication can come in the form of daily
report cards, monthly scheduled meetings, or regular email or tele-
phone contact. These communications should focus on the remaining
areas of difficulty for a child, new situations or obstacles that must be
addressed, and how existing practices such as the use and type of con-
tingencies may need to be tweaked. Problems related to a child’s
extended period of selective mutism could also be addressed. Examples
include finishing extensive make-up work, integrating a child into pre-
viously avoided extracurricular activities, and helping the child build
new friendships.
Exploring and Addressing New Obstacles to Frequent,

Audible Speech
A child’s slip or relapse could be due to recent life changes instead of

failure to practice techniques. Slips or relapses could follow important
family changes, academic problems, peer conflicts, or other new diffi-
culties. Having regular conversations with a child to explore and resolve
new obstacles to speaking in various situations is recommended. If the
child has another mental disorder that seems to interfere with proper
communication, then school-based academic intervention or referral to
a mental health professional outside the school setting (see Chapter 1)
may be necessary.
Slips or relapses with respect to selective mutism could also occur
because a child is inadvertently receiving some new reinforcement for
not speaking. In this case, you and the parents will need to locate the
source of the new reward and resolve the issue. Carson, for example,
may find that someone at her school who is unfamiliar with her history
allows her to communicate using compensatory behavior. Or parents
may respond to a child’s temporary spike in anxiety by allowing him to
skip a social event. Peers are also notorious for “helping” a child with
prior selective mutism navigate a social situation by speaking for her.
Rewards for failure to speak must be removed.
Beginning of a New School Year
A child who previously had selective mutism or reluctance to speak will

often have great trouble resuming a regular pattern of speaking and
social behavior following an extended break from school, such as
summer. This may be especially true if a child is entering a particular
school for the first time and does not know many people. To help
prevent a relapse at this point of the school year, try the following:
• Be sure the parents and the child attend all scheduled orientation
sessions held at the beginning of the school year.
• Conduct a private tour of the school with the parents and child,
emphasizing areas of socializing that might pose particular difficulty
for the child: classrooms, the cafeteria, art and music centers, the
gymnasium, and the playground. Discuss potential obstacles to
good speech.
• Be sure the child knows where to go—such as a counselor’s office—
if she has conflicts with others at school, needs to discuss areas of
difficulty surrounding speaking, or has other adjustment problems
or sources of anxiety.
• Educate relevant school personnel about the child’s history of
selective mutism, strategies that resolved the issue, and important
reminders for preventing a relapse.
• If relevant and appropriate, establish a 504 plan so teachers can
better monitor a child’s speech throughout the day or modify
academic practices so the child’s speech continues to be practiced

and rewarded.
• Establish regular lines of communication among parents, teachers,
and school personnel responsible for addressing the child’s selective
mutism.
• Involve the child in extracurricular activities of his choosing to
boost speech and friendship development.
Booster Sessions
Another relapse prevention method is booster sessions, or special meetings

between you, the parents, and a child who has overcome selective
mutism. The purpose of booster sessions is to review techniques from
your intervention and discuss upcoming issues that may interfere with
proper speaking. Booster sessions are often held during “high-risk” times
such as immediately before a new school year or during class projects
that demand significant verbal input. Carson’s school-based social worker
may wish to meet with Carson and her parents before the start of fourth
grade to boost skills needed to speak frequently and audibly to others.
Booster sessions are especially important when children move from
elementary to middle school and from middle school to high school.
Reminders of a Child’s Success
A relapse prevention method that can be fun is to have a child develop

an art project that represents her gains during your intervention.
Carson, for example, could collect photographs of herself engaging in
difficult tasks such as reading aloud before her class, playing with peers
on the playground, greeting someone at the door, and chatting with
classmates at lunch. These photographs could be arranged in a mosaic
or other project to illustrate her accomplishments and serve as a
reminder of what to do in the future when she is having trouble speak-
ing. Videotapes, drawings, journals, storybooks, posters, and other
creative methods of illustrating a child’s successes in speaking could also
be used in this regard.
Structured Activities during a Break
Children with a history of selective mutism can benefit from continued

involvement in certain activities during breaks from school. Youths with
a history of shyness and failure to speak to others, for example, could

participate in social groups, clubs, teams, or other organized activities
during school breaks. They could also be expected to maintain contact
with former classmates and current friends to arrange mutual play
times, a fun night out, or sleepovers. The idea is to continually place a
child in situations where she must practice her ability to manage anxi-
ety, speak clearly, and converse with others. Parents should continue to
administer proper consequences for speaking and failure to speak
during breaks as well.
Maintaining the Right Attitude
An important part of relapse prevention is the attitude of the parents

concerning a child’s speech. This means two things. First, parents
should not allow backsliding. Once a child demonstrates that he can
speak frequently and audibly to others in a given situation, he should
continue to do so. If Carson could greet people in the supermarket
during intervention, for example, then there are few reasons why she
should suddenly stop doing so. Second, parents must maintain an atti-
tude that proper speech will always be encouraged. The default option
must always be to expect a child to attend social events and speak clearly to
others, even if minor problems are present. Efforts on your part to help
parents maintain a proper attitude about school attendance will serve
to prevent relapse.
Relapse prevention is an essential aspect of intervention for chil-
dren with selective mutism, especially because many of these children
continue to be shy and reserved in their behavior. The remainder of this
chapter covers other interventions for selective mutism and discusses
special issues inherent to this population. You may find that special
strategies are sometimes needed to successfully address certain cases and
prevent relapse.
Other Interventions for Selective Mutism
The behavioral approaches described in this book are the primary inter-
ventions utilized for children with selective mutism or reluctance to
speak. Other interventions have, however, been discussed in the research
literature and are summarized here. In some cases of selective mutism,
a combination of behavioral approaches with these interventions may

be helpful. In other cases, intricate behavioral strategies cannot be
implemented although other approaches can still be beneficial.
Group Intervention
Group intervention for selective mutism or reluctance to speak involves

addressing two or more children together at the same time. Several
advantages exist for group intervention. First, the strategy is cost-
effective because you can implement exposure-based practice, contin-
gency management, social skills and language training, and other
relevant techniques to multiple children at one time. Second, group
intervention allows extensive modeling of appropriate speaking and
social behavior. Children in the group can watch each other speak to a
teacher, increase voice volume, and interact with peers on the play-
ground. Third, group intervention allows children with selective
mutism to practice skills on each other in a safe and nonstressful envi-
ronment. Children in a group can practice introducing themselves to
one another, prompt additional vocal speech from each other, maintain
eye contact with each other, and converse, for example. Finally, group
intervention often facilitates building friendships and social support,
which may lower the risk of future relapse.
Group intervention can be effective, but several caveats must be
recognized. First, not all children will advance at the same pace during
your intervention. Some children will move quickly during your inter-
vention and others will require more time. Be sure no child feels com-
pelled to do something she is not ready to do just because another
group member has already reached a certain level. Second, form a group
based on similarities in child age, cognitive functioning, and speech
level. Do not mix children of different ages, developmental ability, or
degree of selective mutism. Children tend to model positive effects
from peers who are closer to them personally with respect to these char-
acteristics.
Third, consider whether children with selective mutism in your
proposed group primarily have issues related to anxiety, oppositional
behavior, or communication problems. I recommend maintaining
homogeneous groups so that these characteristics are largely separate.
Keep children whose selective mutism relates primarily to social anxiety
separate from those who are clearly more oppositional, for example.
Of course, some overlap in characteristics will occur and this is accept-
able. Recall that many children with selective mutism share character-
istics of anxiety and oppositional behavior. Finally, you may find that
not enough children are available at your school to form a group, so the
procedures discussed in this book would obviously have to be applied
to individuals.
Family Therapy
Family therapy regarding this population refers to educating family

members about selective mutism, exploring family patterns of commu-
nication, addressing enmeshed or overcontrolling parent–child rela-
tionships, and reducing family member pressure on a child to speak.
As mentioned in Chapter 1, you may not have the time or resources to
conduct formal family therapy for a particular case of selective mutism,
but addressing family dynamics to some extent in many of these cases
is crucial for success.
Several researchers have noted that parents of children with selec-
tive mutism tend to be meek, shy, or verbally reserved themselves. You
may find as you address a particular case that parents will also need to
be encouraged to engage in more social, verbal, and otherwise interac-
tive behavior. These parents may also need more information concern-
ing the long-term negative consequences of selective mutism and why
early intervention is important. Some parents and children have a
deeply enmeshed relationship, meaning the parents are overinvolved in
many aspects of the child’s life. During the course of the intervention
you may find that parents need instruction about how to permit a child
to speak and engage in exposures independently. Some parents prefer to
“rescue” their child from anxiety-provoking situations, but this does
not allow the child to practice skills necessary to manage anxiety and
build social and verbal skills.
Other parents tend to be more controlling or domineering in
their approach toward their child and may insist that the child speak
when he is not ready to do so. These cases demand a more measured
approach in which a child gradually speaks in increasingly difficult situ-
ations. Parents should be encouraged to support this gradual approach,
eliminate belligerence when addressing the child, and refrain from
harsh punishments. Addressing these dynamics can often be done in

the context of contingency management practices, especially as
you work with parents to implement moderate rewards and disincen-
tives, restructure commands, and develop effective morning and other
routines.
Pharmacological Intervention
Pharmacological intervention or medication for selective mutism has

been evaluated by some researchers but supporting data remain pre-
liminary. The predominant medication for selective mutism has been
antidepressants, particularly phenelzine, fluoxetine, sertraline, fluvox-
amine, citalopram, and paroxetine. Other medications, such as anxi-
olytics and neuroleptics, have been less commonly used. Most studies
reveal a moderate effect for reducing selective mutism, although side
effects and adverse food and drug interactions are of substantial con-
cern in young children with the disorder.
Medication for selective mutism may decrease physical arousal but
does not necessarily enhance social or related skills necessary for full
symptom improvement. Medication in conjunction with behavioral
techniques may be most applicable to severe cases of selective mutism.
Medication is likely a good choice if a child has very severe anxiety
symptoms that clearly interfere with your ability to implement tech-
niques such as exposure-based practice. You may find that a referral to
a pediatrician or psychiatrist may be necessary in these cases (see the
referral box in Chapter 1).
Internet Intervention
Some researchers (Fung, Manassis, Kenny, & Fiksenbaum, 2002)

reported an innovative use of an Internet-based program for a 7-year-
old child with selective mutism. The researchers emphasized education
about selective mutism, recognizing symptoms of anxiety, using spe-
cific social skills, and practicing anxiety management techniques over
weekly sessions. Homework assignments, such as situations where
speech could be practiced, were provided via email. This approach is
preliminary but may be useful if family members are unwilling or
unable to meet or if you do not have direct access to the child with
selective mutism.
Special Issues Regarding Intervention for Selective Mutism
As you address children with selective mutism and reluctance to speak

you will find that special issues often arise. This section covers many of
the special issues I have faced in my clinic and some of the strategies
that I and other researchers have used to overcome them and maximize
therapeutic effectiveness.
Bilingualism
A particularly difficult issue that arises with some cases of selective

mutism is family bilingualism and a tendency to predominantly speak
a non-English language in the home. I have encountered many cases of
selective mutism where a child will not speak at school in part because
his proficiency with the English language may be limited. Recall that
the diagnostic criteria for selective mutism rules out children who lack
knowledge of, or comfort with, the spoken language required in the
social situation. A child who recently moved to the United States from
South Korea and was placed in an elementary school where everyone
spoke English would naturally be unable to communicate and therefore
would not receive a diagnosis of selective mutism.
The problem that arises is that gray areas exist regarding this diag-
nostic criterion. A typical example is a child who can speak English but
not particularly well because his parents primarily or exclusively speak
a non-English language such as Spanish at home. The child may not
have a communication disorder and may even be willing to speak more
but naturally feels uncomfortable or unsure of himself at school. The
child may fear social rejection or have trouble understanding what the
teacher is saying. Some of these kids remain shy and fail to speak even
when addressed in their parents’ primary language, however.
Several suggestions can be made regarding this situation. First, I do
encourage parents to speak English in the home to a greater extent. I do
not advocate a wholesale adjustment of a family’s value system, but
do try to convey to parents that a child’s better proficiency at English
will enhance his ability to speak clearly to others at school and partici-
pate more meaningfully in academic endeavors. Sometimes this means
that parents need to learn English themselves, bring someone into
the family unit who can converse with the child in English more, or
practice English for a set period of time per day. Most parents I have
encountered are receptive to these ideas and understand the rationale

for them.
Second, the techniques discussed in this book can still apply to a
child in a bilingual type of situation. You may need to enlist the help of
a translator or a cotherapist who speaks the parents’ language, but do
not allow the child or a sibling to translate your statements to the par-
ents. Collaboration with multilingual school personnel may be espe-
cially useful in these cases. Third, I have found that extensive
self-modeling (see Chapter 4) is useful not only to address selective
mutism but also to show parents how you and others will positively
respond to the child’s use of clear, audible English. You may even wish
to extend this process by showing the parents a videotape of their child
speaking English to others at school.
Fourth, I recommend extensive home visits with parents who speak
little English and who may have withdrawn themselves from many
aspects of their child’s education. Many parents in this situation avoid
parent–teacher conferences, participation in orientation and other ses-
sions at school, and discussions about intervening in a child’s speaking
problem. Home visits allow you to establish rapport, convey the impor-
tance of addressing selective mutism, observe family customs and values,
and conduct home-based exposures. Consider closely any cultural
factors that may impinge on your intervention, such as a parent’s belief
that a child should obey directives without the use of rewards.
Finally, you will need to address negative, prejudiced, or otherwise
biased views of the child and his language and cultural values at school
(Toppelberg, Tabors, Coggins, Lum, & Burger, 2005). Teachers and
other school personnel sometimes ignore or become intolerant of chil-
dren who struggle with English. Peers can obviously be harsh as well.
A child faced with a stressful and threatening learning environment will
likely not speak frequently even with extensive intervention. Some cases
of selective mutism thus demand a systemic approach to reduce ostra-
cizing behaviors within a classroom or school.
Difficult Parents
Do you ever have to face difficult parents? Of course you do! Some
parents can obviously be quite challenging to work with and seem to
defy many of your suggestions regarding a particular problem. These
parents may be hostile, skeptical, suspicious, evasive, and pessimistic
about change. You will find some belligerent or combative parents of

children with selective mutism, but this is unusual unless the child is
older or has many comorbid problems such as attention deficit/hyper-
activity disorder or aggression. If you do encounter antagonistic or
argumentative parents, I generally recommend the following:
• Increase collaborative contact with parents via telephone calls or
email or other daily correspondence.
• Meet parents at school or in the home to explain the child’s
speaking problem and discuss means to address the problem. Invite
other professionals working with the family (e.g., pediatrician,
psychiatrist, therapist) to attend the meetings if possible.
• Provide parents with options, such as developing a 504 plan or
conducting in-school exposures, that can accommodate a child’s
needs and allow for effective intervention.
• Explore potential obstacles to your proposed intervention and
suggestions to overcome them.
• Explore the need for a referral to other professionals for extensive
parent or family problems that may interfere with the intervention.
• Outline how a preliminary intervention on your part with the child
has already led to some success regarding frequent and audible
speech, if applicable.
When working with parents of children with selective mutism,
I find that problems other than belligerence are more common. First,
many parents in this population are a bit shy, meek, or reserved them-
selves. As such, they may be slow to recognize that their child has selec-
tive mutism, have trouble grasping the concept of selective mutism,
and fail to understand that the disorder has led to other social and aca-
demic problems. As mentioned in Chapter 1, many parents believe
their child is simply shy and will eventually “grow out of ” whatever
problems he currently faces at school.
I strongly recommend giving the parents as much detail as possible
regarding how far afield their child is vis-à-vis nonverbal behavior.
Discuss with them teacher reports, academic records, and other data
that support your claim. One of the best pieces of evidence for parents
involves a personal but surreptitious observation of their child in the
classroom. Parents can be shown, for example, that their child speaks far
less than classmates (or not at all), withdraws from group activities, and
appears sad or anxious. I also recommend helping parents understand
the difference between common shyness and selective mutism. People

who are shy still interact with others and enjoy academic success, but
children with selective mutism rarely if ever speak, which may lead to
substantial social and academic problems.
Encourage reluctant parents to allow you to begin a limited inter-
vention plan such as some home-based exposures or some self-modeling
at school. Involve parents as much as possible in these endeavors and
show them incremental progress. For example, parents may see that
even a few exposures led to a nice conversation between you and their
child or that a school-based exposure with the teacher led to their child’s
ability to ask to use the restroom. Outline for parents how extended
intervention can lead to other, specific advances in their child’s frequent
and audible speech.
A common second problem is intervention noncompliance, mean-
ing that some parents are not very good at implementing recommenda-
tions to increase a child’s exposure to speaking situations, administer
appropriate consequences, develop a child’s social skills, or extend a
school-based language program at home. Some parents are confused
about doing these things and others parents lack the energy, motiva-
tion, or wherewithal to do so. Whatever the reason, treatment noncom-
pliance will be highly damaging to your attempts to fully address
selective mutism.
Intervention noncompliance may be addressed in several ways.
First, discover the exact reason why parents are having trouble following
through with your recommendations. Parents often have good inten-
tions but simply lack the energy, time, or skills to implement a compli-
cated intervention. I commonly ask parents, after they have agreed to a
wonderful intervention plan, what could possibly go wrong. I am always
surprised by the number of potential problems they raise, but all poten-
tial problems must be addressed before the intervention begins. Parents may
say, for example, that they simply have too hard a time denying their
child ice cream if he does not speak clearly to a clerk or are not struc-
tured enough to schedule formal exposures. In other cases, peer conflict
needs to be resolved or reluctant teachers need to agree to participate
more fully in the intervention process before you can begin.
You may find it necessary to simplify your intervention to fit
the family’s ability. This may mean adopting a slower pace to interven-
tion, giving parents and their child fewer therapeutic homework assign-
ments during the week, or emphasizing areas in which the parents and
child excel. Regarding the latter, you may find that parents and children
have no trouble practicing anxiety management techniques or conduct-
ing spontaneous exposures in community settings. Emphasizing what
the parents and child can do will, at a minimum, help produce some
gains in speaking and perhaps prevent the problem from getting worse.
Be aware as well that many children increase the severity of misbehav-
ior after parents and school personnel begin to implement an interven-
tion. Increased misbehavior is often designed to force parents to
acquiesce to the status quo. This misbehavior may come in the form of
tantrums, increased compensatory behavior, crying, or greater with-
drawal. Parents should be made aware of this possibility, instructed to
extinguish the misbehavior via consequences (Chapter 5), and main-
tain the components of intervention such as exposures.
Comorbid Psychiatric Disorders
As mentioned in Chapter 1, certain mental disorders or other problems

are sometimes comorbid with selective mutism. Common examples
include anxiety disorder, depression, or trauma-related experiences, but
other problems could be involved as well. Many of the techniques
described in this book—especially exposure-based practices—are also
useful for children with considerable levels of general, separation, and
social anxiety. If a child with selective mutism appears anxious in differ-
ent situations, then relaxation and breathing training, exposure-based
practice, and cognitive therapy may be used. As with areas of speaking,
hierarchies can be developed (Chapter 3) regarding anxiety-provoking
situations that the child can eventually master.
Sadness and depression are sometimes a part of selective mutism as
well, especially if a child seems socially alienated. In many cases, the
sadness will dissipate as a child becomes more comfortable speaking to
others. If a child with selective mutism does seem particularly sad, then
emphasize social skills training, participation in extracurricular activi-
ties, and friendship development in addition to techniques to increase
audible speech. In other cases, however, especially with adolescents,
comorbid depression is not completely related to selective mutism and
may be severe. A referral to a child psychologist or psychiatrist is thus
recommended (Chapter 1).
Finally, failure to speak may occasionally be related to a traumatic
experience the child encountered. Examples include personal or family
member illness, accidents, maltreatment, or peer victimization. Failure

or refusal to speak can actually be adaptive for some children who try
to avoid abuse. These cases demand a much more sensitive approach
that usually requires helping a child address the traumatic incident
before proceeding to techniques for selective mutism. In other cases,
treatment for selective mutism can perhaps lead to the child’s ability to
discuss the traumatic event. If a child shows symptoms of posttrau-
matic stress disorder, however, then I recommend referral to a child
psychologist or psychiatrist.
Mental Retardation and Other Developmental Delay
Another special issue that can arise with cases of selective mutism is
mental retardation or other severe developmental delay. Some of the
recommendations made in Chapter 6 are also useful for addressing
children with selective mutism and developmental delay. In other cases,
the developmental delay is severe (e.g., autism) and so language train-
ing tailored for that problem is necessary. If you wish to treat a child
with selective mutism with severe cognitive limitations, you should
adopt a slower pace of intervention, eschewing cognitive techniques
and emphasizing behavioral ones (e.g., exposure-based practice, shap-
ing, contingency management), and integrating your approach into
other programs designed to boost adaptive and social skills.
Final Comments
I hope you find this book helpful in addressing children with selective
mutism or reluctance to speak. I and my graduate students have treated
many of these children for years and so I know how time-consuming,
intense, and personally frustrating many of these cases can be. Please
remember that the work you do with these children is extremely important!
You may find little reward or praise from others when a child success-
fully speaks for the first time and on a regular basis, but be assured that
you have made a gigantic difference in that child’s life. You have opened
the door for that child to achieve greater social and academic progress
than she could have achieved by failing to speak to others. Keep up the
great work!
Appendix
Publishing Companies and Information Regarding

Measures Described in Chapter 2
Multi-Health Systems (North Tonawanda, NY, www.mhs.com).

Pearson/PsychCorp (San Antonio, TX, www.pearsonassessments.com,
www.psychcorp.com).
Pro-Ed (Austin, TX, proedinc.com).
Western Psychological Services (Los Angeles, CA, wpspublish.com).
Child Behavior Checklist and Teacher’s Report Form (Achenbach System of
Empirically Based Assessment, www.aseba.org).
Children’s Depression Inventory (Multi-Health Systems, www.mhs.com).
Child Symptom Inventory-4 (Western Psychological Services, www.wps-
publish.com).
Conners Rating Scales (Multi-Health Systems, www.mhs.com).
Multidimensional Anxiety Scale for Children (Multi-Health Systems, www.
mhs.com).
Screen for Child Anxiety-Related Disorders (from author Boris Birmaher,
Department of Psychiatry, Western Psychiatric Institute and Clinic,
Pittsburg, PA).
Social Anxiety Scale for Children-Revised and Social Anxiety Scale for
Adolescents (from author Annette La Greca: Social anxiety scales for
children and adolescents: Manual and instructions for the SASC,
SASC-R, and SAS-A [adolescents], and parent versions of the scales.
Department of Psychology, University of Miami, Miami, FL).
Social Phobia and Anxiety Inventory for Children (Multi-Health Systems,
www.mhs.com).
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learning and cognition. Malden, MA: Wiley-Blackwell.
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1 Selective Mutism and Reluctance to Speak:

Jenny refuses to speak around unfamiliar individuals, even at home.

Miguel comes from a bilingual household. He does not speak to

D o these cases sound familiar to you? As a school professional, you

Purpose of This Book

The purpose of this book is to illuminate the characteristics of youths

Types of Cases Covered in This Book

many years or that involve intense additional problems such as severe

Referrals to Mental Health Professionals

This book is helpful if no legitimate reason exists for a child’s

Selective Mutism: Diagnostic Features

You might be confused by the many terms used to refer to selective

Table 1.1 Historical Terms Used for Selective Mutism

Speech phobia Ideogenic mutism

in social situations and, especially public situations such as schools,

A second issue surrounding a child’s ability to speak well at home is

Table 1.2 Diagnostic Features of Selective Mutism

Persistent failure to speak in speciﬁc social situations in which speech is

presented at the beginning of this chapter. I have seen many children

Selective Mutism: Associated Features

Some children with selective mutism are also physically anxious

heavily on managing rewards and other consequences for speaking and

Children may display selective mutism for several reasons, all of

Table 1.3 Associated Features of Selective Mutism

Social anxiety and social phobia (fear)

address severe attendance problems [When Children Refuse School: A

Selective Mutism: Epidemiology, Course, and Family

Selective mutism occurs in about 0.2–2.0% of children and adolescents

or inadequate language or social skills. An infamous example of some-

Selective Mutism and Reluctance to Speak

but seem quite intimidated by teachers and other school personnel.

A Working Model of Selective Mutism and Reluctance

Researchers are still developing a comprehensive model of selective

Decrease social anxiety,

Selective mutism Refusal or failure to speak or

Completing tasks for a child,

Figure 1.2. Model of selective mutism and reluctance to speak.

As mentioned, selective mutism appears to be closely linked to

Introduction to Intervention Techniques Discussed in

The most common and empirically supported interventions for selec-

Table 1.4 Key Intervention techniques for Selective Mutism

Exposure-based practice refers to a collection of techniques that require

Exposure-based practice usually involves a hierarchy of speaking

Relaxation Training and Breathing Retraining

As mentioned, youths with selective mutism may have uncomfortable

Stimulus fading involves systematically increasing the difﬁculty of an

Shaping and Prompting

Shaping refers to reinforcing successive approximations of a desired

Self-modeling involves asking parents to audiotape or videotape a child

The recording is then replayed in a low-frequency speaking situation

The techniques described so far focus largely on a child’s anxiety-based

Another behavioral technique for cases of selective mutism that involve

child the opportunity to escape a boring and potentially stressful situa-

Another key subtype of selective mutism involves kids with language or

Speaking to teachers on the playground _ _