BEYOND SHYNESS:

Evidence Based Assessment and

Intervention for Selective Mutism
Katelyn Reed, MS, LLP Taylor Hicks-Hoste, Ph.D., LP, NCSP
Definition of SM (DSM-V)
• Specific anxiety disorder
• Consistent, ongoing failure to speak in specific social situations, especially school
• Not due to a primary language disorder
• Other disorders (e.g., stuttering, autism) have been ruled out
• At least one month in duration (not limited to the first month of school)
• Behavior is deliberate self-protection, not deliberate oppositionality
Common Traits

Mutism Heightened sensitivity

Excessive worries
Blank facial expression,
freezing, poor eye contact
Oppositional/bossy/
inflexible behavior at home
Difficulty responding and/or
initiating nonverbally
Intelligent

Slow to respond Bilingual

Shyness vs. Selective Mutism

Shyness Selective Mutism

• Slow warm up period • Warm-up time MUCH
longer than expected
• Can often respond • Cannot respond at all
with a nod or small -may appear frozen
smile • Dual personality –
• Same demeanor restrained at school
everywhere – quiet and talkative at home
and reserved
Where Does SM Originate?
• NO evidence of causal relationship to
abuse, neglect, or trauma
• Genetic predisposition model (genetic
loading)
• Biological indicators
• Decreased threshold of excitability in
amygdala
• Amygdala reacts more and takes
longer to return to normal
Conceptualizing Selective Mutism
Child is
prompted to
speak or engage

Increased Child gets too

likelihood of anxious and
avoidance avoids

Negative
reinforcement Adult rescues
of behavior

Decreased
anxiety (child
and adult)
Common Comorbidities
• Other anxiety diagnoses
• Social Anxiety
• Separation Anxiety
• Generalized Anxiety
• OCD
• Specific Phobias
• Speech and language disorders/delays (Manassis, 2003; Klein et al, 2012)
• Oppositional behavior
Prevalence Statistics
• Most recent stats show approximately 1%....and growing?
• 1.5-2.6 / 1 female / male Garcia et al (2004)
School Implications
• Academic implications
• Difficulty (if not inability) to assess skills
• Risk of falling behind due to less practice than their peers
• High state of anxiety during the school day may contribute to attention concerns
• Children with SM are often unable to ask clarifying questions
• Behavioral implications
• Participation (partnered work, small group, full class)
• Bathroom accidents
• Often need additional assistance to get needs met in school
• Social Implications
• Social skill dyfluencies (due to lack of practice)
• Decreased chances for engagement, resulting in fewer opportunities for practice of social
problem solving skills
ASSESSMENT AND
INTERVENTION
Evaluative Tools
• Selective Mutism Questionnaire (SMQ)
• School Speech Questionnaire (SSQ)
• Videos from home
• And….
• BASC
• SCARED (Self-Report for Childhood Anxiety Related Disorders) for 8+
• Autism Diagnostic Observation Schedule (ADOS-2)
• Speech/language evaluation
• IQ (nonverbal)
• Etc…
 Name of Child:____________________________ Completed by:_________________________ Date:________

Selective Mutism Questionnaire* (SMQ)

Scoring (to be filled out by parents)

Please consider your child’s behavior and activities of the past month and rate how frequently each

1. Add totals statement is true for your child.

AT SCHOOL

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

3
Always
2
Often
1
Seldom
0
Never
X 0+0+0+0+0+0=0/
section 2. When appropriate, my child talks to selected peers
(his/her friends) at school.
3. When called on by his or her teacher, my child answers.
X
X 6=School=0
4. When appropriate, my child asks his or her teacher
2. Divide by questions.
5. When appropriate, my child speaks to most teachers or
X

X
staff at school.
number of 6. When appropriate, my child speaks in groups or in front
of the class.
X
How much does not talking interfere with school for your
items in child? (please circle) Not at all Slightly Moderately Extremely

section WITH FAMILY

Always Often Seldom Never

3. For total 7. While at home, my child speaks comfortably with the

other family members who live there.
8. When appropriate, my child talks to family members
X
3+2+2+3+2+2=1
X
score, add while in unfamiliar places.
9. When appropriate, my child talks to family members that
don’t live with him/her (e.g. grandparent, cousin).
X 4/6=
10. When appropriate, my child talks on the phone to his/her
up totals parents and siblings.
11. When appropriate, my child speaks with family friends.
X
X
Family=2.33
12. My child speaks to at least one babysitter. X
in each How much does not talking interfere with family
Relationships? (please circle) Not at all Slightly Moderately Extremely

section – IN SOCIAL SITUATIONS (OUTSIDE OF SCHOOL)

DO NOT 13. When appropriate, my child speaks with other children

Always Often Seldom Never
X

divide
who s/he doesn’t know.
14. When appropriate, my child speaks with family friends
who s/he doesn’t know.
X
0+1+2+0+0=3/5
15. When appropriate, my child speaks with his or her doctor
and/or dentist.
X = Other=.6
16. When appropriate, my child speaks to store clerks and/or
X
waiters.
17. When appropriate, my child talks when in clubs, teams or
X
organized activities outside of school.
How much does not talking interfere in social situations
for your child? (please circle) Not at all Slightly Moderately Extremely Total 0+14+3=17
Lower scores represent less frequent speaking behavior (more severe selective mutism
symptoms).

Average Scores For Scores for Scores for

Child’s
Children with SM who Children with Children
Score
are Age 3 – 5 years SM without SM
School 0 .33 (-.11 - .77) .30 2.65
Home/Family 2.33 1.62 (.99 – 2.25) 1.70 2.90
Public/Social .6 .28 (-.12 - .68) .34 2.50
Total 17 13.18 (7.14 – 19.22) 12.99 46

Average Scores For Scores for Scores for

Child’s
Children with SM who Children with Children
Score
are Age 6 - 8 years SM without SM
School .54 (0 – 1.08) .30 2.65
Home/Family 1.52 (.90 – 2.14) 1.70 2.90
Public/Social .40 (-.07 - .87) .34 2.50
Total 14.37 (6.93 – 21.81) 12.99 46

Average Scores For Scores for Scores for

Child’s
Children with SM who Children with Children
Score
are Age 9 - 11 years SM without SM
School .62 (.06 – 1.18) .30 2.65
Home/Family 1.58 (.85 – 2.31) 1.70 2.90
Public/Social .53 (-.03 – 1.09) .34 2.50
Total 15.73 (7.9 – 23.56) 12.99 46

Bergman, R. Lindsey, Keller, Melody L., Piacentini, John and Bergman, Andrea J. (2008) The
Development and Psychometric Properties of the Selective Mutism Questionnaire.
Journal of Clinical Child and Adolescent Psychology, 37: 2, 456-464.
 
Behavioral Observation
  Who did s/he What did     Strategies
Condition communicate s/he say? How did s/he   utilized or
to? communicate? Track: suggested:
  Parent Respond Nonverbal Open-ended:
 
 
Sibling Initiate Whisper Forced Choice:  
  Novel person   Altered Voice/ Nod/Shake:
 

 
  Appearance Point:
One word “Counting” with
2-3 words fingers:
Longer Other:
utterance
       
 
 

Comments:  
 
 
 
 
 
 
 
 
Testing Accommodations
• Nonverbal testing methods, when possible
• Parents trained to administer, clinician monitors administration and scores (work of Klein,
Armstrong and colleagues)
• Rapport and speech building session to be conducted before testing

• Limitations to validity is assumed

• Children with SM more likely to provide 1 word or other short responses for professionally-
administered measures (Gray, Jordan, Ziegler, & Livingston, 2002)
• Children with SM may be unable to take “educated guess” for items approaching their individual
ceiling
• May be unable to ask clarifying questions
• All data likely under-estimate true ability
Research on Behavioral Treatment
• Most supported treatment per research (Kratochwill, 1981; Krohn et al, 1992; Leonard &
Topol, 1993; Tancer, 2002, etc.)
• Effective in increasing production of speech in social situations ( Stone & Kratochwill, 2002)
• RCT: 75% of children in the behavior therapy condition responded to treatment (e.g.,
showed increased functional speaking) while children in the waitlist condition did not
show significant change (Bergman et al. 2013)
• Even more effective when combined with behavioral school and home-based exposure
program (Bergman, 2005)
• Exposure-based practice may be more effective than parent-focused contingency
management (Vecchio & Kearney, 2008)
• Gains made in school-based intervention plans maintained in 5 year follow-up studies
(Oerbeck et al, 2018)
Psychoeducation
• Brain “tricks” us and tells us things are very scary when they are uncomfortable
but manageable
• Need to boss back our brains and try being BRAVE
• Sour candy metaphor
• Using Subjective Units of Distress Scale
• 1-5 or 1-10
• Easy/Medium/Hard
Exposure Model
• Face fears at a reasonable pace
• Scaffold verbal demands such that they move from easier to harder
• Build bravery with each practice (reduce anxiety with each practice)
• Practice repeatedly
• Shorter, but more frequent sessions, if possible

• Offer reinforcement for task completion

• Stickers, points, weekly log that is communicated to parents
  0 1-2 3-4 5 or

  times times times more

Goal:   times

       

1.

       

2.

       

3.

       

4.

       

5. Bonus!! Did something really awesome!!

Avoid Accidental Rescuing
Child Directed Interaction Skills
• PRIDE skills
• P- Praise
• R- Reflection
• I- Imitate
• D- Describe
• E- Enthuasiasm
Verbal Directed Interaction Skills
Do Don’t
Ask Forced Choice Questions Ask yes/no questions
Offer verbal scripts of what to say “Mind read”
Find a Plan B to get a response Allow avoidance of speaking
Encourage appropriate volume Encourage whispering
Direct questions and expectations for speaking Indirect questions
Wait 5-7 seconds for responses Moving on quickly
Patience Seeming anxious/stressed also
 Teacher
Question

Verbal Non-verbal
No Response
Response Response

Wait 5 sec, Wait 5 sec,

Labeled
repeat probe for
Praise
question verbal

Verbal No response
response or nonverbal

Wait 5 sec,
Labeled
reduce
praise
expectations
Time to practice!
 Shaping
• Slowly increasing to full speech from current ability level
Spontaneous Initiation

Scripted Initiation

Full sentence responding

2-3 word responding

1 word responding

Yes/no responding

Sound combinations

Letter sounds
Setting Appropriate Goals/ Shaping

Highest goals Greetings, social niceties, specials’

classes, performances, etc.

Large group Full class speaking, raising hand/initiating,

presentations

Small group Reading group, speech at assigned table, social skills group, lunch bunch

1:1 speech Parents to assist child in speaking to teacher or interventionist, introduce new adults or new peers 1 by 1
Stimulus Fading
• Gradually increasing the number of different people the child speaks to and
settings the child speaks in
• Gradually introducing new people into conversations
• Speaking in new settings with the help of stimulus associated with speaking (e.g.,
communication ladders with speaking partner or keyworker)

https://drive.google.com/file/d/0B0FTysH_x-MPX1NraEtsWVlMakE/view?ts=58ab611f

Can fade in:

Adults
Peers
Groups
Time to practice!
Video Self-Modeling
• Researched as stand alone intervention, whereas many other CBT techniques have
been researched in a package.
• Behavioral procedure wherein video splicing is used to create a recording of child
with SM “talking” to a teacher or another person in the school
• Shows child what it would be like to speak to the NCP

• Can be discrete words spliced together to create full sentences.

• Can be whole sentences spliced together to replicate a conversation
Predictors of Treatment Effectiveness
• Age
• Severity
• Parent involvement
• School involvement
• Professional involvement
School-based Supports:
504 Accommodation Plan
• Extra time to answer questions, during instruction and • Seat assignment next to comfortable peer; away from
on assessments door; back of the classroom
• Student should be included in all classroom activities; • Assigned schedule times for bathroom breaks
participation should be encouraged (e.g., assigning
nonverbal jobs/responsibilities such as cleanup, line • Parents/student notified of changes in routine and/or
leader) special large group activities (e.g., substitutes, fire drills,
schedule changes, field trips)
• Access to small-group instruction
• Allow student and parents to access school environment
• Access to small-group test taking outside school hours (e.g., arrive early, stay late,
summer hours if possible)
• Extended time on tests
• Opportunity to meet teacher prior to school year
• Alternative methods for oral assignments (e.g., 1:1
setting, pre-recorded video) • Participation in social skills group
• Access to nonverbal assessments when possible
• Opportunities for exposure-based practice, 3-5x per
week for 15-30 minute sessions with a key worker
• Home-school communication provided daily/weekly
School-based Supports:
Individualized Education Plan
• A student may qualify for an IEP under the category of
• Other Health Impairment (OHI)
• *would require diagnosis of SM from a medical professional (MD or DO)
• Speech & Language Impairment (SLI)
• Emotional Impairment (EI)
• An IEP may include the aforementioned accommodations, as well as
direct/consultation service time with a special education provider (e.g., SLP, SSW)
How to decide between a 504 vs. IEP?
• Does child require accommodations and/or specialized instruction?
• Most important component of school-based support is providing opportunities for
brave work within the school setting
• In your district, which document will guarantee the student opportunities to work with a
keyworker?
• Also consider additional services/supports student may need:
• Academic supports?
• Speech and Language supports?
• Social skill supports?
 Brave Work in the Schools
Setting
• Brave work (i.e., exposure-
based practices) are
facilitated by a key worker
• •
Any adult who consistently 1:1
has time to work with the
student
• e.g., Paraprofessional,
classroom assistant,
interventionist, special
Small Group
education team member,
specials teacher, custodian
Practice Ideas
• Responding to, and initiating speech, in context of a game with key
worker
Maintaining speech across settings (e.g., lunch room, play ground,
walking down the hall)
• Initiating/responding with NCP (e.g., lunch aide, bus driver, office
secretary, paraprofessional, specials teacher)
• Playing game with peers
• Participating in an academic- or social skills intervention group
• Participating in small group lesson within the classroom, facilitated
by teacher

• Having 1 person serve as a • Sharing idea in front of the whole class

• Raising hand and asking a question
key worker is ideal • Giving a presentation
Large Group
• Remember, only change 1
variable at a time
Take-Home Points
• Children aren’t mute because they WON’T speak but because they CAN’T speak.
• Early behavioral intervention is key.
• Treatment can be VERY effective in treating Selective Mutism.
• A team approach to treatment is essential.
Questions?