Selective Mutism: Summary of Issues, Websites, & Bibliography

(Prepared for members of the 3/7/05 Selective Mutism chat on http:// lan#ua#epatholo#ist!or#$
by Suzanne Hungerford, h!"!, ###$S% #ommunication "isorders and Sciences lattsburgh State &niversity of 'e( )or* suzanne!hungerford+plattsburgh!edu

!speech"

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%Selective mutism (SM$ is a profound pra#matic communication disorder and is ithin the scope of practice of speech/lan#ua#e patholo#ists (S&Ps$! Whom to treat: 'ids ho don(t spea' in certain social situations (usuall) school$ for *"+ ee's or more (not limited to the first month of school$, but do spea' in other situations (t)picall) home$! Who does the treatment: all professionals and families, or'in# as a team, initial -"- or' ma) be done b) school ps)cholo#ist, or speech"lan#ua#e patholo#ist! What to treat: nonverbal and verbal communicative behaviors in various ph)sical, social, and communicative conte.ts! When: /S/P Where: in all conte.ts0 pull"out ma) be needed at first! Ho(: behavior treatments (e!#!, successive appro.imations, reinforcement, stimulus fadin#$! Ph)sician on team ma) ant to add pharmacolo#ical treatment and/or famil) or individual ps)chotherap)! Why: selective mutism is educationall), sociall), communicativel), and vocationall) debilitatin#! .-/,.M/'. IS , ./,M /001-. 1s this a ps)cholo#ical disorder2 1s this a ps)chiatric disorder2 1s this a communication disorder2 1s this a learnin# disorder2 1s this a famil) problem2 1s this a school problem2 3es 3es 3es 3es 3es 3es 4eam member: 4eam member: 4eam member: 4eam member: 4eam member: 4eam member: school ps)ch!/clinical ps)cholo#ist ps)chiatrist, pediatrician speech/lan#ua#e patholo#ist teachers parents all involved school personnel

5ther team members are also possible! "I,2'1S.I# #-I./-I, 01- S/%/#.I3/ M&.ISM 45&1./" 0-1M "SM I3, ,M/-I#,' S)#HI,.-I# ,SS1#I,.I1'6 /! 6onsistent failure to spea' in specific social situations (in hich there is an e.pectation for spea'in#, e!#!, at school$ despite spea'in# in other situations! 7! 4he disturbance interferes ith educational or occupational achievement or ith social communication!

6! 4he duration of the disturbance is at least - month (not limited to the first month of school$! 8! 4he failure to spea' is not due to a lac' of 'no led#e of, or comfort ith, the spo'en lan#ua#e re9uired in the social situation! :! 4he disturbance is not better accounted for b) a 6ommunication 8isorder (e!#!, Stutterin#$ and does not occur e.clusivel) durin# the course of a Pervasive 8evelopmental 8isorder, Schi;ophrenia, or other Ps)chotic 8isorder! <ormerl): elective mutism More common in females (3:-$! =are! Ma) last onl) a fe months, or )ears, or ma) persist!

0,#.S ,B1&. S/%/#.I3/ M&.ISM

Speech/lan#ua#e dela)s/disorders (be)ond the pra#matic disorder of selective mutism$ ma) occur in up to 50> of children ith SM (Mc1nnes, et al!, ?00*$ 6onte.ts of Mutism o School o Stran#ers o 6hildren in #eneral o Specific children o <amil) o <ather o Mother o Siblin# > @A @A *? 3* -3 -* ?

(Schum, ?00-$

severe 7 Selective Mutism 7 mild

-eluctant Speech

Shy

'ormal

Communicative reticence is on a continuum

frozen statue more severe

normal body language, communicative (riting less severe

Selective mutism can be severe or less severe; involving only verbal communication, or involving verbal, written, gestural communication and spontaneous bodily movements.

,SS/SSM/'. ISS&/S
"ue to the nature of SM, assessment can be difficult!

'eed to assess: /ll facets of the pra#matic communication disorder (see belo $ o Parent intervie o 8irect observational assessment: school and home, if possible Bnderl)in# speech/lan#ua#e disorders o 1f child points, receptive communication s'ills ma) be testable (&indamood /uditor) 6onceptuali;ation 4est, PPC4, parts of 6:&<"*, etc!$ o 4herapist ma) #o to child(s home for testin# o /nal)sis of recorded lan#ua#e/speech sample from home o Darrative anal)sis of audiotaped narratives (see Mc1nnis, et al!, ?00*$ o Portfolio anal)sis (artifacts from classroom anal);ed$ /n.iet) o S&P ma) assess communication"related an.iet) b) adaptin# self"report measures used in stutterin# o Ps)cholo#ist ma) assess an.iet) /cademics o Portfolio anal)sis o /chievement testin# that re9uires onl) nonverbal response 6o#nitive Ps)cholo#ical Medical

,SS/SSI'2 .H/ -,2M,.I# #1MM&'I#,.I1' "IS1-"/#ommunication performance in SM is determined by a comple8 interplay among variables! .hese communication pressure variables may differ from child to child! .hese variables must be ta*en into consideration (hen assessing, (hen designing treatment plans, and (hen measuring treatment progress! Some of these important variables are: physical conte8t: classroom ( ith peers present, ith therapist alone, ith teacherE$, principal(s office, pla)#round, school librar), hall a), therap) room, mall, homeE0 type of communication re9uired: sharin# personal vs! non"personal information, sharin# 'no n information vs! novel, readin# a script or boo' vs! spontaneous conversation, rote vs! spontaneous, hi#hl) communicative (sharin# information$ vs! less communicative (namin# a picture, #ame conte.t$, )es/no ans er vs! other0 characteristics of communicative partner$others present in vicinity: familiarit), number present, #ender, peer or non peer, a#e, social role (teacher, principal, therapist$0 communicative functions: re#ulatin# another(s behavior, social interaction, #reetin#, Foint attention, ans erin# 9uestions, re9uestin# information, etc!! 7ehavioral re#ulation t)picall) easier than the social functions of lan#ua#e! /ns erin# 9uestions (non"personal first$ ma) be easier than as'in# 9uestions! interaction$communication modality: nonverbal turn"ta'in# (e!#!, ta'in# a turn in a #ame$, pointin#, ritin#, noddin#, hisperin#, voicin# ith lo volume, voicin# ith normal volume, pla)in# a to) instrument in a band (unvoiced instrument, e!#!, #uitar, then voiced, e!#!, 'a;oo0 or mouth instrument vs! manual instrument$, ma'in# speech noises in non"communicative conte.ts (ch ch ch ch to #o up the ladder, sssssss to #o do n the chute in #ame0 first unvoiced, then voiced$

#hec*list of #ommunicative 0unctions and Means

(1tems adapted from Pri;ant, Getherb) H =oberts, -AA3$ 6hild(s initial: =ater(s name: 8ate of sample: 6onte.t and activit): 6ommunicative partner: 5thers present: Indicates :oint attention 'onverbally 2iving gesture ointing gesture Sho(ing gesture 1ther gesture 4e!g!, reaching, raise hand, push a(ay6 'ormal pro8imity to #ommunicative partner )es$no head nod$sha*e Shoulder shrug Shared affect e8pressed through facial e8pression Holds ob:ect$toy Manipulates ob:ect$toy -eciprocal play arallel play 0ollo(s a verbal re9uest for action ,ns(ers )es$'o ,ns(ers forced choice 9uestions Verbalization (speaking) #ommunicative 0unctions 4specify6: B, S, ;, 1< <
B = Behavioral regulation re9uest ob:ect re9uest action protest S = Social interaction re9uest social routine re9uest comfort greeting calling, re9uest permission, sho(ing off ; = ;oint ,ttention comment re9uest information provide information 1 = 1ther

W=(riting S=spontaneous '=non7verbal 4specify6 -=re9uested

3=verbal

2lobal Measure: > #ommunicative ,cts er Minute$Mode of #ommunication

I'./-3/'.I1'

%%%Most therap) ideas come from ps)cholo#)/ps)chiatr)! S&Ps have a uni9ue perspective and can provide uni9ue contributions to this field! S&Ps 'no that speech is more than motor movements to be shaped behaviorall) I spea'in# is a result of a comple. interpla) bet een motivation, lan#ua#e competence, social bac'#round, co#nitive/emotional demands, pra#matic pressures, communicative needs, communicative pressure, communicative competence, etc!! 1 su##est that e vie selective mutism D54 as a deficit in speech, per se, but a more #lobal deficit in communication (verbal/nonverbal$! 4his point of vie ill lead us to more pra#matic" oriented interventions that tar#et the communication deficit, rather than focusin# on the production of speech, per se (see socio"communication intervention model, belo $! ""SMJ /?,M %/S 10 .H/-, I/S:
Behavior modification 4 ecu*onis and ecu*onis, @AA@6 0i8ed ratio7 and then variable ratio7reinforcement 4primary reinforcers, to*ens, social praise6 for: 'on7verbal attending behaviors 'on7verbal imitation 4clapping, standing, touching toes6 3erbal imitation 4vocalizations, noun labels6 0unctional language 4open7ended 9uestions, etc!6 2eneralization 4use of parents and teachers throughout training *ept the trainer from being the only discriminative stimulus for spea*ing6 Puppets ere used b) trainers, parents and children durin# some of the intervention! Self modeling 4B,udio$3ideo feedfor(ard treatmentsC6 4e!g!, Blum, et al!, @AAD6 #hildren (ith selective mutism listened to audiotapes of themselves spea*ing! .hey brought the tapes from home and repeatedly listened to edited versions of them in situations in (hich they (ere not currently spea*ing 4school, community6! E, variant of this idea is Bvideo self7modeling!CF .he tapes are edited so that they appear that the child is ans(ering a person (ith (hom she$he does not currently spea*! ,nd$or they are edited to appear to be made in conte8ts in (hich the child doesnGt currently spea* 4classroom6! .hese authors report rapid success 4(ee*s6 in H children for (hom behavior therapy (as unsuccessful! #ombination of behavior modification, psychotherapy, and medication 4IoloftJ esp! for *ids (ith physical concomitants 4BstiffnessC6 4Schum, KLL@6 .herapy included: operant conditioning using successive appro8imations, modeling 4siblings, friends6, friends from school visit at home, use Btal*ing scaleC 4described belo(6, rehearsal 4reading familiar passage6! sychotherapy focused on an8iety and tal*ing about being brave vs! nervous!

Successive appro8imations 4from beginning point to end point6: eye contact, head nod, point, noisema*ers, (rite, (hisper (ord, (hisper phrase, (hisper responses at school, (hisper conversation, microphone at school for public spea*ing! .al*ing scale: "iscusses (ith child, and ran*ed spea*ing situations as being Bhard,C Bmedium,C or BeasyC: tal*ing to family, friends or therapistJ reading in class, reading in a group, ma*ing a video at school, tal*ing to classmates at lunch, giving an intervie(, etc! Stimulus 0ading Many therapists include a Bstimulus fadingC techni9ue! 1nce the therapist has the child communicating 4say, in a pull7out speech$language therapy room6, then, the therapist brings in classmates, etc! 4to *eep the therapist from being the only discriminative stimulus for speech6! Similarly, items and people from home can be brought in to school or therapy to ma*e the school environmental stimuli more li*e the home 4in (hich the child spea*s6! Self7reinforcement 4Mehle, et al! @AAD6 Mehle used an edited videotape! .he child (as instructed to pause the video (henever the tape depicted her verbally responding to the teacherGs 9uestions! ,fter pausing, the child (ould select a reinforcer 4pencils, stic*ers, etc!6 .hese researchers also played the videotape in the childGs classroom, to increase the e8pectations for peers that the child (ould communicate! Socio7communication intervention model for severe selective mutism 4Hungerford, et al!, KLLH6 , pragmatic model for therapy that first targets non7communicative, non7verbal reciprocal interaction! 1nce non7verbal interaction is established, therapy moves on to target reciprocal interaction (ith greater communicative demands, *eeping in mind that communicative pressure can be a result of: type of communication 4personal vs! non7personal, sharing *no(n information vs! novel contributions to conversation, reading a script vs! spontaneous conversation6J characteristics of communicative partner 4familiarity, gender, social role 4teacher, principal, therapist66J communicative functions 4regulating anotherGs behavior, social interaction, greeting, :oint attention, ans(ering 9uestions, re9uesting information, etc!6J communication modality 4nonverbal turn7ta*ing, pointing, (riting, nodding, (hispering, voicing6J and physical environment 4classroom, therapy room, school library, playground6! Whenever one of these variables changes, ma*ing for more spea*ing pressure, the therapist may need to move do(n the hierarchy N perhaps again targeting nonverbal reciprocal interaction and moving up the hierarchy to target more interactive, and more verbal behaviors! /ach therapy activity should be analyzed in terms of each of the above variables to determine the overall difficulty of the activity 4amount of communicative pressure6! 3ery small increases in difficulty should be used! .hough the design is pragmatic, the therapy targets are reinforced using a behavioral paradigm! %ong7.erm 1utcomes

It appears that there may be t(o types of SM: transient, in (hich the symptoms resolve (ithin a year, and chronic, in (hich the symptoms are longer lasting! #hildren (ith long7lasting SM are particularly difficult to treat! Symptoms of SM may be chronic in up to OLP of cases 4McInnes, et al!, KLLQ6! .here are not too many follo(7up studies, but here is one positive outcome 4from Mehle et al!, @AAL6: We also brought the formerly mute child to the University to discuss his elective mutism with graduate psychology students. This 6-year-old formerly mute child confidently walked into a rather large room and sat down at a table in front of appro imately !" strange adults# folded his arms and stated# well# what is it you want to know$% after & months follow-up indicated that the formerly mute child was functioning e tremely well. 'e freely communicated verbally with his peers and faculty. 'e also volunteered to assist the authors with other mute children who may be in the district.%

Websites
http:$$(((!asha!org$public$speech$disorders$Selective7Mutism!htm ,merican Speech %anguage Hearing ,ssociationGs site on selective mutism! (((!asha!org If you are an ,SH, member, you can access a number of :ournal articles on selective mutism here, by searching publications! http:$$(((!selectivemutism!org$ 4Selective mutism group, childhood an8iety net(or*, Inc!6 http:$$(((!acposb!on!ca$mutism!html 4.ips for teachers6 http:$$(((!an8ietynet(or*!com$ 4.he ,n8iety 'et(or*6 http:$$(((!nasponline!org$futures$selmutism!html 4BWhen the Words ;ust WonGt #ome 1utC77 &nderstanding Selective Mutism by /lisa Shipon7Blum, "!1!6

Selected -eferences
/dams, J!, H Klasner, P! (-A5*$! :motional involvement in some forms of mutism! Lournal of Speech and Jearin# 8isorders! -A! 5A"+A! /merican Ps)chiatric /ssociation (?000$! 8ia#nostic and Statistical Manual of Mental 8isorders, <ourth :dition, 4e.t =evision! Gashin#ton 86: /merican Ps)chiatric /ssociation! /to)natan, 4! J! (-A@+$! :lective mutism: 1nvolvement of the mother in the treatment of the child! 6hild Ps)chiatr) and Juman 8evelopment! -! -7! -5"?7! 7lac', 7!, H Bhde, 4! G! (-AA?$! :lective mutism as a variant of social phobia! Lournal of the /merican /cadem) of 6hild and /dolescent Ps)chiatr)! 3-! +! -0A0"-0A*!

7lum, D! L!, et al! (-AA@$! 6ase stud): /udio feedfor ard treatment of selective mutism! L! /m! /cad! 6hild /dolesc! Ps)chiatr), 37(-$, *0"*3 7ro ne, :!, Gilson, C!, H &a)bourne, P! (-A+3$! 8ia#nosis and treatment of elective mutism in children! Lournal of the /merican /cadem) of 6hild Ps)chiatr)! ?! +05"+-7! 6line, 4! H 7ald in, S! (-AA*$! Selective Mutism in 6hildren! &ondon: Ghurr Publishers! <ord, Mar) /nn0 Sladec;e', 1n#rid :!0 6arlson, Lohn0 Mratoch ill, H 4homas =! (-AA@$! Selective Mutism: Phenomenolo#ical 6haracteristics! School Ps)cholo#) Nuarterl), v-3 n3 p-A?"??7 Publication 3ear: -AA@ <riedman, =!, H Mara#an, D! (-A73$! 6haracteristics and mana#ement of elective mutism in children! Ps)cholo#) in the Schools! -0! ?*A"?5?! Kiddan, L! L! and =oss, K! L! (-AA7$! Selective Mutism in :lementar) School: Multidisciplinar) 1nterventions &an#ua#e, Speech, and Jearin# Services in Schools Colume ?@, 1ssue ?! Pa#es -?7 " -33 Kol )n, 8! J!, H Geinstoc', =! 6! (-AA0$! Phenel;ine treatment of elective mutism: / case report! Lournal of 6linical Ps)chiatr)! 5-! A! 3@*"3@5! Jarris, J! <! (-AA?I-AA3$! :lective mutism ith accompan)in# phonolo#ical disorder: / case report! Dational Student Speech &an#ua#e Jearin# /ssociation Lournal! ?0! 7@"@?! Ja)den, 4! (-A@0$! 6lassification of elective mutism! Lournal of the /cadem) of 6hild Ps)chiatr)! -A! -! --@"-33! Jill, &!, H Scull, L! (-A@5$! :lective mutism associated ith selective inactivit)! Lournal of 6ommunication 8isorders! -@! -+-"-+7! Jult9uist, /lan (-AA5$! Selective Mutism: 6auses and 1nterventions! Lournal of :motional and 7ehavioral 8isorders, v3 n?, p-00"07 Jun#erford, S!, :d ards, L!, H 1antosca, /! (?003$! / socio"communication intervention model for selective mutism! Paper presented at the conference of the /merican Speech"&an#ua#e"Jearin# /ssociation, 6hica#o! Mehle, 4! L!, Madaus, M! =!, 7aratta, C! S! H 7ra), M! /! (-AA@$! /u#mented self"modelin# as a treatment for children ith selective mutism! (ournal of )chool *sychology# +6(3$, ?*7"?+0! Molvin, 1!, H <undudis, 4! (-A@-$! :lective mute children: Ps)cholo#ical development and bac'#round factors! Lournal of 6hild Ps)cholo#) and Ps)chiatr) and /llied 8isciplines! ??! ?-A"?3?! Mratoch ill, 4! =! (-A@-$! Selective mutism: 1mplications for research and treatment! Jillsdale, DL: &a rence :rlbaum /ssociates! Mrohn, 8! 8!, Gec'stein, S! M!, H Gri#ht, J! &! (-AA?$! / stud) of the effectiveness of a specific treatment for elective mutism! Lournal of the /merican /cadem) of 6hild and /dolescent Ps)chiatr)! 3-! *! 7--"7-@! Mrolian, :! (-A@@$! Speech is silver but silence is #olden: 8a) hospital treatment of t o electivel) mute children! 6linical Social Gor' Lournal! -+! *! 355"377! &ebrun, 3! (-AA0$! Mutism! &ondonDe Lerse): Ghurr Publishers!

McInnes, ,!, 0ung, "!, Manassis, M!, 0i*senbaum, %! & .annoc*, -! 4KLLQ6! Darrative S'ills in 6hildren Gith Selective Mutism: /n :.plorator) Stud)! /merican Lournal of Speech"&an#ua#e Patholo#), 3olume @H, Issue Q! ages HLQ 7 H@O! 'ovember KLLQ Pecu'onis, :! C! H Pecu'onis, M! 4! (-AA-$! /n adapted lan#ua#e trainin# strate#) in the treatment of an electivel) mute male child! (. ,ehav. Ther. - . p. *sychiatr.# !!(-$, A"?-! Po ell, Sha n0 8alle), Mahlono (-AA5$! Ghen to 1ntervene in Selective Mutism: 4he Multimodal 4reatment of a 6ase of Persistent Selective Mutism! Ps)cholo#) in the Schools, v3? n? p--*"?3 /pr -AA5 Pustrom, :!, H Speers, =! (-A+*$! :lective mutism in children! Lournal of the /merican /cadem) of 6hild Ps)chiatr)! 3! ?@7"?A7! /uthor: Schill, Melissa 4!0 /nd 5thers (Sprin#, -AA+$! /n /ssessment Protocol for Selective Mutism: /nalo#ue /ssessment! Bsin# Parents as <acilitators! Lournal of School Ps)cholo#), v3* n- p-"?? Schum, =! (?00-$! Selective mutism! Presentation at the /merican Speech &an#ua#e Jearin# /ssociation 6onvention, De 5rleans, ?00-! Schum, =! (?00?$! Selective mutism: /n inte#rated treatment approach! 4he /SJ/ &eader, 7(-7$, *"+! Sheridan, Susan M!0 /nd 5thers(-AA5$! /ssessment and 4reatment of Selective Mutism: =ecommendations and a 6ase Stud)! Lournal 6itation: Special Services in the Schools, v-0 n- p55"7@ Shreeve, 8! <! (-AA-$! :lective mutism: 5ri#ins in stran#er an.iet) and selective inattention! 7ulletin of the Mennin#er 6linic! 55! *! *A-"50*! Shvar;tman, P!, Jornshtein, 1!, Mlein, :!, 3eche;'el, /!, Oiv, M!, H Jerman, L! (-AA0$! :lective mutism in famil) practice! 4he Lournal of <amil) Practice! 3-! 3! 3-A"3?0! Sma)lin#, &! M! (-A5A$! /nal)sis of si. cases of voluntar) mutism! Lournal of Speech and Jearin# 8isorders! ?*! 55"! Strait, =! (-A5@$! / child ho as speechless in school and social life! Lournal of Speech and Jearin# 8isorders! ?3! ?53"?5*! 4hompson, =! (-A@@$! :lective mutism: 1dentification and differential dia#nosis! 4e.as Lournal of /udiolo#) and Speech Patholo#)! -*! -! -?"-5! 4hompson, =! (-A@A, Dovember$! :lective mutism! Paper presented at the /nnual 6onvention of the /merican Speech"&an#ua#e"Jearin# /ssociation, St! &ouis, M5! Gil'ins, =! (-A@5$! / comparison of elective mutism and emotional disorders in children! 7ritish Lournal of Ps)chiatr)! -*+! -A@"?03! Gri#ht, J! &! (-A+@$! / clinical stud) of children ho refuse to tal' in school! Lournal of the /cadem) of 6hild Ps)chiatr)! ?*! +03"+-7!