Presented by Mary Beth Pummel

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Evidence Based
Selective Mutism
University of Utah

                                     Presented by: Mary Beth Pummel
    Training School Psychologists to be Experts in Evidence Based Practices for Tertiary Students with Serious
                                   Emotional Disturbance/Behavior Disorders

                                          US Office of Education 84.325K

                      Selective Mutism:
                        Diagnostic Features

       Failure to speak in specific social situations despite speaking
        in other settings (DSM-IV-TR).

       Children with selective mutism (SM) often rely on other
        forms of communication to function (gestures, shaking head,
        pointing, grunting, etc.) (Sharp, Sherman, & Gross, 2007).

       Frequently shy, behaviorally avoidant, fearful, and often
        oppositional (Kehle, Madaus, Baratta, & Bray, 1998).
                            Diagnostic Criteria

       313.23 Selective Mutism
           Consistent failure to speak in specific social situations despite
            speaking in other situations
           The disturbance interferes with educational or occupational
            achievement or with social communication
           The duration of the disturbance is at least 1 month
           The failure to speak is not due to a lack of knowledge of, or
            comfort with, the spoken language required in the social situation
           The disturbance is not better accounted for by a Communication
            Disorder and does not occur extensively during the course of a
            Pervasive Developmental Disorder, Schizophrenia, or other
            Psychotic Disorder.
                          Selective Mutism:
            History and Current Conceptualizations

       First described in 1877 as „aphasia voluntaria‟ by Kussmaul
        when documenting a condition in which an individual did not
        speak in certain situations, despite the ability to speak
        (Sharp et al., 2007; Viana, Beidel, & Rabian, 2008).

       Labeled as “elective mutism” in DSM-III and DSM-III-TR
           To reflect the voluntary condition of SM
           Conceptualized as a form of oppositional behavior

       Change to “selective mutism” in DSM-IV (1994)
           To reflect refusal to speak in specific situations
           Currently conceptualized as either a form of oppositional
            behavior or social anxiety
                         Selective Mutism:
                 Prevalence, Etiology and Course

       Less than 1% of school-age children meet diagnostic criteria
        (Sharp et al., 2007).

       No clear etiology: likely a combination of environmental and
        genetic factors (Viana et al., 2008)
           Family history of social phobia or other anxiety disorders
           Maladaptive reinforcement patterns

       Age of onset 2 to 5 years (Cunningham, McHolm, Boyle, Patel,
           Often a significant lag between onset and diagnosis/intervention
           Duration 37 to 151 months (m=6.9 years)
               Selective Mutism:
        Prevalence, Etiology and Course
       SM often occurs comorbidly with other anxiety disorders and
        other psychological symptoms (Sharp et al., 2007; Viana et
        al., 2008).
           Overlapping characteristics with social phobia
           Internalizing symptoms

       Comorbidity with externalizing disorders (Viana et al., 2008)
           Occurs in 6-10% of children diagnosed with SM

       The effect of treatment is stronger if treatment occurs shortly
        after the onset of SM (Stone, Kratochwill, Sladezcek, & Serlin,
                        Selective Mutism:
       Direct Observation

       Parent/Teacher/Child Interview

       Selective Mutism Questionnaire (SMQ) (Bergman, Keller,
        Piacentini & Bergman, 2008).

       Functional Behavior Assessment

       Behavior Rating Scales
           Behavior Assessment System for Children – Second Ed.
           Child Behavior Checklist
           Anxiety Disorders Interview Schedule
           Revised Children‟s Manifest Anxiety Scale
                     Selective Mutism:

       DSM-IV-TR Diagnostic Criteria

       Referral to Pediatrician and Speech-Language Pathologist
                         Selective Mutism:
                     Treatment and Intervention

       Behavior Therapy Models
           Applied Behavior Analysis (ABA)
           Combined approaches: principles of operant conditioning and
            social-learning theory
           Shaping, stimulus fading, contingency management,
            positive/social reinforcement (Stone et al., 2002).

       Self-Modeling
           Positive change in behavior that results from repeated
            observation of oneself producing the desired behavior (Kehle,
            Owen, & Cressy, 1990).
                    Selective Mutism:
               Treatment and Intervention
       Social Skills Training: eye contact, greetings (Fisak, Oliveros,
        Ehrenreich, 2006).

       Parent Training: anxiety management, increase opportunities
        for practice, positive reinforcement (Fisak et al., 2006)

       Social Problem Solving Intervention (O‟Reilly, McNally,
        Sigafoos, Lancioni, Green, Edrisinha et al., 2008)
           The student is taught a generic set of social rules that can be
            easily adapted to different social settings

       Pharmacological Treatment
           Selective Serotonin Reuptake Inhibitors (SSRIs)
           Monoamine Oxidase Inhibitor (MAOI) (Carlson, Mitchell, &
            Segool, 2008)
                        Selective Mutism:
                Fads and Non-EBP Interventions

       No controlled trials of treatment methods for Selective
        Mutism have been conducted (Viana et al., 2008; Stone et al.,
            Research literature consists mostly of single-case experimental
                         Selective Mutism:
       Beare, P., Torgerson, C., & Creviston, C. (2008). Increasing
             verbal behavior of a student who is selectively mute.
             Journal of Emotional and Behavioral Disorders, 16(4),

       Participant: 12 year-old boy, 6th grade student
           Referred for Sp Ed when 5 years old: 30-day trial in self-contained
            classroom for children with EBD
           Received various levels of treatments and placed in a variety of
            settings throughout course of education
           At time of study, in Reg Ed classroom with aide and 30 minutes of
            resource support per day
                          Selective Mutism:
       Assessment
           WISC-III Performance Scaled Score of 90
           WJ-II Revised Tests of Achievement: Scores within the average
            range on Math and Written Language

       A-B-B‟ Multiple-Baseline Design across settings
           A: Baseline
           B: number of prompts delivered was reduced daily
           B‟: goal condition, 3 or fewer prompts to receive reinforcer

       Dependent Measures: Verbal Responses
           Number of responses
           Rate of words spoken per minute
                          Selective Mutism:
       Intervention
           Stimulus Fading:
               Changing settings: Resource room, Study room, Mainstream
               Fading prompts within each setting: number of prompts and
                intensity (loudness of voice)
           A: Baseline
               Asked specific questions, no prompts
               Data were collected using event recording 30-minute time
                        Selective Mutism
       B: Reducing Prompts
           Selected a reinforcer he would like to earn for that session
           Told he could have the reinforcer if he responded to the
            questions in a voice loud enough to be heard by the teacher (20
            times with only 12 prompts)
               Prompts were reduced by 2 during B
       B‟: Goal Condition
           Selected a reinforcer to earn
           Told he could have the reinforcer for 20 verbal responses with 3
            or fewer prompts
                          Selective Mutism:
       Characterized by a failure to speak in specific social
        situations despite speaking in other settings

       Relatively rare condition with onset as early as 2 years of age
           Usually substantial gap between onset and diagnosis/treatment

       Behavioral interventions are most typically used and show
        support for efficacy

       Few assessment materials specific to the condition

       Research
           No large randomized controlled trials
           Limits generalizability of results
       Bergman, R. L., Keller, M. L., Piacentini, J., & Bergman, A. J. (2008). The
              development and psychometric properties of the selective mutism
              questionnaire. Journal of Clinical Child & Adolescent Psychology, 37(2),

       Carlson, J. S., Mitchell, A. D., & Segool, N. (2008). The current state of
               empirical support for pharmacological treatment of selective mutism.
               School Psychology Quarterly, 23(3), 354-372.

       Cunningham, C. E., McHolm, A., Boyle, M. H., & Patel, S. (2004). Behavioral
              and emotional adjustment, family functioning, academic
              performance, and social relationships in children with selective
              mutism. Journal of Child Psychology and Psychiatry, 45, 1363-1372.

       Fisak, B. J. Jr., Oliveros, A., Ehrenreich, J. T. (2006). Assessment and behavioral
                treatment of selective mutism. Clinical Case Studies, 5(5), 382-402.

       Kehle, T. J., Madaus, M. R., Baratta, V. S., & Bray, M. A. (1998). Augmented self-
                modeling as a treatment for children with selective mutism. Journal of
                School Psychology, 36(3), 247-260.
       Kehle, T. J., Owen, S. V., & Cressy, E. T. (1990). The use of self-modeling as an
                intervention in school psychology: A case study of an elective mute.
                School Psychology Review, 19, 115-121.

       Sharp, G. M., Sherman, C., & Gross, A. M. (2007). Selective mutism and
               anxiety: A review of the current conceptualization of the disorder.
               Journal of Anxiety Disorders, 21, 568-579.

       Stone, B. P., Kratochwill, T. R., Sladezcek, I., & Serlin, R. C. (2002). Treatment of
                selective mutism: A best-evidence synthesis. School Psychology
                Quarterly, 17(2), 168-190.

       O‟Reilly, M., McNally, D., Sigafoos, J., Lancioni, G. E., Green, V., Edrisinha, C.,
                et al. (2008). Examination of a social problem-solving intervention to
                treat selective mutism. Behavior Modification, 32(2),182-195.

       Viana, A. G., Beidel, D. C., & Rabian, B. (2008). Selective mutism: A review and
               integration of the last 15 years. Clinical Psychology Review, 29, 57-67.

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