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
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).
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
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
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)
Prevalence, Etiology and Course
SM often occurs comorbidly with other anxiety disorders and
other psychological symptoms (Sharp et al., 2007; Viana et
Overlapping characteristics with social phobia
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 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
DSM-IV-TR Diagnostic Criteria
Referral to Pediatrician and Speech-Language Pathologist
Treatment and Intervention
Behavior Therapy Models
Applied Behavior Analysis (ABA)
Combined approaches: principles of operant conditioning and
Shaping, stimulus fading, contingency management,
positive/social reinforcement (Stone et al., 2002).
Positive change in behavior that results from repeated
observation of oneself producing the desired behavior (Kehle,
Owen, & Cressy, 1990).
Treatment and Intervention
Social Skills Training: eye contact, greetings (Fisak, Oliveros,
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
Selective Serotonin Reuptake Inhibitors (SSRIs)
Monoamine Oxidase Inhibitor (MAOI) (Carlson, Mitchell, &
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
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
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
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
Changing settings: Resource room, Study room, Mainstream
Fading prompts within each setting: number of prompts and
intensity (loudness of voice)
Asked specific questions, no prompts
Data were collected using event recording 30-minute time
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
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
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.