Selective Mutism:Assessment and Intervention

R.T. Busse, PhDChapman University

Counseling and School Psychology Programbusse@chapman.edu

R.T. Busse, 2006 1

DSM Diagnosis and Prevalence

Consistent failure to speak in specific social situations in which there is an expectation for speaking, despite speaking in other situations

The disturbance interferes with educational or occupational achievement or with social communication

The duration of disturbance is at least 1 month [not limited to the first month of school]

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 exclusively during the course of PDD, Schizophrenia, or other psychotic disorder

Selective mutism is believed to occur in less than 1% of children; Some incidence data indicate the disorder occurs slightly more often with girls

Services most often are provided through SST, 504 plans, and to a lesser degree S/L or ED placement

R.T. Busse, 2006 2

Myths and Realities

MythsSelective Mutism is caused by trauma

Children with SM are simply being manipulative and stubborn

Families with SM are socially isolated or “dysfunctional”

Children with SM are simply shy and will “grow out of it”

RealitiesThere are no typical etiologies

Children with SM can be stubborn and families can be protective

Many families are close and socially active

SM is a learned behavior akin to social phobiaSome children do remit “spontaneously”

R.T. Busse, 2006 3

Assessment Issues

To Whom Does the Child SpeakParents, Siblings, Relatives, Peers, Teachers, Others

Where Does the Child SpeakHome, Community, School

How Does the Child SpeakWhispers, Normal Levels

Temperament/Emotional FactorsShyness, Depression, Anxiety

Exclusionary FactorsSpeech/Language, Opportunities to Respond/Perform, Cognitive, Emotional

R.T. Busse, 2006 4

Treatment Considerations

Working with Parents and School Staff Meet the child and family where they are at and work forward

Supply information

Facilitate home/school communication

Normalize the environment

Facilitate opportunities to respond

Allow natural consequences to occur

Alter expectancies for progress

Alter conception of anxiety

Alter protective behaviors

STRESS CONSISTENCY

R.T. Busse, 2006 5

Communication Patterns Alter environment for necessary activities (e.g., bathroom, eating, illness)

Maintain expectancies for speaking behaviors

Avoid Yes/No questions

Allow for response (Wait Time)

Intervention Methods

Goals: Create competing response to mutism and/or diminish anxiety

Reinforcement contingency strategies (TIP: avoid punishment and reductive procedures)

Shaping of verbal responses

Alter setting events (e.g., task demands)

Teach alternative or competing responses (e.g., social skills, relaxation)

Systematic desensitization (e.g., stimulus-fading procedures)

Medication trials (NOTE: poor research base regarding use and effectiveness of medication for SM and on long-term impact on child physiology)

[Note: There is no single treatment for SM; Treatment is chosen, linked, and adjusted to fit the child and environment]

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Key Considerations

LINK intervention to assessment

Start slow and simple and maintain intervention

Avoid “intervention hopping”CONSISTENCY IS KEY

Never retreat from progress points

Some anxiety is expected

Expect failure

Don’t accept failure

When in doubt, consult

Useful websites:www.selectivemutismfoundation.orgwww.selectivemutism.org

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Selective Mutism Observation Form

Child ________________________ Teacher _____________________

Observations should be conducted in various settings to gather data on specifics related to social interactions and communication patterns. 15 minute observations usually are sufficient.

Classroom [Subject _______________; Date ______________________]

Interactions with other children [e.g., smiles, nods, hides face, laughs, whispers, ignored] If possible, try asking names of a couple children and then the target child.

Interactions with teacher [e.g., response to questions – nods, smiles, wriggles; does the teacher ask closed or open questions; does the teacher ignore]

Interactions with tasks/materials [e.g., engages in work; mouths during group activities such as sing alongs; covers mouth]

Unstructured Settings [Playground ______; Hallway_____; Dining____]Interactions with others [e.g., plays, smiles, laughs, whispers, bullied]

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Selective Mutism Interview Form

Child ________________ Informant _______________

Information gathered during the interview should be as specific as possible about the occurrence of the mutism, including antecedent and consequent events

1. Describe the history of the child’s selective mutism

2. To whom does the child speak at home? Parents, siblings, relatives, friends, other adults? On the phone?

3. To whom does the child speak at school? Teacher, other children, with parent? [also ask how the child communicates illness or need to use restroom]

4. If the child speaks, what are the circumstances? With parents? In hallway? In classroom with door open? Closed?

5. To whom does the child speak in the community [at friend’s house, stores, etc]

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Selective Mutism Interview Form [Page 2]

6. How often does the child speak? At what voice level?

7. When does the child stop talking? When nearing school? Getting on bus?

8. What does the child say about not talking? What do parents/teachers say?

9. Describe the child’s behavior at home and school; Defiant? Loud? Quiet?

10. Describe interventions that have been tried and current accommodations

11. Describe resources that may be available and acceptable for intervention; tangible rewards? Family members who can come to school? Teacher availability? Other parents and children?

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The Reading Game Rules

1. Each player takes a turn as The Reader and reads out loud for 1 minute

2. Each player takes a turn as The Timer and times The Reader. The Timer says “Go” to start and “Time’s up” when the minute is over

Getting a Prize!

Each player earns 1 token for taking their turn as The Timer and 2 tokens for taking their turn as The Reader

When a player has earned 6 tokens they choose a prize

If a player does not take a turn, the other players continue the game

The game is over after 6 rounds - the player with the most tokens earns an extra prize

The Talking Game Rules

The Big Boy earns 4 tokens for talking during class to the teacher or one or more other kids

Earning a Prize!

When The Big Boy has earned 4 tokens he chooses a prize from the prize box [one prize for each 4 tokens]

Talking can be saying one word or a bunch of words at one time [including reading out loud in class] - whispering is ok

The Big Boy knows to use his breathing to help with talking

If other kids say anything, the Big Boy knows to say “Of course I talk”

And the teacher knows what to tell other kids

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THE TALKING GAME LEVEL 4 RULES

Every weekend Randy sets goals with his parents for talking with other kids during class

When Randy has talked to 4 different kids he earns a prize from his parents at the end of the week

This week’s goal - I will talk to:1. ________________________2. ________________________3. ________________________4. ________________________

DAY WHO DID I TALK TO?

TEACHER SIGNATURE

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

DID I MEET MY GOAL THIS WEEK?

YES! I earned a prize!

No - I will next week!

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Randy’s Plan

The major purposes of the plan for Randy are to maintain expectations for talking, providing opportunities for talking, and helping Randy become ‘desensitized’ or more comfortable with talking in anxiety provoking situations. Remember our goal is to help Randy move toward speaking, so a little anxiety is expected. We never force him to talk or make a situation too anxiety provoking. Also remember that progress can be slow and we need to learn from our mistakes about what works and what does not.

Randy’ parents will continue to provide Randy with activities to give him the opportunities at home and in the community for talking with children from his class, such as having friends to his home, going to friends’ houses, and engaging in community activities such as going to the movies and school playground. The school playground also is a good place to take Randy with the family to help him become more comfortable with speaking at the school setting. Randy’s parents will only talk about talking with Randy when Randy talks about it.

Randy’s teacher will continue to provide cues to bring him back to task, particularly during classroom activities that require talking. Randy’s teacher will continue to provide Randy with opportunities for responding and when appropriate will use open-ended questions [Good morning Randy, how are you? Randy, what is the answer?] with a 3 second wait time, and then moving on without asking a closed follow-up question. If other children help him by saying he doesn’t talk or if they talk for him, Randy’s teacher will simply say that he does talk and he will when he is ready.

The school psychologist will work with the consultant to use a ’stimulus fading’ procedure. The basic procedure will involve Randy’s father coming after school to read aloud with Randy in the classroom. Randy will earn stickers for reading and when he earns a specified amount [to be determined] he will earn a reward that his parents deem appropriate [such as choosing a family movie or favorite place to eat, or a small reward that he likes]. Randy’s teacher will be outside the classroom and then will slowly move into the classroom once Randy is speaking, and then eventually will join and take over the activity. The school psychologist and the consultant will work with Randy’s father and teacher to ‘tweak’ the specifics of the plan, such as whether the door is open and the speed of progress. Eventually, another child may be asked to join.

Randy’s father will begin by reading in the classroom with Randy without the teacher nearby. This will allow Randy to get a start without extra pressure or anxiety. The next time, the consultant [the ‘talking teacher’] will meet with Randy and his father to explain the plan.

It is important to remember that the plan will take some time to work out and the specifics will change as we progress. Relaxation training may be added if Randy is having too much difficulty.

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