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Author: Stoffel, Bethany, A. Title: Interventions for Children with Selective Mutism

The accompanying research report is submitted to the University of Wisconsin-Stout, Graduate School in partial

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Graduate Degree/ Major: MS Education in School Psychology

Research Adviser: Christine Peterson, Ph.D.

Submission Term/Year: Fall, 2012

Number of Pages: 37

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My research adviser has approved the content and quality of this paper. STUDENT:

NAME Bethany Stoffel DATE: December 13, 2012

ADVISER:

NAME Christine Peterson DATE: December 12, 2012

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Stoffel, Bethany, A. Interventions for Children with Selective Mutism

Abstract

The paper reviews the research literature on interventions for treatment of Selective mutism

(SM), a childhood disorder affecting children who do not speak in specific situations, such as

school, but speak freely in others. There are multiple causes of SM, which require a variety of

different intervention approaches to treat SM. Four different approaches are commonly used to

treat children with SM, including: behavioral; cognitive-behavioral; psychopharmacological; and

multimodal. Each intervention has merits and drawbacks to treating SM. Large, controlled

experiments are difficult to conduct due to the rarity of the disorder. However, larger, controlled

studies must be conducted to determine the efficacy of each intervention approach.

Keywords: selective mutism, cognitive-behavioral intervention, behavioral intervention,

psychopharmacological intervention, multimodal intervention

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Table of Contents

.................................................................................................................................................... Page

Abstract ............................................................................................................................................2

Chapter I: Introduction ....................................................................................................................4

Statement of the Problem .....................................................................................................6

Purpose of the Study ............................................................................................................7

Definition of Terms..............................................................................................................7

Assumptions and Limitations of the Study ........................................................................10

Chapter II: Literature Review ........................................................................................................11

Behavioral Approach to Intervention .................................................................................11

Cognitive-Behavioral Approach to Intervention ...............................................................18

Psychopharmacological Approach to Intervention ............................................................20

Multimodal Approach to Intervention ...............................................................................22

Chapter III: Summary, Critical Analysis, and Recommendations .................................................25

Recommendations for Research ........................................................................................25

Recommendations for Practice ..........................................................................................28

Summary ............................................................................................................................31

References ......................................................................................................................................33

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Chapter I: Introduction

Selective mutism (SM) is a disorder primarily found in young children who talk freely in

some settings, but are mute in others (American Psychiatric Association, 2000). Children with

SM are not simply choosing to be mute, but rather the child is unable to cope with the level of

anxiety that is present in a particular setting, resulting in the child freezing in situations where

there is an expectation to vocalize. Research suggests that this mute behavior is related to the

“fight or fight” phenomenon which occurs in dangerous situations (Bork, 2010). The etiology of

SM has been controversial among researchers; however, the prevailing consensus is that SM is

caused by a variety of environmental and genetic factors combined (Bork, 2010;Viana, Beidel, &

Rabian, 2009).

There is some controversy over what causes this mute behavior to occur in children. In

the past, SM has been viewed as resulting from early psychological or physical trauma (Cleave,

2009). Recent literature has suggested that SM is more closely related to anxiety disorders such

as social phobia, social anxiety, or specific anxiety of expressive speech (Carbone, Schmidt,

Cunningham, McHolm, Edison, Pierre, & Boyle, 2010; Cleave, 2009; Sharkey & McNicholas,

2008). The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text

Revision (DSM-IV-TR) currently categorizes SM as a disorder that is first diagnosed in infancy,

childhood or adolescence (American Psychiatric Association, 2000). The DSM-IV-TR lists

specific criteria that must to be met in order for a diagnosis to be reached. This criterion includes

five parts: (a) the child is sociable in some situations but not others; (b) the symptoms interfere

with educational or occupational achievement; (c) there is no underlying speech or language

disorders; (d) the child is able to understand the language spoken in the situation; and (e) the

interference lasts longer than a one month period (American Psychiatric Association, 2000).

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Selective mutism is most commonly diagnosed around the time a child enters school,

because this is often the first time the child is introduced to a structured setting that has rules and

expectations, which may create anxiety (Carbone, et al., 2010). Children who demonstrate

characteristics of SM can be misperceived as being overly shy, needing time to adjust and

become comfortable in the school setting, or to be using the mute behavior to manipulate others.

Teachers may wait to refer these children for evaluation due to these misperceptions, hoping the

symptoms will go away with time (Carbone et al., 2010; Cleave, 2009).

Selective mutism is considered a rare disorder, occurring in less than 1% of the

population. Nevertheless, research has suggested that many other cases go undiagnosed, leading

experts to believe that SM is more prevalent than previously thought (Carlson, Mitchell, &

Segool, 2008; Cleave, 2009; O’Reilly, McNally, Sigafoos, Lancioni, Green, Edrisinha,

Machalicek, Sorrells, Lang, & Didden, 2008). It is hypothesized that SM is more prevalent in

girls than boys, with estimated ratios from 2.6 to 1, to 1.5 to 1 (Freeman, Garcia, Miller, Dow, &

Leonard, 2004). Other research has indicated that SM is more closely distributed between boys

and girls (Carbone et al., 2010).

Teachers are often the first to identify children with SM. In fact, it is likely that each

teacher will come across at least one child with SM in their career (Shriver, Segool, & Gotmaker,

2011). This creates unique challenges for children and educators to ensure academic access

(Busse & Downey, 2011). Researchers have suggested that teachers are not aware of the signs

and symptoms of SM and do not refer children for evaluation as soon as the symptoms are

noticed. The average age for children with SM to be referred for evaluation is between 6.5 and 9

years of age. This suggests that many students are not receiving interventions as early as needed

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in order to see optimum outcomes and may be at risk for further delays (Carbone et al., 2010;

Cleave, 2009).

Children who are diagnosed with SM tend to have other psychological, developmental,

and/or educational difficulties throughout their lives, which may include lacking independence,

self- confidence, and maturity (Oon, 2010; Busse & Downey, 2011), other language difficulties,

and/or motor delays (Cleave, 2009). Children identified with SM may also be at higher risk of

being on the autism spectrum than children without SM (Sharkey & McNicholas, 2008).

Research has noted that earlier diagnoses are very important for children with SM so that

intervention can be designed and implemented as early as possible. The longer the intervention

is withheld, the higher the risk of the symptoms persisting into adulthood (Sharkey &

McNicholas, 2008). These delays can be avoided by providing early intervention to help

promote normal interactions in the anxiety producing environment (Giddan, Ross, Sechler, &

Becker, 1997). Interventions play an important role in the development of children diagnosed

with SM. It is important to individualize the intervention plans for each child with SM due to the

variance in function of the mute behavior from child to child (Viana, Beidel, & Rabian, 2009).

Further, it is important to include parents, support staff and teachers in the intervention process

to ensure effective and efficient interventions across all of the child’s environments (Cleave,

2009).

Statement of the Problem

The majority of children with SM begin showing signs and symptoms when entering

school, around the age of four or five. Many of these children are not referred for evaluation for

several months after the signs and symptoms appear, with the average age of referral being nine

(Carbone et al., 2010; Cleave, 2009). Many teachers are unaware of the signs and symptoms of

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SM, or the interventions available within the school setting to help these children. The lack of

knowledge among teachers is a problem because it affects the efficiency and effectiveness of

interventions due to delayed interventions. This delay in intervention allows time for the mute

behavior to become a habit, making intervention success more difficult as time continues. The

child has a higher risk of developing other psychological, developmental, or educational delays

throughout their lives without timely intervention (Busse & Downey, 2011;Carbone et al., 2010;

Cleave, 2009; Oon, 2010; Sharkey & McNicholas, 2008).

Purpose of the Study

The purpose of this study is to investigate early intervention options for children with

SM, and to examine the research of several intervention approaches that may be useful for

educators to use with children identified with selective mutism. Various approaches to

intervention have been developed for use within the school setting, including a behavioral model,

a cognitive-behavioral model, and a psychopharmacological model. Other research has

suggested a need for a multimodal approach to intervention, which would incorporate a

combination of interventions and endorse optimum outcomes (Cleave, 2009; Carbone et al.,

2010; Oon, 2010).

Definition of Terms

Behavioral interventions. “Behavior intervention refers to actions taken by school

personnel, parents, and/or agency personnel to improve the behavior of school children. The

focus of the interventions is limited to what are commonly referred to as behavior problems (or

challenges) that are social, interpersonal, and emotional in their nature and effects; it does not

address behaviors associated with poor achievement, such as reading, math or writing problems”

(Lee, 2005, p. 49).

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Cognitive-behavioral interventions. “Cognitive-behavioral interventions integrate

thoughts and behaviors into problem-assessment approaches, conceptualization, and

intervention. The cog-behavioral approach views problems as resulting from both environmental

and cognitive antecedents, and combines what has typically been called the behavioral or

learning approach with the cognitive or semantic approach” (Lee, 2005, p. 95).

Contingency management. “Contingency management programs monitor children’s

progress toward goals and use a system of positive and negative consequences to encourage

behavioral change” (Sattler & Hoge, 2006, p. 355).

Functional behavioral assessment (FBA). A Functional behavior assessment (FBA) is

a set of procedures used to gather information to develop hypotheses about the purpose of a

student’s behavior in order to develop effective interventions (Reid & Nelson, 2002, as cited in

Rathvon, 2008).

Multimodal. An approach to intervention that involves two or more specific

intervention strategies or techniques of different modalities (Salkind, 2008, p. 1:43).

Psychoeducation. “Of or relating to the psychological aspects of education; specifically:

relating to or used in the education of children with behavioral disorders or learning disabilities”

(Psychoeducation, n.d.).

Psychopharmacology. “Psychoeducation, the development, study, and use of drugs for

the modification of behavior and the alleviation of symptoms, particularly in the treatment of

mental disorders” (Psychopharmacology, 2012).

Reinforcement. “Reinforcement is defined as a consequence that increases the likelihood

that a behavior will occur in the future” (Salkind, 2008, p. 2:845).

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Selective mutism. “Selective mutism is characterized by a consistent failure to speak in

specific social situations despite speaking in other situations” (American Psychiatric Association,

2000).

Self- modeling. Self-modeling is defined as learning that occurs as a result of repeated

observation of oneself on edited video-or audio-tapes that depict only desired behaviors

(Dowrick & Dove, 1980, as cited in Rymal & Ste-Marie, 2007, p. S199).

Shaping. “Shaping is the technique whereby a behavior totally outside the learner’s

current repertoire of skills is carefully brought into existence by reinforcing successive

approximations to the desired performance” (Salkind, 2008, p. 1:903).

Stimulus fading. “The transfer of stimulus control by fading out a controlling stimulus

and fading in an alternate stimulus…” (Babbitt, Shore, Smith, Williams, & Coe, 2001, p. 198).

Systematic desensitization. Systematic desensitization involves exposing an individual

to gradually increasing levels of a fear-invoking stimulus while providing the individual with a

way to cope with his or her fear at each stage of exposure (Sattler & Hoge, 2006).

Vocalization. “Using voice (any volume) to initiate communication or to respond to

prompts to communicate” (Shriver, Segool, & Gortmaker, 2011, p. 400).

Vocalization ladder. A term used to represent the shaping process. “The rungs represent

the steps lined up for the child to slowly climb towards normal speech. Metaphorically, at the

bottom of the ladder are steps such as mouthing words, making sounds, and saying consonants;

further up the ladder there are steps such as whispering words, saying single words, saying single

sentences, and uttering phrases; and finally, at the top, we have speaking normally” (Oon, 2010,

p. 219).

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Assumptions and Limitations of the Study

Articles on SM were found through the online database at the Bethel University library

using PsychINFO, as well as the Library database at the University of Wisconsin-Stout using

EBSCO host. The following keywords were used: selective mutism or elective mutism; and

interventions or intervention. Reference books and reference lists were also used in the retrieval

of literature articles.

There are limitations to the findings of this literature review. Many of the studies

reviewed use relatively subjective methods of collecting data such as the use of rating scales,

parent reports, or observations. In addition, these studies often have small sample sizes of

children with selective mutism and do not use a control group during the research process.

These limitations make it difficult to make inferences about the efficacy of the interventions used

and make it difficult to make generalizations about the findings of the studies to other

populations. These limitations do not diminish the usefulness of the findings presented in these

studies, yet some assumptions of these studies must be addressed.

There are several assumptions that must be addressed regarding the findings of this

review. First, it can be assumed that the studies used showed effective results in the majority of

the sample used. Second, it can be assumed that the intervention approaches worked for one or

more of the children in the past, and can currently be used in the individualized implementation

of intervention for children with SM. Third, it can be assumed that each child will respond

differently to intervention approaches. Finally, the intervention methods presented in this review

can serve as a starting point to hypothesize individualized intervention plans for children

suspected of having SM within the educational system.

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Chapter II: Literature Review

There is a limited amount of research on intervention models for children with selective

mutism (SM) in the areas of behavioral, cognitive-behavioral, psychopharmacological, and

multimodal approaches to intervention for children who are diagnosed with SM. This chapter

begins with a description of each model of intervention of SM and includes descriptions of

various techniques used, a summary of the research, and a discussion of the efficacy of each.

Behavioral Approach to Intervention

Behavior therapy is the most widely accepted approach to the intervention of SM

(Cleave, 2009; Carbone, Schmidt, Cunninghamn, McHolm, Edison, St.Pierre, & Boyle., 2010;

Oon, 2010) and is usually the first approach used to treat children after diagnosis (Cohan,

Chavira, & Stein, 2006). This therapy approach proposes that the child with SM has learned the

mute behavior as an avoidance mechanism, or as a means to gain attention from others around

them (Cohan, Chavira, & Stein, 2006). Behavior therapy aims to eliminate reinforcement of the

mute behavior, and increase reinforcement of communicative behaviors (Oon, 2010). Various

techniques are used within this approach including contingency management, shaping,

systematic desensitization, social skills training, and self-modeling. Each of these techniques are

used to induce vocalizations within the environments the child is mute (Cohan, Chavira, & Stein,

2006; Freeman, Garcia, Miller, Dow, & Leonard, 2004). Further, a functional behavioral

assessment (FBA) may be a useful process to use when planning which intervention techniques

to use with a specific child with SM (Shriver, Segool, & Gortmaker, 2011).

Functional Behavioral Assessment to Guide Intervention Planning

There has recently been a shift in the research of SM to explore the effectiveness and

efficiency of using Functional Behavioral Assessment (FBA) to guide the intervention process

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for children with SM within the school. An FBA can provide the intervention team with specific

information on the reasons behind the internalizing behavior problems, such as anxiety or SM.

This information can be used to make decisions on how to approach a child’s needs in the most

effective and efficient manner. Then intervention can then be more individualized, targeting the

specific needs of the individual child (Kern, Starosta, Cook, Bambara, & Gresham, 2007;

Shriver, Segool, & Gortmaker, 2011).

Shriver, Segool, & Gortmaker (2011) have developed a process for using an FBA to

guide in the planning of a behavioral intervention for children with SM. This process begins

with an interview with significant people involved in the child’s life, such as the parents and

teacher. Then the child must be observed in several settings to gain insight as to what the

behavior looks like, and to identify factors that may be contributing to the mute behavior. The

interview and observations help to obtain information regarding where, when, and with whom

the child communicates, as well as how the child communicates. This may include whispering,

gesturing, mouthing words, or speaking normally. It may be difficult to observe a setting in

which the child is willing to speak due to the presence of a stranger, and it may be necessary to

use video-recording to observe the child speaking. The information from the interviews and

observations can be used to identify the antecedent-behavior (AB) model of FBA. This

identifies the reasons (antecedents, A) that contribute to the child being mute (behavior, B) in

certain situations and not in others. This information can be used to identify which behavioral

technique may be most effective for the specific child (Shriver, Segool, & Gortmaker, 2011).

Shriver, Segool, & Gortmaker (2011) developed a table of recommended techniques to

use when planning an intervention for a specific child. This table takes information from the

interview and observations, including the frequency of speech, number of people present, and

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setting, to suggest what behavioral techniques may be most appropriate to implement initially

(Shriver, Segool, & Gortmaker, 2011).

Kern, Starosta, Cook, Bambara, and Gresham (2007) conducted a study using the FBA

process with two school-aged students with SM. Both students showed signs of SM since

entering school with previous unsuccessful interventions attempted. Researchers used a

changing criterion design to examine the effects of differing interventions on vocalizations. The

study used both indirect and direct methods of obtaining information for the FBA. The

information was then used to develop individual hypotheses about the factors contributing to the

mute behavior for each of the children. The teacher was able to develop an intervention based

upon the contributing factors identified in the FBA process. This study found that both students

increased vocalizations as the intervention proceeded. Further, effects of the intervention

persisted in both children one month after the intervention had ceased (Kern et al., 2007).

Contingency Management, Shaping and Stimulus Fading

Contingency management is a behavioral technique commonly used in intervention

models. Contingency management uses positive reinforcement to encourage the child to

communicate in a setting in which the child is typically mute. The rewards must be motivating

for the child in order to encourage the child to communicate (Cohan, Chavira, & Stein, 2006).

Shaping and stimulus fading are techniques commonly used in combination with contingency

management. Shaping involves breaking the overall target goal into smaller goals meant to

encourage the child to reach full vocalization gradually in all settings. This focuses on how the

child communicates (Shriver, Segool, & Gortmaker, 2011). Oon called this process the

vocalization ladder, which may start with small goals, such as mouthing words, then progress to

whispering, and gradually increasing vocalization until the child is able to use verbal

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communication in all settings. The child is rewarded at each step along the vocalization ladder

in order to motivate the child to continue progressing and increase vocalizations until a reward is

no longer needed for the child to vocalize (Oon, 2010).

Stimulus fading is similar to shaping, but focuses on the context in which the

communication occurs, rather than how the child communicates. Stimulus fading involves the

reinforcement of vocalizations in the presence of different stimuli, such as peers, teachers, or

other anxiety provoking individuals or factors. The child with SM begins with a person the child

is comfortable vocalizing around, such as a parent or caregiver in a controlled setting. Once the

child becomes comfortable vocalizing in this setting with the parent or caregiver, a person the

child does not vocalize around, such as the teacher, is gradually added to the situation. At the

same time, the parent or caregiver gradually becomes more distant, eventually fading out of the

setting (Busse & Downey, 2011). Another form of stimulus fading is to gradually increase the

number of people present when the child is communicating, and rewarding the child as the

number of people they communicate around is increased (Viana, Beidel, & Rabian, 2009). The

goal of stimulus fading is to eventually have the child generalize the fading procedure into the

normal classroom setting (Busse & Downey, 2011).

Oon used contingency management and shaping techniques in the intervention of a five-

year-old girl with SM. These techniques were blended into a drama therapy model of

intervention, which used play as the primary reinforcement to gradually increase the girl’s

vocalizations. The girl progressed from being fully mute outside of the house, to being outgoing

and verbally expressive in therapy sessions, as well as in her classroom at school in six weeks. A

one-year follow up of the study showed that the effects of intervention continued to increase

post-intervention (Oon, 2010).

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Systematic Desensitization

Systematic desensitization requires the child to learn relaxation skills to use while he or

she is gradually exposed to anxiety provoking situations (Cohan, Chavira, & Stein, 2006). First,

a trained adult helps the child imagine he or she is in an anxiety provoking situation and

encourages him or her to use the relaxation skills they have learned to overcome or cope with the

anxiety. The child is then encouraged to brainstorm things that could be said in this situation and

then to imagine oneself vocalizing these ideas in that setting. Once the child is able to cope with

an imaginary situation, then the child is gradually introduced to a real situation that may cause

anxiety. This anxiety provoking situation may include having the teacher attend the sessions, or

going to a classroom in which the child has never spoken. The child is then encouraged to

vocalize in the setting while using the relaxation skills to decrease anxiety. The goal is to help

the child learn to use the relaxation skills in real situations in order to increase his or her

vocalizations in all settings. The child is rewarded for communicating in all stages of systematic

desensitization. This process has shown to be a successful form of intervention; however, it may

require many weeks to reach the target goal (Busse & Downey, 2011; Cohan, Chavira, & Stein,

2006).

Beare, Torgerson, & Creviston (2008) used contingency management and systematic

desensitization to increase the verbal communication in a twelve-year-old boy with SM. This

intervention was developed and implemented after other interventions proved unsuccessful.

First, he was rewarded for verbally responding to prompts in a setting in which he was

comfortable, and then was gradually moved to different settings in which he was previously less

comfortable vocalizing in. The prompts were gradually decreased until he was able to

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communicate vocally in multiple settings without the need of prompts (Beare, Torgerson, &

Creviston, 2008).

Auster, Reeney-Kettler, & Kratochwill (2006) also used contingency management and

systematic desensitization to increase the verbal communication of a five-year-old boy diagnosed

with SM. He was first rewarded for communicating in a comfortable setting with his parents and

his teacher. After becoming comfortable in this setting they moved to a classroom setting and he

was eventually able to communicate with his teacher without his parents present (Auster,

Reeney-Kettler, & Kratochwill 2006).

Social Skill Training

Children with SM often struggle with knowing how to communicate appropriately in

social settings and may need training on appropriate behavior in different settings. Research has

found that children with SM and other anxiety disorders have greater difficulty with social skills

than other children. The behavioral approach views the mute behavior as a coping mechanism

that a child with SM might use to confront social situations in which the child may be unsure of

how to interact with others (Carbone et al., 2010). Therefore, instruction of basic social skills is

an important part of the behavioral approach to treating SM. This social skills instruction helps

children with SM to understand the social expectations placed upon them in the school

environment. They must be aware that they are expected to communicate in all settings. They

are shown skills of how to communicate successfully in these situations so they will no longer

need to feel anxious about communicating (Gordon, 2001).

O’Reilly, McNally, Sigafoos, Lancioni, Green, Edrisinha, Machalicek, Sorrells, Lang,

and Didden (2008) conducted a study in which social problem-solving skills were taught to two

sisters diagnosed with SM, one five years of age and the other seven years of age. Neither of

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them had ever spoken in the school setting before the intervention had begun. The therapist met

with them individually and discussed why it is important to vocalize and express their thoughts,

wants, and needs in school. Teachers were then asked to provide five questions that they would

ask the girls in class. These questions were used in individual therapy sessions for the girls to

rehearse their responses. When they felt comfortable with answering the questions, they were

expected to answer them in the classroom in front of the teacher and class. This social problem-

solving method was successful for these two girls; however there could be a variety of situational

reasons for this success, such as the rapport between the therapist and girls. The teachers

reported that both girls remained shy and withdrawn after the end of the sessions, despite the fact

that the intervention had increased their vocalization in the classroom. This was the first study

done using social-problem solving strategies to treat SM. Therefore, replications of this study

must be done to examine the efficacy of this model of behavioral therapy (O’Reilly, McNally,

Sigafoos, Lancioni, Green, Edrisinha, Machalicek, Sorrells, Lang, & Didden, 2008).

Self-Modeling

Self-modeling incorporates the use of video and/or audio recordings of the child with

SM. These recordings are used to help increase the child’s level of comfort with hearing his or

her own voice in the uncomfortable setting. The child records him or herself speaking at home

or in another setting where verbal communication is comfortable, and then the recording is

played back to the child in a setting where the child is typically mute. This allows the child to

become comfortable with hearing his or her own voice in this setting, pushing the child to

eventually communicate vocally there (Busse & Downey, 2011; Sharkey & McNicholas, 2008).

Pigott and Gonzalez (1987) conducted a case study of a 9-year-old boy with SM using

self-modeling techniques. In this study, the boy was observed and video recorded three times

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over three weeks. The video recordings were then edited and shown to the boy each morning

before school for two weeks. The boy was then observed to see how frequently he volunteered

to answer a question and vocalized loud enough for the teacher to hear. The number of

vocalizations increased after the self-modeling technique had been introduced to a point where

he vocalized as much as other children in the classroom by the end of that school year (Pigott &

Gonzalez, 1987).

Cognitive-Behavioral Approach to Intervention

Cognitive-behavioral therapy is an approach typically used to treat anxiety disorders,

which has increasingly been investigated for the efficacy in SM intervention (Viana, Beidel, &

Rabian, 2009). The cognitive-behavioral approach to treating children with SM focuses on

anxiety management (Cohan, Chavira, & Stein, 2006) as well as restructuring the cognition of

the child (Fung, Manassis, Kelly, & Fiksenbaum, 2002). Some literature suggests that this form

of intervention is most appropriate for older children with SM (Cohan, Chavira, & Stein, 2006),

while others have suggested that it is most effective in intervention for younger children with SM

(Sharkey & McNicholas, 2008; Viana, Beidel, & Rabian, 2009). Several different techniques are

used in this approach to intervention, including: (a) child and parent psychoeducation; (b)

behavior techniques, such as relaxation techniques or systematic desensitization; and (c)

cognitive techniques, such as learning to understand bodily signs of anxiety, changing former

cognition in dealing with anxiety provoking situations, and learning more beneficial coping

strategies (Cohan, Chavira, & Stein, 2006). Cognitive-behavioral methods are growing in

popularity with parents as an effective strategy to treat SM (Schwartz, Freedy, & Sheridan,

2006).

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Sharkey, McNicholas, Barry, Begley, and Ahern (2008) administered a cognitive-

behavioral intervention using group therapy and parental psychoeducation. In this study, five

children with SM participated in group therapy for eight weeks. Therapy sessions focused on

increasing their non-verbal and verbal communication. Throughout the therapy sessions, the

children were taught about anxiety, how it affects their lives, and effective ways to handle their

anxiety in certain situations. They were provided with behavioral techniques to gradually gain

experience in using these new techniques. The children also had a scrapbook of the assignments

they completed during the sessions in order to help them remember topics and techniques

discussed in therapy sessions, and generalize them to other environments. The children’s parents

attended eight ninety-minute sessions during which the parents were instructed on how to

manage their child’s everyday behaviors, how to properly respond to their child’s

communication patterns, and how to support their children in the education system. In a six-

month follow up, two of the five children no longer met diagnostic criteria for SM, and the other

three had shown significant gains in their communication and showed decreased levels of

anxiety. However, this study included a small sample size, indicating a need for further study to

compare results of group therapy versus individual therapy (Sharkey, McNicholas, Barry,

Begley, & Ahern, 2008). There are other reported drawbacks with group therapy models, such

as the difficulty finding children to participate who will positively relate to others in the group,

difficulty generalizing one group session to other sessions, and the difference in responses to the

intervention for each child, as one may respond more quickly than others in the group (Carlson,

Mitchell, & Segool, 2008).

Fung, Manassis, and Fiksenbaum (2002) developed an online model of cognitive-

behavioral intervention for children with SM. The program includes fourteen 90-minute sessions

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online, each consisting of 60-minutes for the child and 30-minutes with the parents. In each

session, children are introduced to new skills related to regulating their bodily signals, changing

their thoughts in situations where they feel anxiety, and teaching actions for changing their

behavior in those situations. Program results are available for parents and clinicians to download

in order to monitor the progress of the child. This form of intervention was reported to show

positive effects by the child, parents, and teachers; however statistics and examples were not

provided. The efficacy of internet-based interventions is promising due to the many benefits of

the service model, such as ease of access, flexibility in time and place of delivery, and allowing

the child to develop skills in a comfortable, low-anxiety environment (Fung, Manassis, &

Fiksenbaum, 2002).

Psychopharmacological Approach to Intervention

Psychopharmacological approaches to treating children with SM are based on the

presumption that SM is an indicator of social anxiety, and that medication is an important part of

an intervention plan (Carlson, Mitchell, & Segool, 2008). Most commonly, these approaches are

attempted after other intervention options have been explored and shown to be unsuccessful in

increasing the child’s verbal communication (Freeman et al., 2004). Recent studies have

explored the use of commonly used anti-anxiety medications such as monoamine oxidase

inhibitors (MAOI’s) and selective serotonin reuptake inhibitors (SSRI’s) in the intervention of

SM. Many have concluded that SSRI’s are effective in increasing verbal communication and

have fewer side effects than MAOI’s (Freeman et al., 2004; Gordon, 2001; Sharkey &

McNicholas, 2008). Although it is not known exactly how these medications work, Carlson,

Mitchell, and Segool (2008) predict that these medications affect the levels of serotonin and

gamma-aminobutyric acid (GABA) in the individual’s brain, balancing the levels to decrease

21

anxious feelings. Currently, the most common SSRI studied in children with SM is Fluoxetine.

It is important to note, however, that the FDA has not approved any of these medications for the

use in children, yet they are frequently used in this population (Carlson, Mitchell, & Segool,

2008).

Black and Uhde (1994) conducted a double-blind study of 16 children with SM and the

effects of Fluoxetine on their verbal communication. All of the children treated in the study,

including those receiving a placebo, showed some improvements in their communication, but the

children who received Fluoxetine were reported by parents to have shown significant

improvement. However, the majority of the children still showed symptoms of SM after the

intervention had ceased regardless of receiving Fluoxetine or the placebo (Viana, Beidel, &

Rabian, 2009).

Dummit, Klein, Tancer, and Asche (1996) attempted to expand the research done by

Black and Uhde by testing the level of dosage needed for optimum results, as well as examine

the amount of time required for the medication to show an effect. Fluoxetine was determined to

be a safe and appropriate treatment method for SM in children as young as 5 years of age. Most

children showed improvements with doses as low as 10mg, but others only responded to much

higher doses. After nine weeks, 76% of the children demonstrated improvement due to the

medication. However, some children in the study showed a slight side effect of behavioral

inhibition, which researchers suggest is due to the gradual increase in doses of the medication

(Dummit et al., 1996).

Although both studies reported a significant increase in verbal communication for

children with SM, there are some limitations that must be noted. First, the FDA has issued a

warning against SSRI’s as intervention for young children due to reports of increased suicidal

22

thoughts in children with depression (Sharkey & McNicholas, 2008). This is one reason that

psychopharmacological interventions are typically only attempted after other interventions have

not shown success (Carlson, Mitchell, & Segool, 2008). Second, most studies based on

psychopharmacological medications use small sample sizes and results indicate that symptoms

of SM persist even after the intervention has concluded. Finally, it may take a long period of

time for these medications to show any affect at all. Some have predicted that medication can

take up to twelve to sixteen weeks of consistent consumption before a significant response is

shown in the child (Freeman et al., 2004). However, other researchers have reported effects as

early as 24 hours after the first dose of medication (Carlson, Mitcheel, & Segool, 2008). Some

research indicates that the medications may diminish the child’s inhibitions and lead to

disruptive behaviors. Other studies have reported improvements in other areas, such as speech

and communication, in addition to decreasing mute behavior (Carlson, Mitcheel, & Segool,

2008)

Multimodal Approach to Intervention

The multimodal approach to SM intervention refers a combination of behavioral,

cognitive-behavioral, and psychopharmacological strategies. Most studies focus on one form of

intervention at a time to examine what specific approach is most beneficial on its own.

However, a variety of interventions may be combined for the best outcomes possible, especially

in severe and persistent cases of SM (Freeman et al., 2004). Many researchers have stressed the

need for a variety of models in intervention because each child responds to each model

differently (Viana, Beidel, & Rabian, 2009). Giddan, Ross, Sechler, & Becker (1997) described

their research with a multimodal approach to intervention, which included a combination of

various techniques used in behavioral and cognitive-behavioral approaches. This study included

23

a nine-year-old girl in the 3rd grade identified with SM. It was determined that she was

functioning at the 2nd grade level academically; however, her same-age peers attended fourth

grade. She received individual speech and psychotherapy, as well as individual support in the

classroom. Many different techniques were used, including: psychoeducation, contingency

management, social skill awareness procedures, and shaping. In this case, SM intervention

lasted two years and was found to increase verbal communication in all settings. Researchers

stressed the importance of daily routine, multiple service providers, an intervention plan, and

collaboration between professionals and families (Giddan et al., 1997).

Bork (2010) has also noted the need for a multimodal approach to the intervention of SM.

This research emphasizes the use of augmentative and alternative communication (AAC)

systems in combination with behavioral techniques. AAC systems provide alternative modes of

communication, which include: signing, gestures, written notes, phone, pictures, video-

recording, iPad, iPods, smart phones, and other technological devices. Many of these systems

provide programs or applications designed to improve communication such as speech to text,

text to speech, voice recording, or voice production may also be used. These forms of

communication are used in combination with behavioral methods of shaping speech during the

systematic desensitization process. In these interventions, the child can use the school phone to

call a trusted adult while in the school environment, forcing the child to communicate verbally

while in the school setting. Other suggestions include allowing the child to use a walkie-talkie in

the school setting, write notes to communicate to the teacher, or use self-modeling techniques

with a video-recording to allow the child to become used to hearing one’s own voice in the

school setting.

24

Bork and Wood (2010) developed an iSpeak++ software program for educational settings

to be used specifically when working with children with SM. This program is designed to assist

educators to implement interventions at school. The iSpeak++ program incorporates a number

of different activities, including anxiety-coping exercises, such as imagining talking to someone

while practicing deep breathing, and encouraging self-modeling activities (Bork & Wood, 2010,

as cited in Bork, 2010).

In summary, there are several different approaches to the treatment of SM including,

behavioral, cognitive-behavioral, psychopharmacological, and multimodal. Each of these

approaches has merits and drawbacks, but behavioral interventions have the most research and

support for efficacy. Some research suggests using an FBA process to investigate which

approach may be most effective and efficient for the individual student. Overall, literature

recommends using an intervention approach that is individualized for the student and involves a

wide range of people to support the child in many different settings.

25

Chapter III: Summary and Recommendations

There are many approaches available to teachers and school personnel to intervene with

students with selective mutism (SM). Successful approaches to intervention include behavioral,

cognitive-behavioral, psychopharmacological, and multimodal techniques. There is still a

significant amount of research that must be done to learn more about the etiology of this rare

disorder , as well as the most effective and efficient approaches to intervention. This chapter

presents recommendations for further research, implications for the school setting, and a

summary of the literature presented.

Recommendations for Research

Research on the intervention of SM has increased significantly over the past few decades,

yet more research is still needed in many areas. The rarity of the disorder has limited many

research attempts to small experimental designs, single subject experiments, or uncontrolled case

studies; however, larger scaled, more controlled studies must be conducted in order to gain more

information and understanding about this disorder and determine the most efficacious treatment

plans. Much of the research to date has focused on the effects of intervention in the school

setting however; there is a lack of information regarding the effects of intervention in other

environments. Future research should focus on how these interventions affect the behaviors of

children with SM across multiple environments. Nearly all of the studies reviewed include a

post-intervention follow-up, occurring up to a year later. Many researchers have noted that the

identification of SM may predict other psychological issues into adulthood. More longitudinal

studies should be completed to gain information regarding the specific type and frequency of

persisting symptoms of SM and other psychological issues post-intervention and into adulthood.

Finally, many researchers have indicated that SM could be an indicator of social anxiety rather

26

than a separate disorder. More research is needed to explore the differences in children with SM

in order to determine the best intervention approach to treat each specific cause of mute

behavior.

The behavioral approach to the intervention of SM has shown significant success, as

documented by multiple case studies. These studies need to be replicated to show the efficacy of

this intervention approach. There are very few studies that support the efficacy of using specific

techniques alone, especially social skills training and self-modeling techniques. Further research

should explore the success of different combinations of behavioral techniques. There is a need

for more research to explore the use of functional behavioral assessments (FBA) as a tool to

guide the intervention process. The three-tiered approach needs to be explored further for the

efficacy and usefulness within a school setting. More research much be done with children with

SM to support this approach to intervention.

Experimental investigations on the use and efficacy of the cognitive-behavioral approach

in the literature appear quite limited. More research needs to be done with larger sample sizes,

as well as with control groups, which will show the effect of the intervention compared to other

interventions. Also, further research should examine the outcome of the behavioral modification

technique in combination with early intervention. Due to differing opinions, more clarification is

needed to examine the success of cognitive-behavioral techniques in younger versus older

children with SM. Finally, more information is needed that explores the efficacy of online

service models of intervention.

Psychopharmacological approaches to intervention have many areas which must be

explored. First, a better understanding of the effects of serotonin and GABA in children is

necessary. More information is needed to determine the areas of the brain that are affected by

27

popular medications used to treat SM, and how and why these medications have been found to

increase vocalizations in this population. More information also needs to be obtained about the

side effects of these medications. Currently, there are no medications approved by the FDA for

treating SM in children. The possible risks associated with these medications, such as behavioral

disinhibition, depression, and thoughts of suicide, must be explored to ensure the safety of their

use in this population. The uncertainty of these risks and side-effects cause hesitation in parents

and pediatricians to prescribe these medications to children. There is also a need for more

information to determine the amount of time expected until the medication takes effect.

Currently, studies have reported a time frame of 24 hours to 16 weeks for any results to be seen.

Finally, the major studies using the psychopharmacological approach span from nine to twelve

weeks. This length of time is insufficient to examine the full extent of the effects of medications

on children. Finally, most studies involving psychopharmacological approaches have small

sample sizes and are not methodologically sound. Further research should include a larger

number of participants with methodologically sound procedures.

Multimodal interventions are more difficult to conduct due to the individual response of

each child to different intervention styles. Yet these interventions appear to be beneficial for

children with more persistent cases if SM. Behavioral and cognitive-behavioral interventions

seem to overlap in many studies, but further research is needed to identify the outcomes of

specific combinations. Other combinations of techniques need to be researched, including a

behavioral and psychopharmacological combination, a cognitive-behavioral and

psychopharmacological combination, or a combination of all three. The use of new AAC

devices, such as iPads, smart phones, mp3 players, Dynamo, VoicePal, GoTalk and others, must

be explored for usefulness in the school setting. The functionality of these devices and

28

applications may be significant for children with SM in the school setting. Further, more

research on the effectiveness of the Software Program iSpeak ++, developed by Bork and Wood

(2010), should be explored for use in the school setting.

Recommendations for Practice

Selective mutism is most commonly seen in the educational setting with children

experiencing anxiety in the structured setting. School environments must be prepared to identify

SM in children expediently, and know how to implement interventions in a timely manner. In

order for schools to be prepared, teachers and other school personnel must be knowledgeable

about SM and the signs and symptoms that may be present. The school must have an

intervention team established with members who are knowledgeable of the disorder and know

the best way to implement interventions within the school setting. The school personnel who

may be on this team may include the school psychologist, school social worker, school

counselor, lead teacher, principal, as well as others. This intervention team can work in

conjunction with the classroom teacher to implement an intervention within the school setting, as

well as with the parents of the child to ensure consistency and collaboration across settings.

There are a number of intervention approaches that can be easily implemented in a

classroom setting by the intervention team. These approaches include: behavioral, cognitive-

behavioral, psychopharmacology, and multimodal. Most research supports and suggests that

behavioral interventions tend to be the most successful interventions to use. It is recommended

that the intervention process begins with a functional behavior assessment (FBA) in order to

identify when, where, and with whom the child communicates as well as how the child

communicates in different settings. This information can then be used to inform the intervention

process to decide which approach and techniques may be most effective for the specific child.

29

Although the FBA process appears to be more work for the teacher, the information provided

will help identify which intervention will be the most effective for the individual student,

resulting in a more efficient intervention. In all intervention approaches, the intervention team

must monitor the progress of the child. It is helpful to gather data from the interventions and

create graphs to show if progress is being made. This data can be used to show if the child is

responding to the different interventions attempted. The intervention plan may need to be

modified or changed throughout the implementation of the intervention in order to ensure the

best intervention possible for the child.

Many of the techniques presented in this review are commonly used in the school setting

already. Behavioral techniques such as contingency management, shaping, and social skills

training, are techniques that can be used for a variety of different behaviors within a typical

classroom. Cognitive-behavioral techniques such as relaxation and self-regulation skills are

commonly used with children in the school setting as well. These methods are simple to

implement and can be modified to fit individual students or the whole classroom.

The cognitive-behavioral approach to intervention may require an outside therapist to

help with the intervention process. Configuring outside therapy may be difficult due to the legal

and financial implications of recommending these services; however, many of the self-

monitoring techniques can be taught by a school psychologist or school counselor within the

school setting. Children who are able to see an outside therapist may benefit from the therapist

observing and working with the child across multiple settings, including the school environment.

The therapist can then work in conjunction with the school personnel to provide the child with

support from a variety of adults. This collaboration can also help create consistency across

settings for the child.

30

Some children do not respond to interventions as expected and the use of medications,

such as SSRI’s, may be beneficial to help the student cope with the anxiety. Medications can

help the child’s anxiety decrease, eventually allowing the child to feel less anxiety when

presented with situations where he or she is required to vocalize. Once the medication has been

effective in decreasing the child’s anxiety, the medical doctor can gradually decrease the dosage

and eventually discontinue the medication all together. The goal of using medication as an

intervention is to help the child over the “hump” of anxiety that is felt in the stressful setting and

to eventually be able to vocalize without any anxiety or medication.

It is difficult for schools to suggest the use of medications due to the legal and financial

implications this may bring about by the parents. However, it is important for the schools to

have a discussion with the parents about the possibility of adding medication to the interventions

implemented in the school setting when several other interventions have not shown progress

toward vocalization. Some parents are opposed to the use of medication, especially when the

medications are not approved for use in children by the FDA. If medication is not an option, the

school should work as a team with the parents to determine the next step in intervention. Some

further options may include: intensifying the interventions already attempted; using additional

techniques or methods of intervention; referring the child and family to an outside therapist;

and/or providing the family with more information on intervention models and techniques.

Multimodal approaches can be targeted to specific children and their individual needs. In

the school setting, it is important to use all methods possible to find success for these children.

Therefore, schools must use their resources to help children with SM find success. It is not

necessary to know what intervention worked for a particular child, but rather it is important to

see progress toward full vocalization for the child in the school setting.

31

Summary

Selective mutism (SM) is a rare disorder found in children who speak in some situations

but not in others. The causes of SM vary depending on the child, making it difficult to predict

how each child will respond to each intervention approach. The course of intervention depends

on a variety of individual factors such as personality, motivation, and the desire of the child to

change the behavior. The four current models of intervention include: behavioral; cognitive-

behavioral; psychopharmacological; and multimodal approaches. The behavioral approach is the

most widely used, researched, and practiced approach. This may be because it is often the first

approach attempted, and in many cases found to be successful. Further, research continues to

develop the use of functional behavioral assessment (FBA) to help identify the most appropriate

behavioral technique for an individual child. This advancement to the behavioral approach may

increase its usefulness in the future. Cognitive-behavioral approaches have shown success with

some children with SM. However, this approach requires the child to possess higher cognitive

abilities that allow the child to think about and try to change the behaviors. This may mean that

the cognitive-behavioral approach to intervention is inappropriate for children until they are able

to self-monitor their behavior. Psychopharmacological approaches have shown overall success,

but more information must be gathered to explore the safety of the medications for this

population, as well as identify the type and side effects. This approach may be best used when

all other approaches have been unsuccessful for many months. The multimodal approach to

treating children with SM is a promising theory. Research continues to develop in this area of

intervention with the advancement of technology creating tools for children with SM to use.

More research must be done to discover if these models are more effective than one type of

approach alone. The efficacy of each model is supported in literature, but further research is

32

needed to advance the efficiency of each intervention approach. The rarity of the disorder makes

it difficult to recruit a large number of children for a controlled study, thus making it difficult to

have methodologically sound studies with large sample sizes. All intervention approaches

require the involvement of parents, teachers, therapists, and others closely involved in the child’s

life. The highest level of success has been achieved when intervention techniques are

understood and provided by adults in all aspects of the child’s live, and these adults work

together to support the child with SM in all environments. Overall, intervention of SM takes

patience and endurance to see full effects, but the results can be life changing.

33

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