Presented by: Mary Beth Pummel 05.05.2009

1. Evidence Based Practice: Selective Mutism University of Utah Presented by: Mary Beth Pummel05.05.2009 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 H325K080308

2. 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).

3. DSM-IV-TRDiagnostic 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.

4. 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

5. 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, 2004). • Often a significant lag between onset and diagnosis/intervention • Duration 37 to 151 months (m=6.9 years)

6. 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, 2002)

7. Selective Mutism:Assessment • 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

8. Selective Mutism:Assessment • DSM-IV-TR Diagnostic Criteria • Referral to Pediatrician and Speech-Language Pathologist

9. 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).

10. 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)

11. 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., 2002) • Research literature consists mostly of single-case experimental designs

12. Selective Mutism:Intervention • 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), 248-255. • 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

13. Selective Mutism:Intervention • 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

14. Selective Mutism: • Intervention • Stimulus Fading: • Changing settings: Resource room, Study room, Mainstream classroom • 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 periods

15. 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

18. Selective Mutism:Conclusions • 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

19. References • 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), 456-464. • 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.

20. References • 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.