An Integrated

Behavioural Approach to
Selective Mutism
By: Karen Chiu, Elysa Christy, & Melissa Martin

Agenda

Definition of Selective Mutism

DSM V Diagnostic Criteria
Description of Intervention
Theoretical Basis
Review of Research Basis
Application & Case Study
Limitations
2

What is Selective Mutism?

Selective Mutism (SM) is an impairing behavioral
condition in which a child fails to speak in certain
social situations despite speaking regularly and
normally in other situations (Bergman, 2013).

Age of onset is before age 5

Seems to be more common in girls than boys
Prevalence is just under 1% of 5-7 year olds in the U.S.
Most children with SM have normal language abilities
SM does not appear to be related to the occurrence of trauma

(Bergman, 2013)

DSM V Diagnostic Criteria

Selective Mutism

312.23 (F94.0)

A. Consistent failure to speak in specific social situations in which there is an expectation for
speaking (e.g. at school) despite speaking in other situations.
B. The disturbance interferes with educational or occupational achievement or with social
communication.
C. The duration of the disturbance is at least 1 month (not limited to the first month of
school).
D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the
spoken language required in the social situation.
E. The disturbance is not better explained by a communication disorder (e.g., childhoodonset fluency disorder) and does not occur exclusively during the course of autism
spectrum disorder, schizophrenia, or another psychotic disorder
(American Psychiatric Association, 2013)

Description of Intervention
INTEGRATED BEHAVIORAL APPROACH
A multicomponent treatment approach that is designed for
children 4 to 8 years old with SM
Emphasizes behavioral techniques to be used in conjunction with exposurebased intervention
o

Behavioral interventions target gradual increases in appropriate speaking behaviors across

settings where the child has difficulty speaking

Positive reinforcement is used when habituation occurs towards speaking in anxiety-provoking

settings

The integrated nature of this therapy refers to the goal of integrating input from
the clinician with that from the parents and teacher. Together they form the
intervention team
(Bergman, 2013; Kearney,

Theoretical Basis of Integrated

Behavioral Approach
Behavioral approaches place an emphasis on
observable behavior and environmental aspects that
may contribute to certain behaviors
Exposure and transfer are considered effective
treatment for anxiety-based conditions in children
(McHolm, Cunningham, & Vanier, 2005)

Theoretical Basis of Integrated

Behavioral Approach
More effective than Cognitive Behavioral Therapy (CBT):
o Children in this age group have limited cognitive development and are
typically too young for social phobia CBT treatment.
o Children with SM usually will not speak, which is often required for CBT
o School personnel and/or parents are often involved,
which requires modifications of existing CBT protocols
(Bergman, 2013; McHolm et al., 2005)

Basic Principles of an Integrated

Behavioral Approach
1. Behavior is learned through experience
2. Speaking in gradual steps helps fear go away
3. Tracking the childs progress will help indicate
if the program is working
4. Practice is important
5. Early intervention is best
(McHolm et al., 2005)

Review of Research Basis

Results from a meta-analysis of SM treatment
literature indicated that:
1) Some treatment is better than no treatment
2) Behaviorally-oriented treatment approaches
were better than no treatment
3) Two different behavioral models were not
differentially effective

(Pionek Stone, Kratochwill, Sladezcek, & Serlin,

2002)

Review of Research Basis

Many interventions for younger children involve
hands-on, behavioral interventions, use of imagery
Use of behavioral interventions particularly useful,
given childs inhibition to speak outside of
immediate family
Solid evidence supporting use of behavioral
interventions for SM
10

Review of Research Basis

Forms of behavior modification include:
Contingency management
Stimulus fading
Shaping
Desensitization
Extinction
Aversion
11

Review of Research Basis

Observations consistent across studies:
Singular technique does not address all stimulus
conditions that precede and maintain nonverbal
behavior
Reinforcement goes from continuous to intermittent
schedule
Reinforcer strength related to rate of verbal
behavior
(Watson & Kramer,
1992)

12

Review of Research Basis

Multimethod interventions
Seek to establish relationships between
environmental conditions and verbal behavior
Serve to address different aspects of childs mutism
o Reinforcers used to generate speech
o Stimulus fading used to help children speak in
different environments
(Labbe & Williamson, 1984; Anstendig,
1998)

13

Review of Research Basis

Positive outcomes in increasing verbalizations
reported for contingency management and shaping
in single subject designs and case studies
Successful addition of stimulus fading procedures
to shaping and contingency management
o Builds on success by gradually increasing
number of people and places in which speech is
rewarded
(Cohan, Chavira, & Stein,
2006)

14

Review of Research Basis

Shaping and stimulus fading appear to work well in
school settings
Study found behavioral intervention group improved
significantly more than those in remedial programs
(Sluckin, Foreman, & Herbert, 1991)

Greater gains made when nonverbal behaviors

extinguished while verbal behavior was reinforced
(Piersel & Kratochwill, 1981)
15

Application of Intervention
Assessment
Planning
o Identify Team Members
o Speech Ladder

Intervention
o Build Rapport
o Elicit Speech
Stimulus Fading
Shaping
Contingency Management
o Generalizing Speech
16

Case Study: Le Le
Personal Characteristics
o
o
o
o

5-year-old girl
Chinese national living in Thailand
Mom, dad, 2-year-old brother, nanny
Speaks Mandarin and English

School
o Age 3: small English-medium preschool, began speaking at school in
English
o Age 4: Pre-K at large English-medium international school, 35
students and 4 teachers in open classroom, completely mute at school
17

Assessment Overview
Assessment Questions:
Any other cognitive or SLP deficits?
To whom does she speak fully and freely?
In what settings does she speak fully and freely?
During what activities does she speak fully and freely?
In which languages - Mandarin and/or English?
18

Assessment Overview
Any other cognitive or SLP deficits?
No - achieving benchmark targets (knows letters/numbers, writes sight words in
English, reads simple books in English at home, not an EAL student)
Perfectionistic tendencies
To whom does she speak fully and freely?
Mom, dad, nanny, brother, two Mandarin-speaking friends
In what settings does she speak fully and freely?
At home
During what activities does she speak fully and freely?
Playing games, during normal family activities
In which languages - Mandarin and/or English?
Mandarin/English: mom, one friend/classmate
Mandarin: dad, brother, one friend/classmate
English: Korean classmate

19

Planning Overview
Planning for Intervention
Identify Team Members
o Mom, psychologist,
counsellor, teacher,
keyworker
o Other language partner:
Mandarin-speaking
classmate
*Keyworker = person implementing
intervention
(Johnson & Wintgens, 2001)

20

Stages of Speaking
Planning for Intervention
Typical stages of speaking
Consider people, locations, &
activities
Outline a series of
approximations (steps on a
ladder) tailored to the childs
skills and needs

(Johnson & Wintgens, 2001)

21

(Johnson & Wintgens, 2001)

22

(Johnson & Wintgens, 2001)

23

Speech Ladder: series of approximations (steps on a ladder) tailored to childs skills and needs
24

Tailored Speech Ladder

Friend,
keyworker
Mom, friend,
keyworker

Back of
classroom,
teacher or peer
present

Empty
classroom
after school
Home

English - reading a familiar story,

games with 2-3 word responses

Activities

Keyworker,
classmates or
teacher
Keyworker

English - games w/ longer phrases,

answering simple questions

Center of
classroom,
multiple others
present

Places

People

Teacher,
classmates,
others

English - rote activities, one-word

response games, Whatsapp
messages; Mandarin - talking with
keyworker

English - nonverbal games, listening to

a story; Mandarin - talking near
keyworker, Whatsapp messages

25

Intervention
Build Rapport
o Elicit Speech
Stimulus Fading
Shaping
Contingency Management
o Generalizing Speech

26

Building Rapport & Eliciting Speech

Stimulus Fading / Sliding In Technique: fading in (incrementally
increasing) the number of people present when the child is speaking
Fading in the keyworker
K

M
C

M
C

M
C

(Johnson & Wintgens, 2001; Krysanski, 2003)

27

Eliciting Speech
Shaping: eliciting verbalization or non-verbal communication,
scaffolded in small steps, until desired behaviour (speaking) is reached
through approximation

Le Le is comfortable
recording her voice so she
sends audio recordings from
home, using Whatsapp.

Me: What is your

favorite fruit?

Le Le: I like
strawberries.

(Johnson & Wintgens, 2001)

28

Eliciting Speech
Shaping: games requiring one- or two-word responses
Le Le likes fruit so we do
a variety of activities and
games around this
theme. We also try a
new fruit each week.

BINGO

Fruit Bingo
recognize
names of fruit
say Bingo!

Guessing Game
understsand
quesitons
say Yes! or No!

Le Le:
No!

Me: Is it
yellow?

Fruit Flowers
name types
of fruit
(Johnson & Wintgens, 2001)29

Eliciting Speech
Contingency Management: shaping through positive reinforcement
for verbal or non-verbal communication until desired behaviour is
reached through approximation

Le Le likes cooking, and she is able to

read simple pattern books fluently, so she
earns cooking days by reading books.

(Viana et al., 2009)

30

Generalizing Speech
Across settings
o Keyworker visits school

Across people
o Fade in teacher

Across activities
o Talk during group work

Bye!
T

K
C

Remember: If necessary, repeat same sequence

of speech approximations / activities with each
new person
(Johnson & Wintgens, 2001)31

Theoretical Limitations
Anxiety-based theoretical conceptualization

Is intervention suitable for other subtypes of SM?

Low Functioning Mutism: low COG, academic problems
Sensory/Pathology Mutism: sensory integration difficulties,
oppositional behaviour
Emotional/Behavioural Mutism: EF deficits, oppositional
behaviour
Other variables: speech-language deficits, immigrant populations,
abuse
More comprehensive anxiety: social phobia
(Cleave, 2009; Hultquist, 1995; Mulligan & Christner, 2012)

32

Theoretical Limitations
Success of behavioural approach requires:
o
o
o

all aspects of speech to be addressed - thus time

consuming and technically difficult
early identification - 4-5 years old
CBT techniques integrated for 7+

(Anstendig, 1998; Schum, 2006; Viana et al., 2009)

33

Practical Limitations
Shared beliefs
o
o

Parents, teacher, other team members

Mutism based on underlying anxiety

Child is able to speak.

Child is not being wilfully obstinate.
Child will speak when ready.
Team must support childs efforts to communicate.
(Johnson & Wintgens, 2001;
McHolm et al., 2005)

34

Practical Limitations
Challenges of team approach

Time constraints at school

Availability of parent
Home-school language barrier
Keyworker

Location

Home vs. School

(Johnson & Wintgens, 2001; McHolm et al., 2005)

35

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Washington, D.C.: Author.
Anstendig, K. (1998). Selective mutism: A review of the treatment literature by modality from 19801996.
Psychotherapy: Theory, research, practice, and training, 35, 381391.
Bergman, R.L. (2013). Treatment for children with selective mutism. New York, NY: Oxford University Press.
Cleave, H. (2009). Too anxious to speak? The implications of current research into selective mutism for educational
psychology practice. Educational Psychology in Practice: Theory, Research and Practice in Educational Psychology,
25(3), 233-246. doi: 10.1080/02667360903151791
Cohan, S. L., Chavira, D. A., & Stein, M. B. (2006). Practitioner review: Psychosocial interventions for children with
selective mutism: A critical evaluation of the literature from 19902005. Journal of Child Psychology and Psychiatry,
47(11), 1085-1097.
Johnson, M. & Wintgens, A. (2001). The selective mutism resource manual. London: Speechmark.
Kearney, C.A. (2010). Helping children with selective mutism and their parents. New York, NY: Oxford University
Press.
Krysanski, V. L. (2003). A brief review of selective mutism literature. The Journal of Psychology, 137(1), 29-40.
doi:10.1080/00223980309600597
Labbe, E. E., & Williamson, D. A. (1984). Behavioral treatment of elective mutism: A review of the literature. Clinical
Psychology Review, 4(3), 273-292.

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References
McHolm, A. E., Cunningham, C. E. & Vanier, M. K. (2005). Helping your child with selective mutism: Practical steps to
overcome a fear of speaking. Oakland, CA: New Harbinger Publications.
Mulligan, C. A., & Christner, R. W. (2012). Selective mutism: Cognitive-behavioral assessment and intervention. In: R.
B. Mennuti, R. W. Christner, & A. Freeman. (Eds.) Cognitive-behavioral interventions in educational settings (2nd ed.)
New York: Routledge.
Piersel, W. C. & Kratochwill, T. R. (1981). A teacher-implemented contingency management package to assess and
treat selective mutism. Behaviour Assessment, 3, 371-382.
Pionek Stone, B., Kratchowill, T. R., Sladezcek, I. & Serlin, R. C. (2002). Treatment of selective mutism: A bestevidence synthesis. School Psychology Quarterly, 17(2), 168-190. doi: 10.1521/scpq.17.2.168.20857
Schum, R. L. (2006). Clinical perspectives on the treatment of selective mutism. Journal of Speech and Language
Pathology - Applied Behavior Analysis, 1(2), 140163-190. doi: 10.1037/h0100190
Sluckin, A., Foreman, N., & Herbert, M. (1991). Behavioural treatment programs and selectivity of speaking at followup in a sample of 25 selective mutes. Australian Psychologist, 26(2), 132-137.
Viana, A. G., Beidel, D. C., & Rabian, B. (2009). Selective mutism: A review and integration of the last 15 years. Clinical
Psychology Review, 29, 57-67. doi: 10.1016/j.cpr.2008.09.009
Watson, T. S., & Kramer, J. J. (1992). Multimethod behavioral treatment of longterm selective mutism. Psychology in
the Schools, 29(4), 359-366.

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Recommended Books:

For Educators:
Bergman, 2013

For Educators:
Johnson & Wintgens, 2001

38

Recommended Books:

For Parents: McHolm,

Cunningham & Vanier, 2005

For Parents: Kearney, 2010

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