Download Presented by: Mary Beth Pummel 04.08.2009

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Evidence Based
Practice:
Selective Mutism
University of Utah
Presented by: Mary Beth Pummel
05.05.2009
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
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Selective Mutism:
Diagnostic Features
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Failure to speak in specific social situations despite speaking
in other settings (DSM-IV-TR).
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Children with selective mutism (SM) often rely on other
forms of communication to function (gestures, shaking head,
pointing, grunting, etc.) (Sharp, Sherman, & Gross, 2007).
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Frequently shy, behaviorally avoidant, fearful, and often
oppositional (Kehle, Madaus, Baratta, & Bray, 1998).
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DSM-IV-TR
Diagnostic Criteria
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313.23 Selective Mutism
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Consistent failure to speak in specific social situations despite
speaking in other situations
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The disturbance interferes with educational or occupational
achievement or with social communication
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The duration of the disturbance is at least 1 month
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The failure to speak is not due to a lack of knowledge of, or
comfort with, the spoken language required in the social situation
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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.
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Selective Mutism:
History and Current Conceptualizations
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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).
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Labeled as “elective mutism” in DSM-III and DSM-III-TR
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To reflect the voluntary condition of SM
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Conceptualized as a form of oppositional behavior
Change to “selective mutism” in DSM-IV (1994)
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To reflect refusal to speak in specific situations
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Currently conceptualized as either a form of oppositional
behavior or social anxiety
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Selective Mutism:
Prevalence, Etiology and Course
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Less than 1% of school-age children meet diagnostic criteria
(Sharp et al., 2007).
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No clear etiology: likely a combination of environmental and
genetic factors (Viana et al., 2008)
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Family history of social phobia or other anxiety disorders
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Maladaptive reinforcement patterns
Age of onset 2 to 5 years (Cunningham, McHolm, Boyle, Patel,
2004).
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Often a significant lag between onset and diagnosis/intervention
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Duration 37 to 151 months (m=6.9 years)
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Selective Mutism:
Prevalence, Etiology and Course
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SM often occurs comorbidly with other anxiety disorders and
other psychological symptoms (Sharp et al., 2007; Viana et
al., 2008).
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Overlapping characteristics with social phobia
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Internalizing symptoms
Comorbidity with externalizing disorders (Viana et al., 2008)
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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)
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Selective Mutism:
Assessment
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Direct Observation
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Parent/Teacher/Child Interview
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Selective Mutism Questionnaire (SMQ) (Bergman, Keller,
Piacentini & Bergman, 2008).
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Functional Behavior Assessment
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Behavior Rating Scales
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Behavior Assessment System for Children – Second Ed.
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Child Behavior Checklist
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Anxiety Disorders Interview Schedule
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Revised Children’s Manifest Anxiety Scale
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Selective Mutism:
Assessment
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DSM-IV-TR Diagnostic Criteria
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Referral to Pediatrician and Speech-Language Pathologist
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Selective Mutism:
Treatment and Intervention
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Behavior Therapy Models
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Applied Behavior Analysis (ABA)
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Combined approaches: principles of operant conditioning and
social-learning theory
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Shaping, stimulus fading, contingency management,
positive/social reinforcement (Stone et al., 2002).
Self-Modeling
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Positive change in behavior that results from repeated
observation of oneself producing the desired behavior (Kehle,
Owen, & Cressy, 1990).
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Selective Mutism:
Treatment and Intervention
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Social Skills Training: eye contact, greetings (Fisak, Oliveros,
Ehrenreich, 2006).
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Parent Training: anxiety management, increase opportunities
for practice, positive reinforcement (Fisak et al., 2006)
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Social Problem Solving Intervention (O’Reilly, McNally,
Sigafoos, Lancioni, Green, Edrisinha et al., 2008)
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The student is taught a generic set of social rules that can be
easily adapted to different social settings
Pharmacological Treatment
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Selective Serotonin Reuptake Inhibitors (SSRIs)
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Monoamine Oxidase Inhibitor (MAOI) (Carlson, Mitchell, &
Segool, 2008)
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Selective Mutism:
Fads and Non-EBP Interventions
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No controlled trials of treatment methods for Selective
Mutism have been conducted (Viana et al., 2008; Stone et al.,
2002)
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Research literature consists mostly of single-case experimental
designs
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Selective Mutism:
Intervention
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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.
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Participant: 12 year-old boy, 6th grade student
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Referred for Sp Ed when 5 years old: 30-day trial in self-contained
classroom for children with EBD
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Received various levels of treatments and placed in a variety of
settings throughout course of education
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At time of study, in Reg Ed classroom with aide and 30 minutes of
resource support per day
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Selective Mutism:
Intervention
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Assessment
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WISC-III Performance Scaled Score of 90
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WJ-II Revised Tests of Achievement: Scores within the average
range on Math and Written Language
A-B-B’ Multiple-Baseline Design across settings
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A: Baseline
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B: number of prompts delivered was reduced daily
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B’: goal condition, 3 or fewer prompts to receive reinforcer
Dependent Measures: Verbal Responses
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Number of responses
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Rate of words spoken per minute
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Selective Mutism:
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Intervention
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Stimulus Fading:
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Changing settings: Resource room, Study room, Mainstream
classroom
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Fading prompts within each setting: number of prompts and
intensity (loudness of voice)
A: Baseline
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Asked specific questions, no prompts
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Data were collected using event recording 30-minute time
periods
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Selective Mutism
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B: Reducing Prompts
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Selected a reinforcer he would like to earn for that session
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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)
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Prompts were reduced by 2 during B
B’: Goal Condition
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Selected a reinforcer to earn
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Told he could have the reinforcer for 20 verbal responses with 3
or fewer prompts
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Selective Mutism:
Conclusions
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Characterized by a failure to speak in specific social
situations despite speaking in other settings
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Relatively rare condition with onset as early as 2 years of age
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Usually substantial gap between onset and diagnosis/treatment
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Behavioral interventions are most typically used and show
support for efficacy
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Few assessment materials specific to the condition
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Research
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No large randomized controlled trials
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Limits generalizability of results
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References
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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.
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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.
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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.
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Fisak, B. J. Jr., Oliveros, A., Ehrenreich, J. T. (2006). Assessment and behavioral
treatment of selective mutism. Clinical Case Studies, 5(5), 382-402.
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Kehle, T. J., Madaus, M. R., Baratta, V. S., & Bray, M. A. (1998). Augmented selfmodeling as a treatment for children with selective mutism. Journal of
School Psychology, 36(3), 247-260.
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References
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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.
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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.
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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.
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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.
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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.