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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

Evidence Based Practice: Selective MutismUniversity of Utah

+ 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).

+ 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.

+ 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

+ 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)

+ 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)

+ 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

+ Selective Mutism:Assessment

DSM-IV-TR Diagnostic Criteria Referral to Pediatrician and Speech-Language

Pathologist

+ 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).

+ 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)

+ 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

+ 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

+ 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

+ 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

+ 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

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+ 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

+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.

+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.