Breaking the Silence:

Supporting Students
with Selective Mutism
A Collaboration between School
Psychologists and Speech Language
Pathologists

Welcome!

Latisha Stephenson, M.A., Jyutika Mehta,

LSSP, NCSP Ph.D, CCC-SLP
School Psychology Consultant Consultant for SLP, DHH, AAC
 Learning Objectives

Define and IDEA Criteria and

01 Identify 02 Assessment

03 Practice 04 Addressing Needs

01
Define and
Identify
Selective Mutism Diagnostic
Criteria
Selective Mutism is the inability
to communicate in select social
settings despite being able to
verbally communicate in others
Selective Mutism
Children with selective mutism do not initiate
speech or reciprocally respond when spoken to
by others

Prevalence:

● 0.3-1.9%

Onset:

● Usually before the age of 5, but may not

come to clinical attention until entry into
school

Selective
Mutism
20-30% of all children with SM have subtle speech and
language disorders

More common in girls than boys

Anxiety is the underlying cause

 Selective
Mutism
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
one month (not limited to the first month
of school)

Selective Mutism
D. The failure to speak in 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.
childhood-onset fluency disorder) and does
not occur exclusively during the course of
autism spectrum disorder, schizophrenia, or
another psychotic disorder
 Selective Mutism
Functional Impacts

May result in social impairment. As they

mature, they may face social isolation. In
school, they may suffer academic
impairment because they often do not
communicate with teachers regarding their
academic or personal needs. Severe
impairment in school and social
functioning, including that resulting from
teasing by peers, is common.

Selective Mutism
Differential Diagnosis Needed:
● Silent period in immigrant children learning
a second language
● Communication disorders
● ASD, schizophrenia, or other psychotic
disorder
Predisposing
Factors
Genetics: Family history of anxiety Behavior Inhibited Temperament= social
anxiety
Biological/Biochemical-Neurophysical
(Fight/Flight/Freeze) Environment

Heightened Sympathetic Response: Family stressors/ troubles

Skeletal/muscle stiffening; expressionless;
eye gaze aversion; stiffness-paralysis of the
vocal cords (hypothesized

Studies show that, when confronted

with fearful situations, the amygdala
receives a signal of potential danger Lowered
from the Sympathetic Nervous System
Excitability of
and begins to set off a series of
reactions that help an individual the Amygdala
protect themselves. People with SM
seem to have a decreased threshold of
excitability in the amygdala.
Predisposing
Factors
Trauma Developmental Delay

Bilingual Speech/ Language Difficulty (usually

expressive)
Learning Difficulty (Central Auditory
Processing Disorder) Medication Side Effects

Maintaining Factors
Misinterpretation of symptoms Mistreated – do not address other issues

Anxious, hesitancy in responding, others Environmental stressors – pressure or focus

respond for the child lack of on talking
communication
Increasing Age – becomes habit
Misinterpretation of testing/assessment –
AU, S/L, LLD Development of avoidance behaviors

Misdiagnosis
 SM Indicators
Child does not talk in certain settings, under specific conditions,
and this behavior is consistent

Lack of verbal communication cannot be explained entirely by a

speech/language impairment

No indication of major behavioral, developmental or psychotic

difficulties

Indicators it is NOT SM
Child does not talk in any setting Unusual speech and/or language features

Never developed connected speech at Compulsive adherence to minor details in

home daily routines at home and at school

Has profound learning difficulties Inconsistent speaking habits

Does not talk to anyone Occurs suddenly, with abrupt cessation of

speech
Same limited speaking habits in all settings
 02
IDEA Criteria and
Assessment
Selective Mutism and the Full
and Individual Evaluation

Emotional Disturbance
Inability to learn that An inability to build or
cannot be explained by maintain satisfactory
intellectual, sensory, or
interpersonal relationships with
health factors
peers and teachers

Inappropriate types of A general pervasive mood of

behavior or feelings under unhappiness or depression
normal circumstances

A tendency to develop physical

symptoms or fears associated
with personal or school problems
 Speech Impairment

Stuttering Impaired Articulation

Voice Impairment Language Impairment

Other Health Impairment

Limited strength, vitality, or alertness, including a heightened alertness to
environmental stimuli, that results in limited alertness with respect to the
educational environment

Due to chronic or acute health problems

Team must include a licensed physician, a physician

assistant, or an advanced practice registered nurse
 Comprehensive Evaluation

Speech and Emotional/

Social
Language Behavioral

Cognitive Academic Health

Priority Areas

Detailed History Cognitive Functioning

1 3

2 4

Language Emotionality
Assessment Considerations
History Language
Who does the child talk to? In
Evaluation
Language Comprehension
what settings and
circumstances? Expressive Language

How does the student Nonverbal Communication

communicate? Gestures,
whispering, writing? Articulation

Onset of symptoms? Voice

Other suspected problems? Pragmatic Language

Assessment Considerations
Cognitive Emotionality
Functioning
Nonverbal Assessment Anxiety is often reported as
being the underlying issue
Does the student have the
cognitive skills to converse? However, if those around the
student have been
accommodating, then they
may not report clinical levels of
concern
 Assessment Considerations
If the student is not responding verbally, a video recording can
be obtained from parents

Consider having parents present for the evaluation

Work on developing rapport with the student before jumping

into testing

Assessment Considerations
Try to avoid triggering the child’s anxiety by:

● Minimizing eye contact

● Avoid encouraging the child to “talk” or “speak” but rather to communicate
● Create joint attention using activities the student enjoys
● “Think aloud” describing what the student is doing rather than asking
questions
● Allow plenty or response time
● Continue the conversation even if the student is not responding to you
● Maintain a calm demeanor and receive the student’s responses in a neutral
way
● Consider your seating arrangement
 Assessment Considerations
Use non-threatening tasks such as picture-pointing tasks, when
possible

Acknowledge and respond to the child’s gestures for expressive

communication if the child is nonverbal

Assess the effectiveness of the child’s attempts at nonverbal

communication

Selective Mutism Questionnaire

The Selective Mutism Questionnaire (SMQ) is a caregiver-report

questionnaire that assesses the frequency of selective mutism
symptoms over the preceding two weeks, in three domains: at
school, speech in home/family environments, and in
community/social setting

bit.ly/SMQ2023
03
Let’s
Practice!
With your group, discuss the how
you would address these cases

Scenario 1
Sean is an 11 year old boy just beginning 6th grade. He is experiencing recent
onset of SM at school. This school is his fourth school in six years. Parents
describe his temperament as pretty typical with minimal anxiety noticed in
the past. Sean has not spoken to teachers in these first three weeks of
school. He has been observed speaking with 2-3 peers during lunch. Sean
reportedly speaks freely at home and in most settings outside of the home.
Teachers are concerned because of his lack of ability to express what he
knows during class and would like to refer to CMIT. What is your
recommendation?
 Scenario 2
Mya is a five year old girl in Kindergarten. Mya’s parents and teachers describe her as
incredibly timid and report she has not spoken to teachers or peers in school at all during the
first 9 week period. Parents shared with the teacher that Mya also had a difficult time
speaking to preschool teachers, although she eventually did, and she has always had a difficult
time separating from her parents. Even now, she needs encouragement and reassurance to
enter school so parents walk her to the door rather than drop her off in the carpool line. Mya
is inconsistently using nonverbal communication and is sometimes not able to communicate
her needs in the classroom. Teachers are concerned about her social skill development and
academics but are not sure what to do. Parents are concerned in those areas as well but
report no communication concerns at home. Mya has been referred for a Full Individual
Evaluation. How will you assess her speech, language, and communication skills?

Scenario 3
Tiffany is eight years old. She has a history of anxiety and parents reported when she began
preschool, at 3 years old, there was a period of time that she “refused” to speak in school. Parents
reported she can be really stubborn at times and if she decides she doesn’t want to do something,
she will outright refuse. Parents are aware that Tiffany has not been speaking to teachers in school.
They have tried offering rewards to Tiffany at home if her teachers let them know she has spoken
that day but she still won’t speak so she has never earned the reward. Tiffany has whispered to her
classroom teacher and the school librarian multiple times. She has one friend that she will speak to
(usually whispering in her ear so others cannot hear), but if that friend is absent, Tiffany will not seek
out other peers. Tiffany is really good about communicating nonverbally. She will write her responses
and will nod or shake her head to affirm or deny. Tiffany seems to enjoy participating in class, but not
verbally. Parents reported that although Tiffany speaks at home, it can sometimes be difficult for
friends and family and even for parents themselves to understand her and when she is expressing a
lot, she seems to stutter. The MTSS meeting, which you were not invited to, resulted in a referral for
a speech/language evaluation. What’s next?
 04
Addressing
Needs
Selective Mutism in School

Treatment Considerations
The effectiveness of treatment depends on:
● how long the child has had selective mutism
● whether the child has co-occurring communication or learning
difficulties or anxieties
● the cooperation of everyone involved in the child’s treatment
plan

The focus of treatment is not on speaking, but reducing the

anxiety the child has for speaking to and being heard by
others
 General Treatment Principles
Communicate with family & professionals regarding expectations/progress

Progress can be a very slow process

Time to success could be 6 months to 2 years

Anxious people are “frozen” people with very little energy left – so we must slice the
steps to treatment very thin in order to reach the child

Use more verbs instead of nouns when discussing the child (what you do, what we
can do to help, etc) SM is not “who you are” it is “the situation”

Don’t get too bound to “label” of selective mutism, especially when dealing
with/discussing children

Principles of Treatment
(Johnson and Wintgens, 2001)
Use a behavioral approach

Make the child an active partner in treatment process

Follow a systematic progression, changing 1 variable at a time

Take into account the level of severity

Let the child set the pace

Never allow a child to struggle to communicate

Adopt a relaxed, matter-of-fact style of interaction

Ensure a united, consistent approach

 Treatment Plan
School/Education Accommodations and Interventions
KEY: Teacher enables without realizing it
All School personnel to be educated about SM and child’s level of
social comfort – what the child’s communication abilities are
Whole Child Approach – address concomitant issues
Medication
Alternative Treatments

Treatment Plan Should Assist With:

Building Social Engagement Skills

Progressing Communicatively

Management of Difficult Behaviors

Acknowledgement for Understanding and Inner Control

•Structure, Routine, Consistency

The Set Up of Ideal Situations

 Stages of Social Communication
Comfort Scale

bit.ly/SSCCS2023

Treatment Strategies
Behavior Strategies: CBT strategies:
● Contingency management ● Best for children 7 years old
● Shaping reinforcement and older
● Stimulus fading ● Identify anxious thoughts
● Systematic desensitization and how anxiety makes
● Social skills them feel
● Self-modeling ● Identify and challenge
maladaptive beliefs
● Develop a coping plan to
deal with distress
 How Do We Start?
First step: determine how the child relates to the difficulty he/she has
in getting the words out

Second step: Determine words to describe the difficulty

Child has to relate to and admit difficulty

So, How Do We Do That?

Feeling Charts

Rating Scales

Talking Scales

Talking Maps

Comfort Journals

SM is about control – so we help them transfer control from

mutism to strategies they can use for social communication.
 Social Engagement/ Comfort
Small Environments

Few People

Quiet/Less Stimuli/Relaxed

No pressure ‘to speak’

Stimulate Responding
SHOW

POINT

NOD

WRITE

BOARD GAMES

AAC!
 Games
Use sounds to respond before moving Mr./Mrs. Handover Mr./Mrs. Takeover
to shaping
Use a verbal intermediary
Hi/Bye Game
Waving game
Yes/No game (with peers and/or
therapist) Clock-watcher

Interview game Eye Spy (w/people)

Accommodations
Allowing enabling the child to communicate nonverbally

No pressure to
Allow gestures
speak

AAC, word board,

Tablet for writing
pictures

Sit with a
familiar person
 Intervention
Any communication is good communication

Dyads/small group

Minimize attention to the child

Home communication/reading sample

AAC

Intervention
Talking about Talking:
● Why talking so hard
● Brave v/s shy

Process comments

Goal-setting

Ownership of communication (which system works best)

HW assignments
 Self-Rating Scales

Avoid!
Begging or cajoling the child to speak

Trying to rationalize with the child

Pressuring the child to speak

Punishing, blaming, isolating or ignoring the child

Drawing a lot of attention to the child when he/she makes a

communicative attempt (may make a shy and anxious child even
more uncomfortable)

Teasing and enabling from peers

 What Helps
Not blaming the child, but viewing the problem as an opportunity to
make a very significant difference in the child’s life

Treating the child as equally as possible to other children

Allowing the child to use any mode of communication possible (but

always reinforcing higher levels): picture exchange, writing, pointing,
whispering, drawing

Being patient and calm; not letting your frustration become

counterproductive; know that the process may take 6 months to 2+
years

Factors Impacting Progress

Age when first identified Child’s ability to “self-reflect”

Extent of Mutism Level of support

Degree of Anxiety felt by the child Experience of those involved and

working with children
Staff and parental attitudes
Continued Support May Be Needed

Speech/language therapy (think Social skills development

AAC to begin with)
Assertiveness training
General language work with
Community program
activities that increase
communication load and Maintaining a supportive
promote confidence environment

Increased responsibility to raise

self-esteem

Classmates as Helpers

Be a good friend Include all children Do not try to make your

in all activities friend talk if he/she
does not want to right
now

Do not tell people “Johnny is just “If you play with

“he can’t talk” or really shy but he him and eat lunch
“he doesn’t talk” likes kids.” with him, he will be
less shy.”
 Dismissal
Child is not being held back educationally or socially

Child can talk to strangers

Parents and school staff are no longer worried

Child is happy and appears able to handle situations with very little
support needed

Child can carry on with building confidence in social situations using

strategies that are effective

Thanks!

Latisha Stephenson, M.A., LSSP, NCSP Jyutika Mehta, Ph.D, CCC-SLP

School Psychology Consultant Consultant for SLP, DHH, AAC
[email protected] [email protected]
 References
Selective Mutism (Member page)

http://www.asha.org/slp/clinician/SelectiveMutism

Selective Mutism (Public Page):

http://www/asha.org/public/speech/disorders/SelectiveMutism.htm

Evidence-Based Practice: http://www.asha.org/members/ebp/

References
Johnson, Maggie & Wintgens, Alison. The selective mutism: resource manual.
Speechmark Publishing Ltd, 2001.

Kervatt, Gail Goetz. The silence within: a teacher-parent guide to helping

selectively mute and shy children, 1999.

Schum, R. (2006). Clinical perspectives on the treatment of selective mutism.

Journal of Speech-Language Pathology and Applied Behavioral Analysis,
1(2), 149-163.
 References
Schum, R. (2002). Selective mutism – an integrated approach. ASHA Leader, 7
(17), 4-6.

Shipon-Blum, Elisa. The ideal classroom setting for the selectively mute child:
a guide for parents, teachers, and other childcare professionals. Childhood
Anxiety Network, Inc., 2001.

Mount, M. (2010). Successful Treatment Strategies to Utilize for Children with

Selective Mutism (SM). Region 10 ESC presentation.