1
Author: Stoffel, Bethany, A. Title: Interventions for Children with Selective Mutism
The accompanying research report is submitted to the University of Wisconsin-Stout, Graduate School in partial
completion of the requirements for the
Graduate Degree/ Major: MS Education in School Psychology
Research Adviser: Christine Peterson, Ph.D.
Submission Term/Year: Fall, 2012
Number of Pages: 37
Style Manual Used: American Psychological Association, 6th edition
I understand that this research report must be officially approved by the Graduate School and that an electronic copy of the approved version will be made available through the University Library website
I attest that the research report is my original work (that any copyrightable materials have been used with the permission of the original authors), and as such, it is automatically protected by the laws, rules, and regulations of the U.S. Copyright Office.
My research adviser has approved the content and quality of this paper. STUDENT:
NAME Bethany Stoffel DATE: December 13, 2012
ADVISER:
NAME Christine Peterson DATE: December 12, 2012
---------------------------------------------------------------------------------------------------- -----------------------------
This section for MS Plan A Thesis or EdS Thesis/Field Project papers only Committee members (other than your adviser who is listed in the section above) 1. CMTE MEMBER’S NAME: DATE:
2. CMTE MEMBER’S NAME: DATE:
3. CMTE MEMBER’S NAME: DATE:
--------------------------------------------------------------------------------------------------------------------------------- This section to be completed by the Graduate School This final research report has been approved by the Graduate School.
Director, Office of Graduate Studies: DATE:
2
Stoffel, Bethany, A. Interventions for Children with Selective Mutism
Abstract
The paper reviews the research literature on interventions for treatment of Selective mutism
(SM), a childhood disorder affecting children who do not speak in specific situations, such as
school, but speak freely in others. There are multiple causes of SM, which require a variety of
different intervention approaches to treat SM. Four different approaches are commonly used to
treat children with SM, including: behavioral; cognitive-behavioral; psychopharmacological; and
multimodal. Each intervention has merits and drawbacks to treating SM. Large, controlled
experiments are difficult to conduct due to the rarity of the disorder. However, larger, controlled
studies must be conducted to determine the efficacy of each intervention approach.
Keywords: selective mutism, cognitive-behavioral intervention, behavioral intervention,
psychopharmacological intervention, multimodal intervention
3
Table of Contents
.................................................................................................................................................... Page
Abstract ............................................................................................................................................2
Chapter I: Introduction ....................................................................................................................4
Statement of the Problem .....................................................................................................6
Purpose of the Study ............................................................................................................7
Definition of Terms..............................................................................................................7
Assumptions and Limitations of the Study ........................................................................10
Chapter II: Literature Review ........................................................................................................11
Behavioral Approach to Intervention .................................................................................11
Cognitive-Behavioral Approach to Intervention ...............................................................18
Psychopharmacological Approach to Intervention ............................................................20
Multimodal Approach to Intervention ...............................................................................22
Chapter III: Summary, Critical Analysis, and Recommendations .................................................25
Recommendations for Research ........................................................................................25
Recommendations for Practice ..........................................................................................28
Summary ............................................................................................................................31
References ......................................................................................................................................33
4
Chapter I: Introduction
Selective mutism (SM) is a disorder primarily found in young children who talk freely in
some settings, but are mute in others (American Psychiatric Association, 2000). Children with
SM are not simply choosing to be mute, but rather the child is unable to cope with the level of
anxiety that is present in a particular setting, resulting in the child freezing in situations where
there is an expectation to vocalize. Research suggests that this mute behavior is related to the
“fight or fight” phenomenon which occurs in dangerous situations (Bork, 2010). The etiology of
SM has been controversial among researchers; however, the prevailing consensus is that SM is
caused by a variety of environmental and genetic factors combined (Bork, 2010;Viana, Beidel, &
Rabian, 2009).
There is some controversy over what causes this mute behavior to occur in children. In
the past, SM has been viewed as resulting from early psychological or physical trauma (Cleave,
2009). Recent literature has suggested that SM is more closely related to anxiety disorders such
as social phobia, social anxiety, or specific anxiety of expressive speech (Carbone, Schmidt,
Cunningham, McHolm, Edison, Pierre, & Boyle, 2010; Cleave, 2009; Sharkey & McNicholas,
2008). The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM-IV-TR) currently categorizes SM as a disorder that is first diagnosed in infancy,
childhood or adolescence (American Psychiatric Association, 2000). The DSM-IV-TR lists
specific criteria that must to be met in order for a diagnosis to be reached. This criterion includes
five parts: (a) the child is sociable in some situations but not others; (b) the symptoms interfere
with educational or occupational achievement; (c) there is no underlying speech or language
disorders; (d) the child is able to understand the language spoken in the situation; and (e) the
interference lasts longer than a one month period (American Psychiatric Association, 2000).
5
Selective mutism is most commonly diagnosed around the time a child enters school,
because this is often the first time the child is introduced to a structured setting that has rules and
expectations, which may create anxiety (Carbone, et al., 2010). Children who demonstrate
characteristics of SM can be misperceived as being overly shy, needing time to adjust and
become comfortable in the school setting, or to be using the mute behavior to manipulate others.
Teachers may wait to refer these children for evaluation due to these misperceptions, hoping the
symptoms will go away with time (Carbone et al., 2010; Cleave, 2009).
Selective mutism is considered a rare disorder, occurring in less than 1% of the
population. Nevertheless, research has suggested that many other cases go undiagnosed, leading
experts to believe that SM is more prevalent than previously thought (Carlson, Mitchell, &
Segool, 2008; Cleave, 2009; O’Reilly, McNally, Sigafoos, Lancioni, Green, Edrisinha,
Machalicek, Sorrells, Lang, & Didden, 2008). It is hypothesized that SM is more prevalent in
girls than boys, with estimated ratios from 2.6 to 1, to 1.5 to 1 (Freeman, Garcia, Miller, Dow, &
Leonard, 2004). Other research has indicated that SM is more closely distributed between boys
and girls (Carbone et al., 2010).
Teachers are often the first to identify children with SM. In fact, it is likely that each
teacher will come across at least one child with SM in their career (Shriver, Segool, & Gotmaker,
2011). This creates unique challenges for children and educators to ensure academic access
(Busse & Downey, 2011). Researchers have suggested that teachers are not aware of the signs
and symptoms of SM and do not refer children for evaluation as soon as the symptoms are
noticed. The average age for children with SM to be referred for evaluation is between 6.5 and 9
years of age. This suggests that many students are not receiving interventions as early as needed
6
in order to see optimum outcomes and may be at risk for further delays (Carbone et al., 2010;
Cleave, 2009).
Children who are diagnosed with SM tend to have other psychological, developmental,
and/or educational difficulties throughout their lives, which may include lacking independence,
self- confidence, and maturity (Oon, 2010; Busse & Downey, 2011), other language difficulties,
and/or motor delays (Cleave, 2009). Children identified with SM may also be at higher risk of
being on the autism spectrum than children without SM (Sharkey & McNicholas, 2008).
Research has noted that earlier diagnoses are very important for children with SM so that
intervention can be designed and implemented as early as possible. The longer the intervention
is withheld, the higher the risk of the symptoms persisting into adulthood (Sharkey &
McNicholas, 2008). These delays can be avoided by providing early intervention to help
promote normal interactions in the anxiety producing environment (Giddan, Ross, Sechler, &
Becker, 1997). Interventions play an important role in the development of children diagnosed
with SM. It is important to individualize the intervention plans for each child with SM due to the
variance in function of the mute behavior from child to child (Viana, Beidel, & Rabian, 2009).
Further, it is important to include parents, support staff and teachers in the intervention process
to ensure effective and efficient interventions across all of the child’s environments (Cleave,
2009).
Statement of the Problem
The majority of children with SM begin showing signs and symptoms when entering
school, around the age of four or five. Many of these children are not referred for evaluation for
several months after the signs and symptoms appear, with the average age of referral being nine
(Carbone et al., 2010; Cleave, 2009). Many teachers are unaware of the signs and symptoms of
7
SM, or the interventions available within the school setting to help these children. The lack of
knowledge among teachers is a problem because it affects the efficiency and effectiveness of
interventions due to delayed interventions. This delay in intervention allows time for the mute
behavior to become a habit, making intervention success more difficult as time continues. The
child has a higher risk of developing other psychological, developmental, or educational delays
throughout their lives without timely intervention (Busse & Downey, 2011;Carbone et al., 2010;
Cleave, 2009; Oon, 2010; Sharkey & McNicholas, 2008).
Purpose of the Study
The purpose of this study is to investigate early intervention options for children with
SM, and to examine the research of several intervention approaches that may be useful for
educators to use with children identified with selective mutism. Various approaches to
intervention have been developed for use within the school setting, including a behavioral model,
a cognitive-behavioral model, and a psychopharmacological model. Other research has
suggested a need for a multimodal approach to intervention, which would incorporate a
combination of interventions and endorse optimum outcomes (Cleave, 2009; Carbone et al.,
2010; Oon, 2010).
Definition of Terms
Behavioral interventions. “Behavior intervention refers to actions taken by school
personnel, parents, and/or agency personnel to improve the behavior of school children. The
focus of the interventions is limited to what are commonly referred to as behavior problems (or
challenges) that are social, interpersonal, and emotional in their nature and effects; it does not
address behaviors associated with poor achievement, such as reading, math or writing problems”
(Lee, 2005, p. 49).
8
Cognitive-behavioral interventions. “Cognitive-behavioral interventions integrate
thoughts and behaviors into problem-assessment approaches, conceptualization, and
intervention. The cog-behavioral approach views problems as resulting from both environmental
and cognitive antecedents, and combines what has typically been called the behavioral or
learning approach with the cognitive or semantic approach” (Lee, 2005, p. 95).
Contingency management. “Contingency management programs monitor children’s
progress toward goals and use a system of positive and negative consequences to encourage
behavioral change” (Sattler & Hoge, 2006, p. 355).
Functional behavioral assessment (FBA). A Functional behavior assessment (FBA) is
a set of procedures used to gather information to develop hypotheses about the purpose of a
student’s behavior in order to develop effective interventions (Reid & Nelson, 2002, as cited in
Rathvon, 2008).
Multimodal. An approach to intervention that involves two or more specific
intervention strategies or techniques of different modalities (Salkind, 2008, p. 1:43).
Psychoeducation. “Of or relating to the psychological aspects of education; specifically:
relating to or used in the education of children with behavioral disorders or learning disabilities”
(Psychoeducation, n.d.).
Psychopharmacology. “Psychoeducation, the development, study, and use of drugs for
the modification of behavior and the alleviation of symptoms, particularly in the treatment of
mental disorders” (Psychopharmacology, 2012).
Reinforcement. “Reinforcement is defined as a consequence that increases the likelihood
that a behavior will occur in the future” (Salkind, 2008, p. 2:845).
9
Selective mutism. “Selective mutism is characterized by a consistent failure to speak in
specific social situations despite speaking in other situations” (American Psychiatric Association,
2000).
Self- modeling. Self-modeling is defined as learning that occurs as a result of repeated
observation of oneself on edited video-or audio-tapes that depict only desired behaviors
(Dowrick & Dove, 1980, as cited in Rymal & Ste-Marie, 2007, p. S199).
Shaping. “Shaping is the technique whereby a behavior totally outside the learner’s
current repertoire of skills is carefully brought into existence by reinforcing successive
approximations to the desired performance” (Salkind, 2008, p. 1:903).
Stimulus fading. “The transfer of stimulus control by fading out a controlling stimulus
and fading in an alternate stimulus…” (Babbitt, Shore, Smith, Williams, & Coe, 2001, p. 198).
Systematic desensitization. Systematic desensitization involves exposing an individual
to gradually increasing levels of a fear-invoking stimulus while providing the individual with a
way to cope with his or her fear at each stage of exposure (Sattler & Hoge, 2006).
Vocalization. “Using voice (any volume) to initiate communication or to respond to
prompts to communicate” (Shriver, Segool, & Gortmaker, 2011, p. 400).
Vocalization ladder. A term used to represent the shaping process. “The rungs represent
the steps lined up for the child to slowly climb towards normal speech. Metaphorically, at the
bottom of the ladder are steps such as mouthing words, making sounds, and saying consonants;
further up the ladder there are steps such as whispering words, saying single words, saying single
sentences, and uttering phrases; and finally, at the top, we have speaking normally” (Oon, 2010,
p. 219).
10
Assumptions and Limitations of the Study
Articles on SM were found through the online database at the Bethel University library
using PsychINFO, as well as the Library database at the University of Wisconsin-Stout using
EBSCO host. The following keywords were used: selective mutism or elective mutism; and
interventions or intervention. Reference books and reference lists were also used in the retrieval
of literature articles.
There are limitations to the findings of this literature review. Many of the studies
reviewed use relatively subjective methods of collecting data such as the use of rating scales,
parent reports, or observations. In addition, these studies often have small sample sizes of
children with selective mutism and do not use a control group during the research process.
These limitations make it difficult to make inferences about the efficacy of the interventions used
and make it difficult to make generalizations about the findings of the studies to other
populations. These limitations do not diminish the usefulness of the findings presented in these
studies, yet some assumptions of these studies must be addressed.
There are several assumptions that must be addressed regarding the findings of this
review. First, it can be assumed that the studies used showed effective results in the majority of
the sample used. Second, it can be assumed that the intervention approaches worked for one or
more of the children in the past, and can currently be used in the individualized implementation
of intervention for children with SM. Third, it can be assumed that each child will respond
differently to intervention approaches. Finally, the intervention methods presented in this review
can serve as a starting point to hypothesize individualized intervention plans for children
suspected of having SM within the educational system.
11
Chapter II: Literature Review
There is a limited amount of research on intervention models for children with selective
mutism (SM) in the areas of behavioral, cognitive-behavioral, psychopharmacological, and
multimodal approaches to intervention for children who are diagnosed with SM. This chapter
begins with a description of each model of intervention of SM and includes descriptions of
various techniques used, a summary of the research, and a discussion of the efficacy of each.
Behavioral Approach to Intervention
Behavior therapy is the most widely accepted approach to the intervention of SM
(Cleave, 2009; Carbone, Schmidt, Cunninghamn, McHolm, Edison, St.Pierre, & Boyle., 2010;
Oon, 2010) and is usually the first approach used to treat children after diagnosis (Cohan,
Chavira, & Stein, 2006). This therapy approach proposes that the child with SM has learned the
mute behavior as an avoidance mechanism, or as a means to gain attention from others around
them (Cohan, Chavira, & Stein, 2006). Behavior therapy aims to eliminate reinforcement of the
mute behavior, and increase reinforcement of communicative behaviors (Oon, 2010). Various
techniques are used within this approach including contingency management, shaping,
systematic desensitization, social skills training, and self-modeling. Each of these techniques are
used to induce vocalizations within the environments the child is mute (Cohan, Chavira, & Stein,
2006; Freeman, Garcia, Miller, Dow, & Leonard, 2004). Further, a functional behavioral
assessment (FBA) may be a useful process to use when planning which intervention techniques
to use with a specific child with SM (Shriver, Segool, & Gortmaker, 2011).
Functional Behavioral Assessment to Guide Intervention Planning
There has recently been a shift in the research of SM to explore the effectiveness and
efficiency of using Functional Behavioral Assessment (FBA) to guide the intervention process
12
for children with SM within the school. An FBA can provide the intervention team with specific
information on the reasons behind the internalizing behavior problems, such as anxiety or SM.
This information can be used to make decisions on how to approach a child’s needs in the most
effective and efficient manner. Then intervention can then be more individualized, targeting the
specific needs of the individual child (Kern, Starosta, Cook, Bambara, & Gresham, 2007;
Shriver, Segool, & Gortmaker, 2011).
Shriver, Segool, & Gortmaker (2011) have developed a process for using an FBA to
guide in the planning of a behavioral intervention for children with SM. This process begins
with an interview with significant people involved in the child’s life, such as the parents and
teacher. Then the child must be observed in several settings to gain insight as to what the
behavior looks like, and to identify factors that may be contributing to the mute behavior. The
interview and observations help to obtain information regarding where, when, and with whom
the child communicates, as well as how the child communicates. This may include whispering,
gesturing, mouthing words, or speaking normally. It may be difficult to observe a setting in
which the child is willing to speak due to the presence of a stranger, and it may be necessary to
use video-recording to observe the child speaking. The information from the interviews and
observations can be used to identify the antecedent-behavior (AB) model of FBA. This
identifies the reasons (antecedents, A) that contribute to the child being mute (behavior, B) in
certain situations and not in others. This information can be used to identify which behavioral
technique may be most effective for the specific child (Shriver, Segool, & Gortmaker, 2011).
Shriver, Segool, & Gortmaker (2011) developed a table of recommended techniques to
use when planning an intervention for a specific child. This table takes information from the
interview and observations, including the frequency of speech, number of people present, and
13
setting, to suggest what behavioral techniques may be most appropriate to implement initially
(Shriver, Segool, & Gortmaker, 2011).
Kern, Starosta, Cook, Bambara, and Gresham (2007) conducted a study using the FBA
process with two school-aged students with SM. Both students showed signs of SM since
entering school with previous unsuccessful interventions attempted. Researchers used a
changing criterion design to examine the effects of differing interventions on vocalizations. The
study used both indirect and direct methods of obtaining information for the FBA. The
information was then used to develop individual hypotheses about the factors contributing to the
mute behavior for each of the children. The teacher was able to develop an intervention based
upon the contributing factors identified in the FBA process. This study found that both students
increased vocalizations as the intervention proceeded. Further, effects of the intervention
persisted in both children one month after the intervention had ceased (Kern et al., 2007).
Contingency Management, Shaping and Stimulus Fading
Contingency management is a behavioral technique commonly used in intervention
models. Contingency management uses positive reinforcement to encourage the child to
communicate in a setting in which the child is typically mute. The rewards must be motivating
for the child in order to encourage the child to communicate (Cohan, Chavira, & Stein, 2006).
Shaping and stimulus fading are techniques commonly used in combination with contingency
management. Shaping involves breaking the overall target goal into smaller goals meant to
encourage the child to reach full vocalization gradually in all settings. This focuses on how the
child communicates (Shriver, Segool, & Gortmaker, 2011). Oon called this process the
vocalization ladder, which may start with small goals, such as mouthing words, then progress to
whispering, and gradually increasing vocalization until the child is able to use verbal
14
communication in all settings. The child is rewarded at each step along the vocalization ladder
in order to motivate the child to continue progressing and increase vocalizations until a reward is
no longer needed for the child to vocalize (Oon, 2010).
Stimulus fading is similar to shaping, but focuses on the context in which the
communication occurs, rather than how the child communicates. Stimulus fading involves the
reinforcement of vocalizations in the presence of different stimuli, such as peers, teachers, or
other anxiety provoking individuals or factors. The child with SM begins with a person the child
is comfortable vocalizing around, such as a parent or caregiver in a controlled setting. Once the
child becomes comfortable vocalizing in this setting with the parent or caregiver, a person the
child does not vocalize around, such as the teacher, is gradually added to the situation. At the
same time, the parent or caregiver gradually becomes more distant, eventually fading out of the
setting (Busse & Downey, 2011). Another form of stimulus fading is to gradually increase the
number of people present when the child is communicating, and rewarding the child as the
number of people they communicate around is increased (Viana, Beidel, & Rabian, 2009). The
goal of stimulus fading is to eventually have the child generalize the fading procedure into the
normal classroom setting (Busse & Downey, 2011).
Oon used contingency management and shaping techniques in the intervention of a five-
year-old girl with SM. These techniques were blended into a drama therapy model of
intervention, which used play as the primary reinforcement to gradually increase the girl’s
vocalizations. The girl progressed from being fully mute outside of the house, to being outgoing
and verbally expressive in therapy sessions, as well as in her classroom at school in six weeks. A
one-year follow up of the study showed that the effects of intervention continued to increase
post-intervention (Oon, 2010).
15
Systematic Desensitization
Systematic desensitization requires the child to learn relaxation skills to use while he or
she is gradually exposed to anxiety provoking situations (Cohan, Chavira, & Stein, 2006). First,
a trained adult helps the child imagine he or she is in an anxiety provoking situation and
encourages him or her to use the relaxation skills they have learned to overcome or cope with the
anxiety. The child is then encouraged to brainstorm things that could be said in this situation and
then to imagine oneself vocalizing these ideas in that setting. Once the child is able to cope with
an imaginary situation, then the child is gradually introduced to a real situation that may cause
anxiety. This anxiety provoking situation may include having the teacher attend the sessions, or
going to a classroom in which the child has never spoken. The child is then encouraged to
vocalize in the setting while using the relaxation skills to decrease anxiety. The goal is to help
the child learn to use the relaxation skills in real situations in order to increase his or her
vocalizations in all settings. The child is rewarded for communicating in all stages of systematic
desensitization. This process has shown to be a successful form of intervention; however, it may
require many weeks to reach the target goal (Busse & Downey, 2011; Cohan, Chavira, & Stein,
2006).
Beare, Torgerson, & Creviston (2008) used contingency management and systematic
desensitization to increase the verbal communication in a twelve-year-old boy with SM. This
intervention was developed and implemented after other interventions proved unsuccessful.
First, he was rewarded for verbally responding to prompts in a setting in which he was
comfortable, and then was gradually moved to different settings in which he was previously less
comfortable vocalizing in. The prompts were gradually decreased until he was able to
16
communicate vocally in multiple settings without the need of prompts (Beare, Torgerson, &
Creviston, 2008).
Auster, Reeney-Kettler, & Kratochwill (2006) also used contingency management and
systematic desensitization to increase the verbal communication of a five-year-old boy diagnosed
with SM. He was first rewarded for communicating in a comfortable setting with his parents and
his teacher. After becoming comfortable in this setting they moved to a classroom setting and he
was eventually able to communicate with his teacher without his parents present (Auster,
Reeney-Kettler, & Kratochwill 2006).
Social Skill Training
Children with SM often struggle with knowing how to communicate appropriately in
social settings and may need training on appropriate behavior in different settings. Research has
found that children with SM and other anxiety disorders have greater difficulty with social skills
than other children. The behavioral approach views the mute behavior as a coping mechanism
that a child with SM might use to confront social situations in which the child may be unsure of
how to interact with others (Carbone et al., 2010). Therefore, instruction of basic social skills is
an important part of the behavioral approach to treating SM. This social skills instruction helps
children with SM to understand the social expectations placed upon them in the school
environment. They must be aware that they are expected to communicate in all settings. They
are shown skills of how to communicate successfully in these situations so they will no longer
need to feel anxious about communicating (Gordon, 2001).
O’Reilly, McNally, Sigafoos, Lancioni, Green, Edrisinha, Machalicek, Sorrells, Lang,
and Didden (2008) conducted a study in which social problem-solving skills were taught to two
sisters diagnosed with SM, one five years of age and the other seven years of age. Neither of
17
them had ever spoken in the school setting before the intervention had begun. The therapist met
with them individually and discussed why it is important to vocalize and express their thoughts,
wants, and needs in school. Teachers were then asked to provide five questions that they would
ask the girls in class. These questions were used in individual therapy sessions for the girls to
rehearse their responses. When they felt comfortable with answering the questions, they were
expected to answer them in the classroom in front of the teacher and class. This social problem-
solving method was successful for these two girls; however there could be a variety of situational
reasons for this success, such as the rapport between the therapist and girls. The teachers
reported that both girls remained shy and withdrawn after the end of the sessions, despite the fact
that the intervention had increased their vocalization in the classroom. This was the first study
done using social-problem solving strategies to treat SM. Therefore, replications of this study
must be done to examine the efficacy of this model of behavioral therapy (O’Reilly, McNally,
Sigafoos, Lancioni, Green, Edrisinha, Machalicek, Sorrells, Lang, & Didden, 2008).
Self-Modeling
Self-modeling incorporates the use of video and/or audio recordings of the child with
SM. These recordings are used to help increase the child’s level of comfort with hearing his or
her own voice in the uncomfortable setting. The child records him or herself speaking at home
or in another setting where verbal communication is comfortable, and then the recording is
played back to the child in a setting where the child is typically mute. This allows the child to
become comfortable with hearing his or her own voice in this setting, pushing the child to
eventually communicate vocally there (Busse & Downey, 2011; Sharkey & McNicholas, 2008).
Pigott and Gonzalez (1987) conducted a case study of a 9-year-old boy with SM using
self-modeling techniques. In this study, the boy was observed and video recorded three times
18
over three weeks. The video recordings were then edited and shown to the boy each morning
before school for two weeks. The boy was then observed to see how frequently he volunteered
to answer a question and vocalized loud enough for the teacher to hear. The number of
vocalizations increased after the self-modeling technique had been introduced to a point where
he vocalized as much as other children in the classroom by the end of that school year (Pigott &
Gonzalez, 1987).
Cognitive-Behavioral Approach to Intervention
Cognitive-behavioral therapy is an approach typically used to treat anxiety disorders,
which has increasingly been investigated for the efficacy in SM intervention (Viana, Beidel, &
Rabian, 2009). The cognitive-behavioral approach to treating children with SM focuses on
anxiety management (Cohan, Chavira, & Stein, 2006) as well as restructuring the cognition of
the child (Fung, Manassis, Kelly, & Fiksenbaum, 2002). Some literature suggests that this form
of intervention is most appropriate for older children with SM (Cohan, Chavira, & Stein, 2006),
while others have suggested that it is most effective in intervention for younger children with SM
(Sharkey & McNicholas, 2008; Viana, Beidel, & Rabian, 2009). Several different techniques are
used in this approach to intervention, including: (a) child and parent psychoeducation; (b)
behavior techniques, such as relaxation techniques or systematic desensitization; and (c)
cognitive techniques, such as learning to understand bodily signs of anxiety, changing former
cognition in dealing with anxiety provoking situations, and learning more beneficial coping
strategies (Cohan, Chavira, & Stein, 2006). Cognitive-behavioral methods are growing in
popularity with parents as an effective strategy to treat SM (Schwartz, Freedy, & Sheridan,
2006).
19
Sharkey, McNicholas, Barry, Begley, and Ahern (2008) administered a cognitive-
behavioral intervention using group therapy and parental psychoeducation. In this study, five
children with SM participated in group therapy for eight weeks. Therapy sessions focused on
increasing their non-verbal and verbal communication. Throughout the therapy sessions, the
children were taught about anxiety, how it affects their lives, and effective ways to handle their
anxiety in certain situations. They were provided with behavioral techniques to gradually gain
experience in using these new techniques. The children also had a scrapbook of the assignments
they completed during the sessions in order to help them remember topics and techniques
discussed in therapy sessions, and generalize them to other environments. The children’s parents
attended eight ninety-minute sessions during which the parents were instructed on how to
manage their child’s everyday behaviors, how to properly respond to their child’s
communication patterns, and how to support their children in the education system. In a six-
month follow up, two of the five children no longer met diagnostic criteria for SM, and the other
three had shown significant gains in their communication and showed decreased levels of
anxiety. However, this study included a small sample size, indicating a need for further study to
compare results of group therapy versus individual therapy (Sharkey, McNicholas, Barry,
Begley, & Ahern, 2008). There are other reported drawbacks with group therapy models, such
as the difficulty finding children to participate who will positively relate to others in the group,
difficulty generalizing one group session to other sessions, and the difference in responses to the
intervention for each child, as one may respond more quickly than others in the group (Carlson,
Mitchell, & Segool, 2008).
Fung, Manassis, and Fiksenbaum (2002) developed an online model of cognitive-
behavioral intervention for children with SM. The program includes fourteen 90-minute sessions
20
online, each consisting of 60-minutes for the child and 30-minutes with the parents. In each
session, children are introduced to new skills related to regulating their bodily signals, changing
their thoughts in situations where they feel anxiety, and teaching actions for changing their
behavior in those situations. Program results are available for parents and clinicians to download
in order to monitor the progress of the child. This form of intervention was reported to show
positive effects by the child, parents, and teachers; however statistics and examples were not
provided. The efficacy of internet-based interventions is promising due to the many benefits of
the service model, such as ease of access, flexibility in time and place of delivery, and allowing
the child to develop skills in a comfortable, low-anxiety environment (Fung, Manassis, &
Fiksenbaum, 2002).
Psychopharmacological Approach to Intervention
Psychopharmacological approaches to treating children with SM are based on the
presumption that SM is an indicator of social anxiety, and that medication is an important part of
an intervention plan (Carlson, Mitchell, & Segool, 2008). Most commonly, these approaches are
attempted after other intervention options have been explored and shown to be unsuccessful in
increasing the child’s verbal communication (Freeman et al., 2004). Recent studies have
explored the use of commonly used anti-anxiety medications such as monoamine oxidase
inhibitors (MAOI’s) and selective serotonin reuptake inhibitors (SSRI’s) in the intervention of
SM. Many have concluded that SSRI’s are effective in increasing verbal communication and
have fewer side effects than MAOI’s (Freeman et al., 2004; Gordon, 2001; Sharkey &
McNicholas, 2008). Although it is not known exactly how these medications work, Carlson,
Mitchell, and Segool (2008) predict that these medications affect the levels of serotonin and
gamma-aminobutyric acid (GABA) in the individual’s brain, balancing the levels to decrease
21
anxious feelings. Currently, the most common SSRI studied in children with SM is Fluoxetine.
It is important to note, however, that the FDA has not approved any of these medications for the
use in children, yet they are frequently used in this population (Carlson, Mitchell, & Segool,
2008).
Black and Uhde (1994) conducted a double-blind study of 16 children with SM and the
effects of Fluoxetine on their verbal communication. All of the children treated in the study,
including those receiving a placebo, showed some improvements in their communication, but the
children who received Fluoxetine were reported by parents to have shown significant
improvement. However, the majority of the children still showed symptoms of SM after the
intervention had ceased regardless of receiving Fluoxetine or the placebo (Viana, Beidel, &
Rabian, 2009).
Dummit, Klein, Tancer, and Asche (1996) attempted to expand the research done by
Black and Uhde by testing the level of dosage needed for optimum results, as well as examine
the amount of time required for the medication to show an effect. Fluoxetine was determined to
be a safe and appropriate treatment method for SM in children as young as 5 years of age. Most
children showed improvements with doses as low as 10mg, but others only responded to much
higher doses. After nine weeks, 76% of the children demonstrated improvement due to the
medication. However, some children in the study showed a slight side effect of behavioral
inhibition, which researchers suggest is due to the gradual increase in doses of the medication
(Dummit et al., 1996).
Although both studies reported a significant increase in verbal communication for
children with SM, there are some limitations that must be noted. First, the FDA has issued a
warning against SSRI’s as intervention for young children due to reports of increased suicidal
22
thoughts in children with depression (Sharkey & McNicholas, 2008). This is one reason that
psychopharmacological interventions are typically only attempted after other interventions have
not shown success (Carlson, Mitchell, & Segool, 2008). Second, most studies based on
psychopharmacological medications use small sample sizes and results indicate that symptoms
of SM persist even after the intervention has concluded. Finally, it may take a long period of
time for these medications to show any affect at all. Some have predicted that medication can
take up to twelve to sixteen weeks of consistent consumption before a significant response is
shown in the child (Freeman et al., 2004). However, other researchers have reported effects as
early as 24 hours after the first dose of medication (Carlson, Mitcheel, & Segool, 2008). Some
research indicates that the medications may diminish the child’s inhibitions and lead to
disruptive behaviors. Other studies have reported improvements in other areas, such as speech
and communication, in addition to decreasing mute behavior (Carlson, Mitcheel, & Segool,
2008)
Multimodal Approach to Intervention
The multimodal approach to SM intervention refers a combination of behavioral,
cognitive-behavioral, and psychopharmacological strategies. Most studies focus on one form of
intervention at a time to examine what specific approach is most beneficial on its own.
However, a variety of interventions may be combined for the best outcomes possible, especially
in severe and persistent cases of SM (Freeman et al., 2004). Many researchers have stressed the
need for a variety of models in intervention because each child responds to each model
differently (Viana, Beidel, & Rabian, 2009). Giddan, Ross, Sechler, & Becker (1997) described
their research with a multimodal approach to intervention, which included a combination of
various techniques used in behavioral and cognitive-behavioral approaches. This study included
23
a nine-year-old girl in the 3rd grade identified with SM. It was determined that she was
functioning at the 2nd grade level academically; however, her same-age peers attended fourth
grade. She received individual speech and psychotherapy, as well as individual support in the
classroom. Many different techniques were used, including: psychoeducation, contingency
management, social skill awareness procedures, and shaping. In this case, SM intervention
lasted two years and was found to increase verbal communication in all settings. Researchers
stressed the importance of daily routine, multiple service providers, an intervention plan, and
collaboration between professionals and families (Giddan et al., 1997).
Bork (2010) has also noted the need for a multimodal approach to the intervention of SM.
This research emphasizes the use of augmentative and alternative communication (AAC)
systems in combination with behavioral techniques. AAC systems provide alternative modes of
communication, which include: signing, gestures, written notes, phone, pictures, video-
recording, iPad, iPods, smart phones, and other technological devices. Many of these systems
provide programs or applications designed to improve communication such as speech to text,
text to speech, voice recording, or voice production may also be used. These forms of
communication are used in combination with behavioral methods of shaping speech during the
systematic desensitization process. In these interventions, the child can use the school phone to
call a trusted adult while in the school environment, forcing the child to communicate verbally
while in the school setting. Other suggestions include allowing the child to use a walkie-talkie in
the school setting, write notes to communicate to the teacher, or use self-modeling techniques
with a video-recording to allow the child to become used to hearing one’s own voice in the
school setting.
24
Bork and Wood (2010) developed an iSpeak++ software program for educational settings
to be used specifically when working with children with SM. This program is designed to assist
educators to implement interventions at school. The iSpeak++ program incorporates a number
of different activities, including anxiety-coping exercises, such as imagining talking to someone
while practicing deep breathing, and encouraging self-modeling activities (Bork & Wood, 2010,
as cited in Bork, 2010).
In summary, there are several different approaches to the treatment of SM including,
behavioral, cognitive-behavioral, psychopharmacological, and multimodal. Each of these
approaches has merits and drawbacks, but behavioral interventions have the most research and
support for efficacy. Some research suggests using an FBA process to investigate which
approach may be most effective and efficient for the individual student. Overall, literature
recommends using an intervention approach that is individualized for the student and involves a
wide range of people to support the child in many different settings.
25
Chapter III: Summary and Recommendations
There are many approaches available to teachers and school personnel to intervene with
students with selective mutism (SM). Successful approaches to intervention include behavioral,
cognitive-behavioral, psychopharmacological, and multimodal techniques. There is still a
significant amount of research that must be done to learn more about the etiology of this rare
disorder , as well as the most effective and efficient approaches to intervention. This chapter
presents recommendations for further research, implications for the school setting, and a
summary of the literature presented.
Recommendations for Research
Research on the intervention of SM has increased significantly over the past few decades,
yet more research is still needed in many areas. The rarity of the disorder has limited many
research attempts to small experimental designs, single subject experiments, or uncontrolled case
studies; however, larger scaled, more controlled studies must be conducted in order to gain more
information and understanding about this disorder and determine the most efficacious treatment
plans. Much of the research to date has focused on the effects of intervention in the school
setting however; there is a lack of information regarding the effects of intervention in other
environments. Future research should focus on how these interventions affect the behaviors of
children with SM across multiple environments. Nearly all of the studies reviewed include a
post-intervention follow-up, occurring up to a year later. Many researchers have noted that the
identification of SM may predict other psychological issues into adulthood. More longitudinal
studies should be completed to gain information regarding the specific type and frequency of
persisting symptoms of SM and other psychological issues post-intervention and into adulthood.
Finally, many researchers have indicated that SM could be an indicator of social anxiety rather
26
than a separate disorder. More research is needed to explore the differences in children with SM
in order to determine the best intervention approach to treat each specific cause of mute
behavior.
The behavioral approach to the intervention of SM has shown significant success, as
documented by multiple case studies. These studies need to be replicated to show the efficacy of
this intervention approach. There are very few studies that support the efficacy of using specific
techniques alone, especially social skills training and self-modeling techniques. Further research
should explore the success of different combinations of behavioral techniques. There is a need
for more research to explore the use of functional behavioral assessments (FBA) as a tool to
guide the intervention process. The three-tiered approach needs to be explored further for the
efficacy and usefulness within a school setting. More research much be done with children with
SM to support this approach to intervention.
Experimental investigations on the use and efficacy of the cognitive-behavioral approach
in the literature appear quite limited. More research needs to be done with larger sample sizes,
as well as with control groups, which will show the effect of the intervention compared to other
interventions. Also, further research should examine the outcome of the behavioral modification
technique in combination with early intervention. Due to differing opinions, more clarification is
needed to examine the success of cognitive-behavioral techniques in younger versus older
children with SM. Finally, more information is needed that explores the efficacy of online
service models of intervention.
Psychopharmacological approaches to intervention have many areas which must be
explored. First, a better understanding of the effects of serotonin and GABA in children is
necessary. More information is needed to determine the areas of the brain that are affected by
27
popular medications used to treat SM, and how and why these medications have been found to
increase vocalizations in this population. More information also needs to be obtained about the
side effects of these medications. Currently, there are no medications approved by the FDA for
treating SM in children. The possible risks associated with these medications, such as behavioral
disinhibition, depression, and thoughts of suicide, must be explored to ensure the safety of their
use in this population. The uncertainty of these risks and side-effects cause hesitation in parents
and pediatricians to prescribe these medications to children. There is also a need for more
information to determine the amount of time expected until the medication takes effect.
Currently, studies have reported a time frame of 24 hours to 16 weeks for any results to be seen.
Finally, the major studies using the psychopharmacological approach span from nine to twelve
weeks. This length of time is insufficient to examine the full extent of the effects of medications
on children. Finally, most studies involving psychopharmacological approaches have small
sample sizes and are not methodologically sound. Further research should include a larger
number of participants with methodologically sound procedures.
Multimodal interventions are more difficult to conduct due to the individual response of
each child to different intervention styles. Yet these interventions appear to be beneficial for
children with more persistent cases if SM. Behavioral and cognitive-behavioral interventions
seem to overlap in many studies, but further research is needed to identify the outcomes of
specific combinations. Other combinations of techniques need to be researched, including a
behavioral and psychopharmacological combination, a cognitive-behavioral and
psychopharmacological combination, or a combination of all three. The use of new AAC
devices, such as iPads, smart phones, mp3 players, Dynamo, VoicePal, GoTalk and others, must
be explored for usefulness in the school setting. The functionality of these devices and
28
applications may be significant for children with SM in the school setting. Further, more
research on the effectiveness of the Software Program iSpeak ++, developed by Bork and Wood
(2010), should be explored for use in the school setting.
Recommendations for Practice
Selective mutism is most commonly seen in the educational setting with children
experiencing anxiety in the structured setting. School environments must be prepared to identify
SM in children expediently, and know how to implement interventions in a timely manner. In
order for schools to be prepared, teachers and other school personnel must be knowledgeable
about SM and the signs and symptoms that may be present. The school must have an
intervention team established with members who are knowledgeable of the disorder and know
the best way to implement interventions within the school setting. The school personnel who
may be on this team may include the school psychologist, school social worker, school
counselor, lead teacher, principal, as well as others. This intervention team can work in
conjunction with the classroom teacher to implement an intervention within the school setting, as
well as with the parents of the child to ensure consistency and collaboration across settings.
There are a number of intervention approaches that can be easily implemented in a
classroom setting by the intervention team. These approaches include: behavioral, cognitive-
behavioral, psychopharmacology, and multimodal. Most research supports and suggests that
behavioral interventions tend to be the most successful interventions to use. It is recommended
that the intervention process begins with a functional behavior assessment (FBA) in order to
identify when, where, and with whom the child communicates as well as how the child
communicates in different settings. This information can then be used to inform the intervention
process to decide which approach and techniques may be most effective for the specific child.
29
Although the FBA process appears to be more work for the teacher, the information provided
will help identify which intervention will be the most effective for the individual student,
resulting in a more efficient intervention. In all intervention approaches, the intervention team
must monitor the progress of the child. It is helpful to gather data from the interventions and
create graphs to show if progress is being made. This data can be used to show if the child is
responding to the different interventions attempted. The intervention plan may need to be
modified or changed throughout the implementation of the intervention in order to ensure the
best intervention possible for the child.
Many of the techniques presented in this review are commonly used in the school setting
already. Behavioral techniques such as contingency management, shaping, and social skills
training, are techniques that can be used for a variety of different behaviors within a typical
classroom. Cognitive-behavioral techniques such as relaxation and self-regulation skills are
commonly used with children in the school setting as well. These methods are simple to
implement and can be modified to fit individual students or the whole classroom.
The cognitive-behavioral approach to intervention may require an outside therapist to
help with the intervention process. Configuring outside therapy may be difficult due to the legal
and financial implications of recommending these services; however, many of the self-
monitoring techniques can be taught by a school psychologist or school counselor within the
school setting. Children who are able to see an outside therapist may benefit from the therapist
observing and working with the child across multiple settings, including the school environment.
The therapist can then work in conjunction with the school personnel to provide the child with
support from a variety of adults. This collaboration can also help create consistency across
settings for the child.
30
Some children do not respond to interventions as expected and the use of medications,
such as SSRI’s, may be beneficial to help the student cope with the anxiety. Medications can
help the child’s anxiety decrease, eventually allowing the child to feel less anxiety when
presented with situations where he or she is required to vocalize. Once the medication has been
effective in decreasing the child’s anxiety, the medical doctor can gradually decrease the dosage
and eventually discontinue the medication all together. The goal of using medication as an
intervention is to help the child over the “hump” of anxiety that is felt in the stressful setting and
to eventually be able to vocalize without any anxiety or medication.
It is difficult for schools to suggest the use of medications due to the legal and financial
implications this may bring about by the parents. However, it is important for the schools to
have a discussion with the parents about the possibility of adding medication to the interventions
implemented in the school setting when several other interventions have not shown progress
toward vocalization. Some parents are opposed to the use of medication, especially when the
medications are not approved for use in children by the FDA. If medication is not an option, the
school should work as a team with the parents to determine the next step in intervention. Some
further options may include: intensifying the interventions already attempted; using additional
techniques or methods of intervention; referring the child and family to an outside therapist;
and/or providing the family with more information on intervention models and techniques.
Multimodal approaches can be targeted to specific children and their individual needs. In
the school setting, it is important to use all methods possible to find success for these children.
Therefore, schools must use their resources to help children with SM find success. It is not
necessary to know what intervention worked for a particular child, but rather it is important to
see progress toward full vocalization for the child in the school setting.
31
Summary
Selective mutism (SM) is a rare disorder found in children who speak in some situations
but not in others. The causes of SM vary depending on the child, making it difficult to predict
how each child will respond to each intervention approach. The course of intervention depends
on a variety of individual factors such as personality, motivation, and the desire of the child to
change the behavior. The four current models of intervention include: behavioral; cognitive-
behavioral; psychopharmacological; and multimodal approaches. The behavioral approach is the
most widely used, researched, and practiced approach. This may be because it is often the first
approach attempted, and in many cases found to be successful. Further, research continues to
develop the use of functional behavioral assessment (FBA) to help identify the most appropriate
behavioral technique for an individual child. This advancement to the behavioral approach may
increase its usefulness in the future. Cognitive-behavioral approaches have shown success with
some children with SM. However, this approach requires the child to possess higher cognitive
abilities that allow the child to think about and try to change the behaviors. This may mean that
the cognitive-behavioral approach to intervention is inappropriate for children until they are able
to self-monitor their behavior. Psychopharmacological approaches have shown overall success,
but more information must be gathered to explore the safety of the medications for this
population, as well as identify the type and side effects. This approach may be best used when
all other approaches have been unsuccessful for many months. The multimodal approach to
treating children with SM is a promising theory. Research continues to develop in this area of
intervention with the advancement of technology creating tools for children with SM to use.
More research must be done to discover if these models are more effective than one type of
approach alone. The efficacy of each model is supported in literature, but further research is
32
needed to advance the efficiency of each intervention approach. The rarity of the disorder makes
it difficult to recruit a large number of children for a controlled study, thus making it difficult to
have methodologically sound studies with large sample sizes. All intervention approaches
require the involvement of parents, teachers, therapists, and others closely involved in the child’s
life. The highest level of success has been achieved when intervention techniques are
understood and provided by adults in all aspects of the child’s live, and these adults work
together to support the child with SM in all environments. Overall, intervention of SM takes
patience and endurance to see full effects, but the results can be life changing.
33
References
American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental
disorders (DSM-IV-TR) (4th ed., text revision). Washington, DC: American Psychiatric
publishing, Inc.
Auster, E. R., Feeney-Kettler, K. A., & Kratochwill, T. R. (2006). Conjoint behavioral
consultation: Application to the school-based treatment of anxiety disorders. Education &
Treatment of Children, 29(2), 243-256. Retrieved from http://web.ebscohost.com/ehost/
pdfviewer/pdfviewer?sid=22852646-7d14-4839-bc65-02498ab567ad%40sessionmgr
13&vid=7&hid=8
Babbitt, R. L., Shore, B. A., Smith, M., Williams, K. E., & Coe, D. A. (2001). Stimulus fading in
the treatment of adipsia. Behavioral Interventions, 16(3), 197-207. doi:10.1002/bin.094
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.
doi:10.1177/1063426608317356
Black, B. & Uhde, T. (1994). Treatment of elective mutism with fluoxtine: A double-blind,
placebo-controlled study. Journal of the American Academy of Child and Adolescent
Psychiatry, 33(7), 1000-1006. Retrieved from http://web.ebscohost.com/ehost/detail
?vid=5&hid=8&sid=22852646-7d14-4839-bc65-02498ab567ad%40sessionmgr
13&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=ehh&AN=9502091779
Bork, P. M. (2010). Prospect of selective mutism intervention: Techno style. The international
journal of technology, knowledge, and society. 6(3), 37-42. Retrieved from
http://web.ebscohost.com/ehost/detail?vid=4&hid=8&sid=22852646-7d14-4839-bc65-
34
02498ab567ad%40sessionmgr13&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9
h&AN=66384961
Busse, R. T., & Downey, J. (2011). Selective mutism: A three-tiered approach to prevention and
intervention. Contemporary School Psychology, 15, 53-63. Retrieved from
http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=22852646-7d14-4839-bc65-
02498ab567ad%40sessionmgr13&vid=9&hid=8
Carbone, D., Schmidt, L. A., Cunningham, C. C., McHolm, A. E., Edison, S., St. Pierre, J., &
Boyle, M. H. (2010). Behavioral and socio-emotional functioning in children with selective
mutism: A comparison with anxious and typically developing children across multiple
informants. Journal of Abnormal Child Psychology, 38(8), 1057-1067. doi: 10.1007/s10802-
010-9425-y
Carlson, J. S., Mitchell, A. D., & Segool, N. (2008). The current state of empirical support for
the pharmacological treatment of selective mutism. School Psychology Quarterly, 23(3),
354-372. doi:10.1037/1045-3830.23.3.354
Cleave, H. (2009). Too anxious to speak? the implications of current research into selective
mutism for educational psychology practice. Educational Psychology in Practice, 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
1990-2005. Journal of Child Psychology and Psychiatry, 47(11), 1085-1097.
doi:10.1111/j.1469-7610.2006.01662.x
35
Dummit, E. S., III, Klein, R. G., Tancer, N. K., & Asche, B. (1996). Fluoxetine treatment of
children with selective mutism: An open trial. Journal of the American Academy of Child &
Adolescent Psychiatry, 35(5), 615-621. doi:10.1097/00004583-199605000-00016
Freeman, J. B., Garcia, A. M., Miller, L. M., Dow, S. P., & Leonard, H. L. (2004). Selective
mutism. In T. L. Morris, & J. S. March (Eds.), Anxiety disorders in children and adolescents
(2nd edition ed., pp. 280-301). New York, NY: The Guilford Press.
Fung, D. S. S., Manassis, K., Kenny, A., & Fiksenbaum, L. (2002). Web-based CBT for
selective mutism. Journal of the American Academy of Child & Adolescent Psychiatry,
41(2), 112-113. doi:10.1097/00004583-200202000-00003
Giddan, J. J., Ross, G. J., Sechler, L. L., & Becker, B. R. (1997). Selective mutism in elementary
school: Multidisciplinary interventions. Language, Speech, and Hearing Services in
Schools, 28(2), 127-133. Retrieved from http://web.ebscohost.com/ehost/detail?vid=
13&hid=8&sid=22852646-7d14-4839-bc6502498ab567ad%40sessionmgr13&bdata
=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9h&AN=9706254269
Gordon, N. (2001). Mutism: Elective or selective, and acquired. Brain & Development, 23(2),
83-87. doi:10.1016/S0387-7604(01)00186-3
Kern, L., Starosta, K. M., Cook, C. R., Bambara, L. M., & Gresham, F. R. (2007). Functional
assessment-based intervention for selective mutism. Behavioral Disorders, 32(2), 94-108.
Retrieved from http://web.ebscohost.com/ehost/detail?vid=16&hid=8&sid=22852646-7d14-
4839-bc65-02498ab567ad%40sessionmgr13&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%
3d#db=eric&AN=EJ785293
Lee, S. W. (Ed.). (2005). Encyclopedia of school psychology. Thousand Oaks, CA: Sage
Publication, Inc.
36
Oon, P. P. (2010). Playing with gladys: A case study integrating drama therapy with behavioral
interventions for the treatment of selective mutism. Clinical Child Psychology and
Psychiatry, 15(2), 215-230. doi:10.1177/1359104509352892
O'Reilly, M., McNally, D., Sigafoos, J., Lancioni, G. E., Green, V., Edrisinha, C., Machalicek,
W., Sorrells, A., Lang, R., & Didden, R. (2008). Examination of a social problem-solving
intervention to treat selective mutism. Behavior Modification, 32(2), 182-195.
doi:10.1177/0145445507309018
Pigott, H., & Gonzales, F. P. (1987). Efficacy of videotape self-modeling in treating an electively
mute child. Journal Of Clinical Child Psychology, 16(2), 106-110.
doi:10.1207/s15374424jccp1602_1
Psychoeducation. (n.d.). In Merriam-Webster Online. Retrieved from http://www.merriam-
webster.com/medical/psychoeducational
Psychopharmacology. (2012). In Encyclopedia Britannica. Retrieved from
http://www.britannica.com/EBchecked/topic/481796/psychopharmacology
Rathvon, N. (2008). Effective school interventions. (2nd. Ed.). New York, NY: The Government
Press.
Rymal, A. M., & Ste-Marie, D. M. (2007). The influences of a self-modeling intervention on
self-regulatory processes: A qualitative analysis. Journal Of Sport & Exercise Psychology,
29S199. Retrieved from http://ezproxy.lib.uwstout.edu:2170/ehost/pdfviewer/pdfviewer?vid
=9&hid=11&sid=c8a2f222-b7c7-4b7a-9b87-34f767ed9d1b%40sessionmgr14
Salkind, N. J. (Ed.). (2008). Encyclopedia of educational psychology. (Vols. 1-2). Thousand
Oaks, CA: SAGE Publications, Inc.
37
Sattler, J. M., & Hoge, R. D. (2006). Assessment of children: Behavioral, social, and clinical
foundations. (5th ed.). La Mesa, CA: Jerome M. Sattler, Publisher, Inc.
Schwartz, R. H., Freedy, A. S., & Sheridan, M. J. (2006). Selective mutism: Are primary care
physicians missing the silence? Clinical Pediatrics, 45(1), 43-48.
doi:10.1177/000992280604500107
Sharkey, L., McNicholas, F., Barry, E., Begley, M., & Ahern, S. (2008). Group therapy for
selective mutism - A parents' and children's treatment group. Journal of Behavior Therapy
and Experimental Psychiatry, 39(4), 538-545. doi:10.1016/j.jbtep.2007.12.002
Sharkey, L., & McNicholas, F. (2008). 'More than 100 years of silence', elective mutism: A
review of the literature. European Child & Adolescent Psychiatry, 17(5), 255-263.
doi:10.1007/s00787-007-0658-4
Shriver, M. D., Segool, N., & Gortmaker, V. (2011). Behavior observations for linking
assessment to treatment for selective mutism. Education and treatment for children, 34 (3),
389-411. Retrieved from http://web.ebscohost.com/ehost/detail?vid=26&hid=8&sid=
22852646-7d14-4839-bc65-02498ab567ad%40sessionmgr13&bdata=JnNpdGU9Z
Whvc3QtbGl2ZQ%3d%3d#db=ehh&AN=62852286
Viana, A. G., Beidel, D. C., & Rabian, B. (2009). Selective mutism: A review and integration of
the last 15 years. Clinical Psychology Review, 29(1), 57-67. doi:10.1016/j.cpr.2008.09.009