Selective Mutism in the Public School Setting: A Case Study John F. Trembley, MSEd, CCC-SLP Kingston City School District State University of New York, New Paltz

This was once called: Elective mutism: Continuous refusal to talk in most social situations, including school Continuous refusal to talk in most social situations, including school An ability to speak and comprehend spoken language An ability to speak and comprehend spoken language (DSM-III, 3 rd edition, revised, APA, 1987)

Selective Mutism: “Selective mutism is characterized by the appropriate use of language in certain settings, with total and persistent lack of language use elsewhere.” (Giddan, et al, 1997)

Diagnostic Criteria for Selective Mutism Consistent failure to speak in specific situations, despite speaking in other situations Consistent failure to speak in specific situations, despite speaking in other situations The disturbance interferes with educational or occupational achievement or with social communication The disturbance interferes with educational or occupational achievement or with social communication Duration: at least 1 month Duration: 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 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 The disturbance is not better accounted for by a Communication Disorder (DSM-IV-TR, 2000, p. 127) (DSM-IV-TR, 2000, p. 127)

Our Student: Initial Profile: CA: 11.8 CA: 11.8 Classified as a student with special education needs…multiply disabled Classified as a student with special education needs…multiply disabled Placed in a 12:1:1 classroom 9/03 Placed in a 12:1:1 classroom 9/03 Received counseling, speech/language services, occupational therapy services Received counseling, speech/language services, occupational therapy services Received informal diagnosis of “selective mutism” from previous school district Received informal diagnosis of “selective mutism” from previous school district

Communication behaviors on intake: Limited eye contact with classmates and adults Limited eye contact with classmates and adults Tendency towards solitary play behaviors Tendency towards solitary play behaviors Pointing gestures to indicate requests Pointing gestures to indicate requests One word utterances characterized by minute lip movements with no vocalizations One word utterances characterized by minute lip movements with no vocalizations

Video segment: A.B.’s communication functioning— June, 2004

The treatment plan: Utilizing components of the Socio- Communication Intervention Model for Selective Mutism (Hungerford, et al, 2003) Utilizing components of the Socio- Communication Intervention Model for Selective Mutism (Hungerford, et al, 2003) consultation with program author consultation with program author Setting up a collaborative approach with classroom teacher and parents Setting up a collaborative approach with classroom teacher and parents

Social-Communication Intervention Model for Selective Mutism Accounts for nonverbal and verbal components of social interaction as well as speech & situation variables, including Accounts for nonverbal and verbal components of social interaction as well as speech & situation variables, including 1. Eye contact 2. Non-verbal turn taking 3. Non-verbal indicators of joint attention 4. Writing Encourages a scaffolded approach when manipulating variables during social interaction Encourages a scaffolded approach when manipulating variables during social interaction (Hungerford, et al, 2003) (Hungerford, et al, 2003)

The Implementation of Therapy: Employed a scaffolded, task-analyzed approach, including:… Employed a scaffolded, task-analyzed approach, including:… Communication modality Communication modality Characteristics of communication Characteristics of communication Physical environment Physical environment

Communication Modality: Pointing>>>writing>>>blowing on whistles>>>whispering>>>more forceful, audible whispering>>>vocalizing words>>>phrases>>>sentences Pointing>>>writing>>>blowing on whistles>>>whispering>>>more forceful, audible whispering>>>vocalizing words>>>phrases>>>sentences

Characteristics of Communication partners: VERY FAMILIAR TO THE LESS FAMILIAR… Familiar adult Familiar adult Less familiar adult… Less familiar adult… Familiar peer Familiar peer Familiar peer group Familiar peer group Familiar peer group with unfamiliar peer Familiar peer group with unfamiliar peer Classroom Classroom

Physical Environment: Communication lab therapy room Communication lab therapy room Empty classroom Empty classroom Empty hallway Empty hallway Crowded hallway Crowded hallway Structured classroom Structured classroom Free-time: classroom Free-time: classroom

Pragmatic language treatment in group setting: Social language skills targeted: Identifying common categories Identifying common categories Identifying comment types (opinion, compliment, suggestion, insult, threat) Identifying comment types (opinion, compliment, suggestion, insult, threat) Using the telephone Using the telephone Progress was assessed utilizing baseline and post-treatment checklists…

To encourage increased breath support and more “forceful” whispering—individual treatment sessions including: Train whistles…requiring less air expulsion to create noise Train whistles…requiring less air expulsion to create noise Tube noise makers…requiring more forceful air expulsion to extend tube, and yet more air force to create noise Tube noise makers…requiring more forceful air expulsion to extend tube, and yet more air force to create noise During these activities, clinician and student would each have a whistle, taking turns blowing and making sounds

Also during individual treatment sessions: One-word whispers were modeled and practiced—louder whispers with increased breath support encouraged- A.B. whispered one word utterances standing 10 ft. from the clinician Intelligibility was assessed as percentage of words whispered correctly interpreted by the clinician…

The transition to vocalization… A.B. came into school with a cold and was observed to be repeatedly clearing his throat A.B. came into school with a cold and was observed to be repeatedly clearing his throat It was pointed out to A.B. that he used his voice when he cleared his throat It was pointed out to A.B. that he used his voice when he cleared his throat During a subsequent session, A.B. and clinician took turns purposely producing throat-clearing vocalizations…this practice limited to 5x per session During a subsequent session, A.B. and clinician took turns purposely producing throat-clearing vocalizations…this practice limited to 5x per session

The transition to vocalization… A.B. encouraged to make throat-clearing sound, immediately followed by the word “hi” A.B. encouraged to make throat-clearing sound, immediately followed by the word “hi” Throat-clearing behavior extinguished in one session, resulting in a vocalized “hi” at a very low voice volume Throat-clearing behavior extinguished in one session, resulting in a vocalized “hi” at a very low voice volume

Vocalization November, 2004—A.B. producing short phrases with phonation during sentence repetition tasks in individual, then group sessions November, 2004—A.B. producing short phrases with phonation during sentence repetition tasks in individual, then group sessions December, 2004—A.B. produced 10 spontaneous utterances with phonation during individual session December, 2004—A.B. produced 10 spontaneous utterances with phonation during individual session

Vocalization April, 2005—Classroom teacher reports A.B. is producing average 2-3 utterances consisting of 2-3 words during a typical classroom activity April, 2005—Classroom teacher reports A.B. is producing average 2-3 utterances consisting of 2-3 words during a typical classroom activity September, 2005—A.B. actively participating in classroom discourse utilizing a normalized voice volume, freely joining in with classmates during free-time activities…school staff has on occasion admonished A.B. for inappropriately shouting out of turn September, 2005—A.B. actively participating in classroom discourse utilizing a normalized voice volume, freely joining in with classmates during free-time activities…school staff has on occasion admonished A.B. for inappropriately shouting out of turn

Video segment: A.B.’s communication functioning— June, 2005

Sources and suggested readings… American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4 th ed., text revision). Washington D.C.: Author. Blum, N.J., Kell, R.S., Starr, H.L., Lender, W.L., & Osborne, M.L. (1998). Case study: Audio feedforward treatment of selective mutism. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 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, Harris, H.F. (1996). Elective mutism: A tutorial. Language, Speech and Hearing Services in Schools, 27, Hungerford, S., Edwards, J., Iantosca, A. (2003, November). A Socio-Communciation Model for Selective Mutism. Paper presented at the meeting of the American Speech-Language-Hearing Association, Chicago, IL. McInnes, A., Fung, D., Manassis, K., Fiksenbaum, L., & Tannock, R. (2004). Narrative skills in children with selective mutism: An exploratory study. American Journal of Speech-Language Pathology, 13, Schum, R.L. (2003). Selective mutism: An integrated treatment approach. The ASHA Leader Online, 1-11.