IACAPAP Textbook of Child and Adolescent Mental Health

Chapter

F.5

ANXIETY DISORDERS

SELECTIVE MUTISM
2019 edition

Beate Oerbeck, Katharina Manassis, Kristin Romvig Overgaard& Hanne Kristensen
Beate Oerbeck PhD
Oslo University Hospital,
Division of Mental Health andAddiction, Oslo, Norway
Conflict of interest: nonereported

Katharina Manassis MD,
FRCP(C)
University of Toronto,
Department of Psychiatry,
Toronto, Canada
Conflict of interest: nonereported

Kristin Romvig Overgaard
MD, PhD
Oslo University Hospital,
Division of Mental Health andAddiction, Oslo, Norway
Conflict of interest: nonereported

Hanne Kristensen MD, PhD
Centre for Child and Adolescent
Mental Health, Eastern andSouthern Norway, Oslo,
NorwayConflict of interest: nonereported
This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2019. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Oerbeck B, Manassis K, Overgaard KR, Kristensen H. Selective mutism. In Rey JM, Martin A (eds), JM Rey’s
IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatryand Allied Professions 2019.

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IACAPAP Textbook of Child and Adolescent Mental HealthSelective mutism (SM) is a disorder characterized by a consistent failure to
speak in specific settings (e.g., school, social situations) despite speaking normallyin others (e.g., at home). SM is a relatively rare but serious condition that causes
significant social and academic impairment if left untreated. Since the publicationin 2013 of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)(American Psychiatric Association, 2013), SM has been classified as an anxiety
disorder and the name changed from elective mutism to selective mutism, reflecting
a shift in the understanding of SM from an act of will to a lack of ability to speakin specific situations. This chapter reviews the clinical presentation, prevalence,course, etiology, diagnosis, assessment, and treatment of SM with emphasis on
aspects relevant to practicing clinicians.

Table F.5.1 Shifts in the understanding of selective mutism over time
1877

1934

1994

2013

Neurologist

Child psychiatrist

DSM-IV:DSM-5:

Adolph Kussmaul:

Moritz Tramer:

Aphasia voluntaria

Elective mutism

Selective mutism classified among
disorders first diagnosed ininfancy, childhood, or adolescence

Selective mutism
classified as ananxiety disorder

CLINICAL PRESENTATIONThe cardinal symptom of SM is the failure to speak in certain situations,most notably in kindergarten or school. Thus, symptoms are typically context
specific. This discrepancy in speaking behavior is central to the disorder but it
often leads to misunderstandings and suspicion as both teachers and parents tend
to think that children behave in all situations the way they observe themselves (e.g.,
if a child does not speak at school the teacher may think that she does not speak
at home either). SM can also be person-specific (e.g., the child may be mute withsome persons but not with others). Different individuals may increase or lessen
symptoms considerably within the same situation. For example, friendly, funnypeople who talk and keep the “conversation” going independent of the child’s
active participation, are helpful. Children with SM often find it easier to talk toother children compared to adults. Some will occasionally be able to whisper to abest friend at school. The video clips illustrate the clinical features typically foundin SM.
A feature of children with SM is that they differ widely in their ability
to use nonverbal communication (e.g., eye contact, gestures, nodding andpointing). While some use nonverbal communication effectively, others are noncommunicative and might not even laugh or cough in front of others. The latterare often unable to express their needs (going to the toilet, hunger, thirst, or pain),highlighting the potential seriousness of this condition.

Selective Mutism

F.5“I can’t start totalk, because theneverybody will just talkabout what I do…”
(Adolescent boy)

Click on the image to viewa video clip of child withselective mutism

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IACAPAP Textbook of Child and Adolescent Mental HealthIn spite of the considerable stress experienced at school, school refusal israre. SM is often comorbid with other anxiety disorders, especially social anxiety
disorder, and with neurodevelopmental disorders, especially language disorders.
Immigrant, bilingual children are overrepresented.
The clinical vignette of Ann illustrates the temperamental traits often foundin children with SM. It also illustrates how inability to speak may be different indifferent settings, which may cause frustration due to people thinking that mutism
is deliberate.

“I’d really like to talk to
you but something, andI don’t know what it is,makes it impossible forme…”(Adolescent girl)

Typically SM has onset between 2 and 5 years of age but is usually notrecognized until children start school, where speaking is an integral part of thelearning and socialization processes. Children with SM are generally afraid to makemistakes and dislike being the focus of attention. Their “solution”—muteness
and, sometimes, trying to be invisible—becomes part of the problem. Whenthey occasionally do talk, they get everybody’s attention, which they find anxietyprovoking, perpetuating mutism in a vicious circle.
Children with SM are often asked why speaking is so difficult; they generallyfind it hard to explain. Some older children with SM have described the feelingof having a great lump in the throat hindering speech. Children with SM exhibit
significant social and academic impairment (Carbone et al, 2010; Remschmidt
et al, 2001; Bergman et al, 2002). The video clips on the right side illustrate thetypical symptoms in two children, a boy and a girlAnn
Ann, a 5-year-old girl, was referred to the mental health services because ofsuspected SM. Her mutism had lasted since she started in kindergarten at age three. Bothher parents and teachers had hoped that her muteness would improve spontaneously andthus postponed seeking help. Now, they worried that her lack of speech would continue atschool and wanted help.

Click on the images toview a documentary(Help Me to Speak) that
follows two children withselective mutism. Part 1(above, 12:15) and part 2(below, 13:11) illustrate thesymptoms and behavior.

Ann had developed normally but parents described her as shy and “slow to warm up”
in new situations and when meeting strangers. Both parents recognized this temperamental
trait in themselves and her mother still struggled with social anxiety.
At home, Ann was a lively and happy girl. She spoke freely with both parents, her
younger sister and a playmate. When the extended family was visiting, she talked to her
grandparents on her mother’s side but not to her father’s parents, making them unhappy.
They thought that her not speaking was deliberate and argued for putting more pressure on
her to speak, resulting in conflict with the parents.
Outside the home, Ann spoke to her parents when no one was within earshot, but her
parents had to speak for her in all situations, like in shops and at the dentist. When invited toa friend’s party, she would go if a parent joined her but she did not talk.
In the kindergarten, Ann seemed happy but did not speak to either adults or children.
She talked to her parents in the cloakroom but got silent when others appeared. However,
she used gestures freely and communicated well with teachers and peers by nodding andpointing. She was always included in play and the other children often spoke for her and did
not seem bothered by her lack of speech. This behavior stood in contrast with her first few
months in kindergarten. At that time she cried extensively when the parents left and did notcommunicate with gestures. The increased nonverbal communication and general behavior
in the kindergarten raised hope of a spontaneous remission of her mutism.

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PREVALENCE AND COURSE
SM is estimated to affect approximately 1% of the child population;
prevalence rates from 0.1% to 2.2%, depending on the sample and the diagnostic
criteria used. Although similar gender ratios have been described, most researchsuggests that SM is more common in girls (girl/boy ratio of 1.5:1 to 2.6:1) (Bergman
et al, 2002; Hua & Major, 2016). When one asks parents when symptoms started,
they generally find it hard to pinpoint the onset and often say the child “has always
been like this”. This type of statement underlines a temperamental trait found in
SM: behavioral inhibition—characterized by shyness, timidity, withdrawal, andfear of the unfamiliar (Gensthaler et al, 2016a; Muris et al, 2015).
The few long-term follow-up studies that exist show that although symptomsof SM can lessen over time, some persist. As adults these individuals typically
suffer from communication problems and social anxiety and are at higher risk forother psychiatric disorders (Remschmidt et al, 2001; Steinhausen & Juzi, 1996).
However, the pressure to speak diminishes because adults can more easily choose
whom to be with and what they want to do.

ETIOLOGY
No single cause for SM has been found thus far. However, the understandingof this disorder has changed over the years from an act of willfulness of the child,to a lack of ability to speak in certain situations (see Table F.5.1). As for mostchild psychiatric disorders, it should be hypothesized an interplay of genetic,
temperamental, neurodevelopmental and environmental factors, summarized
below (for an overview of SM and a thorough examination of its etiology, see
Cohan et al, 2006b; Muris & Ollendick, 2015; Hua & Major, 2016):
•

•

•

•

Genetic factors. SM, social reticence and social anxiety run in families(Black & Uhde, 1995). A specific gene variation has been found to be
associated with both SM and social anxiety disorder (Stein et al, 2011)
Temperament. The behavioral inhibition trait (fearfulness and avoidancein unfamiliar situations) is generally associated with a greater risk forlater anxiety disorders (Hirshfeld-Becker et al, 2007). Consistent
with the link between social anxiety disorder and SM, there is also an
association between SM and behavioral inhibition (Gensthaler et al,
2016a)
Neurodevelopmental factors. Children with SM have higher rates ofseveral neurodevelopmental conditions. The most prevalent are speech
and language problems but elimination disorders and motor delay arealso common. There is a small overlap with autism spectrum disorders
and with lower intellectual capacity, although the majority of children
with SM have IQ within the normal range (Kristensen, 2000; Cohanet al, 2006b)
Environmental factors. Bilingual children are overrepresented in SM.
Transitions such as starting school and meeting new people may trigger
and are especially hard for children with SM. In contrast to shy children
who will warm up over time, children with SM continue to be muteand withdrawn

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DIAGNOSIS
Diagnostic criteria
•

•

•

•

•

Selective mutism is characterized in DSM-5 by a consistent failure to
speak in specific settings (e.g., school, social situations) despite talking
normally in other settings (e.g., at home) (American Psychiatric
Association, 2013)
DSM-5 specifies that the selective absence of speech should be present
for at least one month to establish the diagnosis. This does not apply tothe first month of school as many young children are silent when they
face a new situation, such as starting school
Importantly, the failure to speak cannot be attributed to a lack ofknowledge of, or discomfort with the spoken language required in thesocial situation
The disturbance is not better explained by a communication disorder(e.g., childhood-onset fluency disorder or stuttering) and does notoccur exclusively during the course of autism spectrum disorder,
schizophrenia, or another psychotic disorderFinally, the child’s lack of speech should interfere with daily functioning:
The absence of speech hinders the child’s capacity to function at schoolor in social interactions.

SM is also called selective mutism in ICD-11 (World Health Organization,2018). The description is similar to that in DSM-5, and it has been includedin the section “Anxiety or fear-related disorders”. ICD-11 exclusion criteria
include autism spectrum disorder, schizophrenia, and transient mutism which ismanifestation of separation anxiety in young children.

Diagnostic challenges
The diagnostic overlap between SM and several other child psychiatricdisorders often found in the clinic can make the diagnosis of SM difficult. Neither
DSM, nor ICD specify whether the criterion “consistent lack of speech” means
THE KEY DIAGNOSTIC QUESTION
Does the child speak normally in at least one setting (e.g., home) but show
mutism in other settings (e.g., kindergarten or school)?
•If yes, ask parents to elaborate on the clinical presentation of their child’s
speaking behavior, how long the muteness has lasted, and what has been done,with what effect, to help the child.

In addition:•
Ensure that the child does not have a hearing problem.
•
Gather information on the child’s general developmental history (oral motor,
motor, language) to exclude acute muteness due to psychological trauma or
acquired brain damage.
•
Information on academic functioning in kindergarten/school is mandatory.
•
Assessment of nonverbal language and reasoning ability (intelligence) isadvisable.

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5IACAPAP Textbook of Child and Adolescent Mental Healthspeaking to adults. Of note, some children with SM speak or whisper to a “bestfriend” in school. Another challenge is whether some speaking in class (like insmall groups of students, alone with a teacher, or with teachers and children insmall groups) still qualifies for a diagnosis. In these cases, support for and against
the diagnosis can be found in the degree of impairment the muteness creates.
However, more specific guidelines do not exist. Clinical judgement of impairment
must be used, and the decision is thus dependent upon the clinician’s skills andexperience.
Diagnosing SM in bilingual children is particularly difficult. They are often
overlooked—their muteness being attributed to a lack of understanding of the new
language. Often overlooked in this subgroup are comorbid speech and language
disorders, masked by the muteness and bilingualism. Getting information on, orassessing language ability in the child’s native language is essential. For diagnosis,
the main point is that mutism must be prolonged or is disproportionate to thedegree of second language knowledge and exposure (Toppelberg et al, 2005).

Diagnosing selective
mutism in bilingual
children•••Mutism should havelasted for at least six
monthsMutism is present inboth languages
There are associatedsymptoms of anxiety or
inhibited behavior.

Comorbidity
Children with SM often present with symptoms of other anxiety disorders,
particularly social anxiety disorder. Studies have found this comorbidity in about
90 % of cases (Gensthaler et al, 2016b; Oerbeck et al, 2014).
Separation anxiety disorder is common, especially in younger children.
However, school refusal is rare. Neurodevelopmental conditions are frequent.
The most prevalent are speech and language problems, elimination disorders, andmotor delay. SM has been found comorbid with autism spectrum disorders in<10% of cases. Attention deficit/hyperactivity disorder is rare (Kristensen, 2000).
There has been some controversy concerning the understanding of
oppositional behavior observed in some children with SM. Children with SMhave been described over the years as controlling, stubborn and oppositional, often
implying a primary problem in the family dynamics. The shift in DSM-5, where
SM is understood as an anxiety disorder rather than a manifestation of oppositional
behavior, is thus significant.
The largest study to date on children with SM (n=130) found that social
anxiety was the most prominent additional feature. Almost half also had borderline
clinical scores for speech and language problems—an important reminder asthese problems may easily go unnoticed in these children. Another 45% showedborderline clinical scores on oppositional behavior. Only 12% had a “pure”
social anxiety (Cohan et al, 2008). The authors suggest that the oppositionality
shown by children with SM is often present only in situations that require verbal
communication. That is, they become oppositional and non-compliant whenpressured to speak when they are anxious about doing so.

Differential diagnosis
The symptom overlap often found in the clinic can make diagnosis difficult,particularly when using ICD-11 criteria, which requires excluding the presenceof autism spectrum disorder, schizophrenia, and transient mutism as part ofseparation anxiety in young children.

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According to DSM-5, SM should not be diagnosed if symptoms are better
explained by other disorders such as a communication disorder, autism, schizophrenia
or other psychotic disorder.
Although somewhat difficult, the importance of diagnosing comorbid
neurodevelopmental disorders is underlined. One purpose of such diagnoses
is to highlight areas of strength and difficulty so that appropriate support andintervention are organized in kindergarten or school. If the child shows multiplesocial and communication delays or mutism in the context of other socially odd
behaviors, autism spectrum disorder is more likely the primary diagnosis. The large
overlap between SM and social anxiety disorder is recognized in both DSM and
ICD. For individuals with social anxiety disorder and suspected selective mutism,making an accurate diagnosis is essential. Gathering information from multiple
sources on the presence of selective muteness is needed. Dismissing children withSM as just being socially anxious is potentially harmful.

ASSESSMENT
The diagnostic assessment of SM must be based on information from bothparents and teachers to ensure accurate information on the child’s failure to speak
appropriately in certain social situations. A multi-informant perspective is criticaldue to the situational nature of the condition. Parents may in fact be unaware
for a long time of the child’s mutism at school. Evaluation generally includes a
combination of diagnostic interviews and questionnaires completed by parents
and teachers and behavioral observations of the young child. Older children canbe asked to nod to questions or complete written questionnaires. Some young
children with SM (aged 4 to 5 years) are able to complete “talking maps” withthe help of a parent. However, the degree to which children with SM can convey
information in this new, stressful situation, with unfamiliar adults is quite variable
and not essential for a diagnosis to be made.

Diagnostic interviews
The Schedule for Affective Disorders and Schizophrenia for School-Aged
Children: Present and Lifetime Version (K-SADS-PL) (Kaufman et al, 2013) and theAnxiety Disorder Interview for DSM-IV Child and Parent Version (ADIS-IV-C/P)(Albano & Silverman, 1996) are common interviews used. These interviews aredesigned for children 6-18 years, but adequate diagnoses can be made in children
below age six as long as the behavioral concepts and the understanding of life
interference is adapted to be relevant to a preschool child (Birmaher et al, 2009).
Alternatively, the Preschool Age Psychiatric Evaluation (PAPA) (Egger & Angold,2004) can be used.
As SM is an anxiety disorder, the ADIS seems particularly relevant. The
ADIS assesses anxiety, mood, externalizing, tics, substance use and pervasive
developmental disorders according to the DSM. Very useful is a “feelings
thermometer” that allows the child and parents to quantify the severity of anxiety
symptoms and interference with the child’s functioning. Anxiety ratings are used
to assist in diagnostics. Further, they can be used for self-monitoring (in older

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PRACTICAL ISSUES IN ASSESSMENT AND TREATMENT
•
•
•
•
•
•
•

•
•
•
•
•
•
•

Most children with SM cooperate in a structured test situation if they are willing and well
preparedParents can join in and assist in the presentation of items if the child wishes
Before the testing starts, tell children that they do not have to talk to you
Show the test material and explain alternative answering formats they can use, such as
pointing, nodding, or writing responses (older children)
The child is to sit beside the clinician, not opposite, as is usual during testing, to avoid
direct eye contact that often makes these children uncomfortable. In this way both thechild and the clinician focus on the test material in front of them
Untimed tests of receptive vocabulary are preferable as children with SM can be slow toanswer due to fear of making mistakes
One useful test is the Peabody Picture Vocabulary Test (Dunn & Dunn, 2007) where
the clinician speaks a word and the child points to the corresponding picture amongalternatives. Other non-verbal tests intended to provide a quick estimate of verbal ability,
scholastic aptitude, and intelligence can also be used
For evaluation of potential articulation problems and the child’s pragmatic language,
parents are encouraged to use a digital recorder to record speech in everyday situations
at home (e.g., playing, talking to a sibling or parent)
Create joint attention using a pleasurable play activity rather than focusing on the child“Think aloud” when speaking (e.g., “I wonder if this will fit here?”) rather than questioning
the child directly
Choose conversation topics connected to a pleasurable activity you do together or toother neutral topics, rather than the child’s feelings or his/her personal issues
Periods of silence are inevitable when working with these children. Some people find thissilence awkward and tend to chatter it away. Work on being relaxed and be sure to givethe child enough time to respond rather than chatter or talk for the child all the time
After some time, calmly continue the “dialogue” even though the child may not respondverbally, thereby taking pressure off the child to talk, increasing its comfort and moving“the dialogue” forward
Receive an eventual verbal response in a neutral, not too emotional way. Calmly
acknowledge what the child said, and carry on with what you were doing together.

children) and parent-monitoring of anxiety, and to assess response to treatment
over time.
Younger children may be able to use simpler visual models such as handdrawn or printed smiley and upset faces. An example of a talking map for theschool situation for younger children can be found below. Depending on age, one
can ask the child to point or to draw stars in situations they do talk. One can alsouse colorful post-it notes: green for talking, yellow for non-verbal communication,and red for muteness. Older children can also construct their own talking maps,
such as listing people they talk to, and people they will work on being able to talkto in different settings. Clinicians need to be creative to engage the child in theprocess.

Rating scales
GeneralSeveral rating scales for anxiety symptoms are available (see Chapter F.1of the textbook). The free to use Revised Children’s Anxiety and Depression Scale

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EXAMPLE OF A TALKING MAP FOR YOUNGER CHILDREN, SCHOOL VERSION
The talking map is helpful in the assessment of selective mutism. Depending on the age, one can ask
the child to point or draw stars in situations they do talk, or use colorful post-it notes, for example green
for talking, yellow for nonverbal communication, and red for muteness. The map can provide information
on how the child views their speaking behavior in different situations. It can also be used to evaluatechange over time.

Child’s name:_______________________________Age:_____
Who helped to complete the map______________Date______On the way to school

In the classroom

In a small group

Alone with teacher or other adults (who?)

In other rooms at school

During meals

Out during recess

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9IACAPAP Textbook of Child and Adolescent Mental Health(RCADS) includes a screening item on speaking behavior:
Item 38. My child feels afraid if he/she has to talk in front of the class.
The response alternatives are “never”, “sometimes”, “often” and “always” anda user’s guide is available at the website.

Example items fromthe Bergman School
Speech Questionnaire(teacher rated)

Selective mutism questionnaires•

The most widely used standardized questionnaires were developed by
Lindsey Bergman and are included in her recent manual for the treatment of SM(Bergman, 2013). A parent version, The Selective Mutism Questionnaire (Bergman
et al, 2008) and the teacher rated School Speech Questionnaire (Bergman et al,2002) are available free at this website. Versions in other languages are available bycontacting the author.

Item 3. Whencalled on by his/
her teacher, thisstudent answers
verbally.

•

Item 4. Whenappropriate, thisstudent asks you(the teacher)questions.

Although an overall score can be obtained by adding the ratings as an
expression of the severity of the mutism, these questionnaires are quantitative
measures of severity only, there is no diagnostic cut-off score. Diagnosis should bebased on the clinical examination. SM questionnaires are helpful in the assessmentof SM symptoms before, during and after treatment. In the parent version ratings
are made for three different settings: school, home, and in social situations outsideschool. Overall subscale scores and a total score can be obtained. The teacher
version rates speaking behavior in the school as assessed by the teacher.

(Rating options are: always,
often, seldom, never)

The Social Communication Anxiety Inventory (S-CAI) by Elisa Shipon-Blum
highlights the variety of SM behaviors by increasing the response options: noncommunicative, nonverbal, transitional and verbal stages (see example items forthe “home” situation below).
The Frankfurt Scale for the Assessment of Selective Mutism (FSSM) by
Angelika Gensthaler includes both a diagnostic and a severity scale. The FSSM
is available in three versions for preschool children aged 3-7 (FSSM 3-7), pupils
aged 6-11 (FSSM 6-11), and adolescents aged 12-18 (FSSM 12-18). The German
version has been validated (Gentshaler et al, 2018). The manual and a number ofauthorized translations of the FSSM are available for download.

TREATMENT
It is helpful to conceptualize treatment taking into account three groups offactors:
1. Vulnerability factors (genetics, temperament, social anxiety, behavioral
inhibition, and neurodevelopmental disorders). The focus of treatment
is not in changing temperament. If neurodevelopmental disorders arepresent, adequate help for these must be implemented at school.
2. Triggering factors (transitions and unexpected events such as starting
kindergarten or school, migration, use of a new language). Children
with SM benefit from preparation, training, and by being allowed
more time to adjust to the new situation or transition, as well as from astructured environment where they know what to expect.
3. Sustaining factors (the behavior of the people surrounding the mutechild). There are two opposite risks. One is to accept the child’s

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IACAPAP Textbook of Child and Adolescent Mental Healthavoidance, speaking for them and accepting their inability to improvetheir communication. The other is to expect communication thatthe child is unable to meet in that situation. Although well intended,both attitudes are not helpful, increase the child’s discomfort and canaggravate symptoms (see text box below).
SM is widely considered hard to treat and there are few high quality studies
of effectiveness. The treatment literature has been dominated by case studies or caseseries including a wide array of treatment approaches reflecting to a large extent thetheoretical orientation of the authors. Data are still scarce on treatment outcomes
and on predictors of these outcomes. The few existing long-term outcome studies
are retrospective, with little specific information about the treatment given at theclinics years ago. In 2006, a review of the psychosocial treatment literature statedwith some caution that cognitive behavioral therapy was recommended (Cohan etal, 2006a). In recent years, evidence based CBT interventions especially adapted
for children with SM have been developed (Klein et al, 2016; Bergman, 2013;
Oerbeck et al, 2014). All advocate early intervention and, although somewhat
different in design, frequency, duration, and location of treatment sessions,striking similarities exist between them and with pioneering work on the treatmentof SM by British, Canadian and American groups (Johnson & Wintgens, 2016;
McHolm et al, 2005; Kearney, 2010). Another Canadian group published a reviewof treatment for SM (psychosocial approaches and use of medication) (Manassis,2009).

Psychoeducational
resources useful forchildren with selective
mutism and theirfamilies(click on the image to
get more information)

Psychosocial treatments
For the sake of simplicity, common key treatment factors are outlined below.
Then, a brief review of the evidence about psychosocial interventions is presented
and illustrated with case examples.
•Interventions are in general multidisciplinary and focus on decreasing
anxiety, increasing social speech and ameliorating SM-related
impairment•

All approaches emphasize the behavioral components of the CBT, as
the symptom of mutism and the typically young age of onset makecognitive restructuring less feasible. Graduated exposure tasks andrewards for speaking behavior (reward contingency) are used•

Parental involvement is essential. Psychoeducation about SM andinformation on how to best help their children by reducing enabling
behaviors (for instance, communicating for their mute children) andby providing communication opportunities in low-anxiety homeand public situations, is mandatory. See side textbox for suggested
literature to use for children with SM. See also a parental information
leaflet offered by SMIRA, a British support group for SM.

•

Extensive involvement of, and coordination with teachers areneeded, as children with SM tend to be most symptomatic at school.
Psychoeducation about SM, consultations during treatment, andsimple exposure tasks at school are used.
As children with SM often fail to speak to the therapist, a strategy to•

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Suggested advice forpeers
Most people are afraidof something. This
child finds it hard to
speak. There are ways
to help him/her speak.
This is how you can
help:

•

•

When someone
does not speak,
people can feelawkward aroundthat person. Be
friendly towards
the child and try toinclude him/her inplay activities•

Don’t talk about
this child being
unable to speak toother people and,in general, don’t
speak for the child•Don’t make a fuss
if the child starts totalk, just continue
with what you
were doing.

secure early child engagement is vital. Seeking information about what
the child really likes, the use of funny favorite games and play activities,
and making rewards attractive are central.
A main treatment goal is to decrease speech anxiety by reducing
pressure to speak and increasing comfort by not expecting the child tolook directly at the therapist. This behavior may seem like a paradoxicalintervention and to work against the ultimate goal of increasing speech.
However, this has been found crucial for children with SM to loosen
up and engage in communication with unfamiliar people in a newsituation.

The integrated behavioral therapy for SM developed by Lindsey R
BergmanThis treatment is conducted at the clinic by experienced clinicians withparental participation using graded exposure tasks to the feared stimuli/situation(verbal communication) (Bergman, 2013). Therapists are in close communication
with teachers to ensure relevance of exposure tasks at school. A pilot randomized
controlled study including 21 children (4 to 8 years of age) found a significant
increase of speech after treatment, with no change in wait-list controls (Bergman
et al, 2002). Importantly, 67% of the children who received treatment no longer

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IACAPAP Textbook of Child and Adolescent Mental Healthfulfilled diagnostic criteria for SM and clinical gains were maintained at 3 months
follow-up (Bergman et al, 2013). Diagnostic comorbidity was not assessed but
significant reductions were found in social anxiety symptoms per parent but not
per teacher report. See Appendix F.5.1 for an overview of the 20 sessions in the
Bergman treatment approach.
Bergman’s manual provides forms and charts helpful in the assessment andtreatment of SM, including suggested exposure exercises. Structured assignments,
planned rewards, outcome description and the rating of child’s feelings arehighlighted. See Appendix F.5.2 and F.5.3 for examples. Click here to accessresources that you can download from the manual.

The Social Communication Anxiety Treatment (S-CAT) developed by
Elisa Shipon-Blum
This treatment is also conducted at the clinic with parental participation using
graduated exposure tasks and consultation with teachers to ensure understandingof SM and relevance of exposure tasks at school. The therapy consists of nine
3-weekly sessions employing extensive transfer of control to parents between
the sessions to promote generalization of therapeutic gains. S-CAT incorporates
behavioral and cognitive strategies to help children communicate socially withina framework of verbalization stages (see Appendix F.5.3) that become increasingly
demanding, using the SM-Social Communication Comfort Scale.
A pilot study without a control group of the S-CAT program, which
included 40 children with SM aged 5 to 12 years, found a significant increase ofspeech as rated by parents. Low SM symptom severity and high family therapy
compliance were associated with better outcome (Klein et al, 2016).

A mother’s question
My daughter M. is 8 years old and in second grade. She was always very shy,speaking only to my husband and I, my son, her grandparents and some aunts and uncles.
Today she speaks to everyone in our immediate family. In school she would only speak to her
gym teacher privately. We have been seeing a therapist for over a year now. […] The therapist
and I are trying to educate M’s teachers on SM. I’ve been bringing her in early before any
kids get in and sometimes M. will read some words to her teacher. I also taped her oral bookreports for her teacher to hear. M has one very good friend that she will speak to in school.
She feels very comfortable with this friend and because of her has been able to make newfriends and join after school activities. Her teachers, especially the gym teacher, feel that M.
is using this girl as a crutch. They want to separate them next year. I am totally against thisbecause M. is less anxious around this other girl. I know how frustrating it is when you don’t
get any communication. I think her teacher probably thinks she can cure M. by keeping heraway from her friend. But I think keeping M. with kids she feels comfortable with can only help
her. They seem to think she needs to have other friends. M. does have other friends she just
can’t initiate friendships on her own.

Greta
Greta was a 5 year old
girl with SM from age 3,
when she began attending
kindergarten. She wasbilingual with mutism
present in both languages.
Her adolescent brotherwas still suffering fromSM despite a long contact
with mental healthservices.
When introducing theexposure tasks during
the three home visits,
Greta started to talk to thetherapist in the second
session, when they
played her favorite game.
She continued to talk to
the therapist when thetreatment was continued
in a separate room inthe kindergarten. She
was eager to participate
in making a ranking listof persons who should
be invited in, preferringto start with peers.
Interestingly, the first peer
she invited was a shy,timid girl—Greta told thetherapist that her friend
also needed this speechtraining!
After 6 weeks, Greta
began to whisper to peers
outside the training room,and during the following
2 weeks she started totalk freely to peers andadults. At follow-up 5
years later, she still spokein all situations and had
no symptoms of social
anxiety.

My question to you is, “Should M. be separated from the only girl she can comfortably
talk to?”
What do you think?

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IACAPAP Textbook of Child and Adolescent Mental Health

The home and school based intervention for SM by Hanne
Kristensen and her group
This treatment starts at home, where the child feels safer and is more likely
to start talking and extends to school where the symptoms are more severe. This
treatment approach could be particularly useful in rural areas or where accessto expert clinics is lacking. A teacher or another key person may carry out theintervention under supervision from a clinician. See Appendix F.5.4 for an
overview of the home and school based intervention.
A favorable outcome was found in a pilot study of seven preschool children
diagnosed with long standing SM (mean 20 months) (Oerbeck et al, 2012). Six ofthe seven children spoke freely in all preschool settings after a mean of 14 weeks
treatment, and still did at the 1.5 year follow-up. In a randomized controlled
study including 24 children with SM (age 3 to 9 years), we found a significant
increase of speech after three months of treatment, with no change in wait-list
controls (Oerbeck et al, 2014).
A follow-up study of 24 children 1.5 years after a six-month treatment
program showed no decline of effect. On the contrary, there was a small but
significant increase in speaking behavior over time (Oerbeck et al, 2015). Younger
age at the start of treatment and less severe SM symptoms were associated with
better outcome. A long-term follow up of 30 of 32 children (aged 3-9 years) who
completed this program in Norway showed that, according to parents and teachers,
21of 30 children no longer fulfilled diagnostic criteria for SM. Four children still
suffered from SM and five showed partial remission (e.g., they spoke in some but
not all school situations). Information from the children themselves was includedin this follow-up; children rated their overall quality of life as good (Oerbeck etal, 2018).

Pharmacotherapy
The use of medication in children with SM is largely “off label” due tothe paucity of empirical evidence; medication should be considered only in very
special circumstances. Currently there are two small blind trials, one for fluoxetine
and the other for sertraline (Manassis et al, 2016). Medications used are largely
based on extrapolating results from the treatment of other anxiety disorders. It
is important to acknowledge this reality and to explain the rationale for using
medication—e.g., lack of response to psychological treatment, the strong link
between SM and social anxiety disorder (Compton et al, 2014). This often makes
families wonder if it is worth risking the potential adverse effects of medication.
However, the risk of deterioration in social and academic functioning can be highwhen SM is not effectively treated, and medication has the potential to improvethese functional outcomes (Manassis & Tannock, 2008). If anxiety decreases
with medication, some children may progress more quickly with psychosocial
treatment. It is also reassuring to families if one indicates that medication response(positive or negative) and side effects will be monitored closely, and there is a planfor discontinuing medication once the child is speaking normally in most social
settings.

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IACAPAP Textbook of Child and Adolescent Mental Health

When may medication be useful in SM?
In the case of Ellen, the child’s symptoms persisted for over two years despite
four months of intensive psychosocial treatment. An attempt at a “fresh start” witha change of school had failed and her social functioning was clearly deteriorating.
These events seemed to justify the use of medication. However, the question ofwhen to use medication in SM is not easy to answer (see also video clips #3 and#4. When deciding whether or not to recommend medication, several factors must
be considered:•••

The limited evidence of effectiveness and potential side effects,
particularly in pre-pubertal children
Medication should be used in concert with psychosocial treatment,
not as a monotherapy, although further study of such combination
treatment is needed (Ostergaard, 2018).
It must be clear that the child is failing to respond to psychosocial
treatment alone and that symptoms are severe and handicapping. Thereis some debate as to how long psychosocial treatment should continue
before adding medication but most authors suggest several months

Click on the pictures toview the documentary (Help
Me to Speak) that follows
two children with selective
mutism. Part 3 (above,
14:05) and part 4 (below,
13:11) illustrate aspectsof the psychological andpharmacological treatment.

Ellen
Ellen was a 6½ year old girl when first assessed. She had migrated to Europe withher family from Southeast Asia when she was three years old. At home she was fluent in boththe local language and her native tongue. Ellen was described by her parents as quiet andshy throughout her life but otherwise seemed to have developed normally. When starting
kindergarten, she was completely silent at school but her teacher was pleased to have acompliant, non-disruptive child in her class. She reassured the parents that Ellen would
probably participate nicely once she adapted to her new environment. However, Ellen did not
speak at school that year or the next year.
Ellen was referred for mental health assessment at the end of first grade because,
given her silence, the teacher had difficulty evaluating her academic progress. Ellen was
diagnosed with SM. Non-verbal communication with peers was observed, resulting in somefriendships. She was often included in games with her peers and several of them spoke on her
behalf in class. The assessing clinician suggested behavioral therapy to encourage speaking.
Her family was convinced that a “fresh start” at a new school the following September would
solve the problem, so the suggested interventions were not pursued.
At her new school, in grade 2, Ellen still did not speak. Moreover, she had lost
contact with peers from her previous school and was bullied at the new school. She became
increasingly withdrawn, putting her head on her desk for most of the school day withoutlooking up. The school arranged for a speech pathologist to work with Ellen and introduced abehavior modification program shown to increase speech in similar cases but 4 months later
there was no progress. A second mental health assessment was done—Ellen was then 7½
years old—and medication was recommended. Seeing their daughter’s deterioration, theparents were now willing to consider this option.
Fluoxetine 10mg per day was started. Ellen tolerated the medication without side
effects. Six months later, she was noted to be smiling more but not yet speaking despite
further work with the speech pathologist and continuing in the behavioral program. Dosage
was increased to 15mg per day (20mg and 10mg capsules in alternative days). Within three
weeks, she started whispering to peers. After a further month, she started speaking with theteacher if seen in private. Ellen continued on medication and was also allowed to continue
with the same teacher in Grade 3 resulting in the development of normal social speech,
friendships, and good academic progress that year. Medication was tapered soon after thestart of Grade 4, as Ellen continued to speak normally in all environments.

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As in many other childpsychiatric conditions where
studies of optimal dosage arelacking, the general rule forprescribing in SM is “start low
and go slow”

15

IACAPAP Textbook of Child and Adolescent Mental Health••Because older children appear to have a lower rate of response topsychosocial treatment than younger ones (Oerbeck et al, 2015),
medication may be considered earlier in older children. Medication
may also be considered earlier in locations where psychosocial treatment
is not readily available.
The clinician must weigh the potential risks and benefits of medication
in a given case and help the child and family understand these as well.

Choice of medication
Fluoxetine is the best studied though there are some reports for otherselective serotonin reuptake inhibitors (SSRI’s) and also for two monoamineoxidase inhibitors (MAOIs): phenelzine and moclobemide (Manassis et al, 2016).
The use of MAOIs in children is to be avoided given the potential side effects andfoodstuffs interactions. We recommend starting with fluoxetine and switching tosertraline if there is poor tolerance or lack of response.

How should medication be prescribed?
Younger children (under age 7 or so) may start with 5mg of fluoxetine perday, either in liquid form or (if not available) by taking a 10mg capsule every otherday. Due to its long half-life, the dosage of fluoxetine can be titrated by adjusting
the number of capsules taken per week. If switching to sertraline, 12.5mg per day
could be prescribed initially (i.e., half a 25mg capsule). As in the case example ofEllen, dosage adjustment may be needed because children vary widely in their
medication needs and tolerance.
It is prudent to monitor the child’s weight, which is sometimes affected by
medication-related nausea, especially early in treatment. Behavioral activation, a
SSRI adverse effect, is not uncommon in children (Strawn et al, 2015); it may
require a reduction of the dose or change of medication. The possibility of anincrease in suicidal behaviour, although uncommon (Bridge et al, 2007), shouldbe mentioned to the family and appropriate steps put in place to ensure safety.
When evaluating benefit, it is important to obtain information from teachers aswell as parents, and from the child once communicating a little. When medicated,
improvement is often not noted in the home environment, where symptoms are
typically less severe, but is more noticeable at school. Improvement can take time:
typically two to four weeks at an optimal dose, but often several more weeks beforechange translates into more appropriate verbal communication. Regular follow up,
e.g., every couple of weeks, is ideal in order to monitor for adverse effects, adjust
dosage, and continue with psychosocial treatment.

Once the child is progressing
with social speech, it isimportant to maintainmedication for a few months
to optimize the benefits ofco-occurring psychosocial
treatment, allow children tobuild confidence in their newsocial abilities, and avoid
setbacks

Tapering off medication over the summer vacation is usually not advisable,
as the start of school in autumn is often a challenging time for children with SM,
sometimes prompting relapse. Nevertheless, when the child speaks normally inmost social settings and has established good social and academic functioning,clinicians should taper off medication. Usually, this is done by reducing dosage,
waiting for a few weeks for the re-emergence of symptoms, reducing dosage further
and waiting again, and then stopping medication if the symptoms do not recur. If
symptoms do recur, medication is increased to the lowest previously effective level.
Then, medication dosage can be re-evaluated every six months or so, ensuring thatthe child continues on the lowest dosage needed. The risks and benefits of longterm medication use are unknown.
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IACAPAP Textbook of Child and Adolescent Mental Health

CULTURALLY SPECIFIC ISSUES
The boundaries between normality and pathology vary across cultures.
Hence, whether a behavior is considered problematic will differ. The thresholdof tolerance for situational muteness varies across cultures, social settings, andfamilies. However, for SM—that is, in terms of the disorder itself—just about
all cultures (even those where shyness/reticence is considered a positive quality)
would consider the behavior aberrant and parents would want help to improvetheir child’s functioning.
In our opinion, the cultural issues that demand most sensitivity in relation
to SM have to do with treatment:•Internationally, there is variation about the importance placed onchildren’s ability to present orally at school. Also varying is the amountVincent van Gogh: Portrait of Camille Roulin. Van Gogh Museum, Amsterdam

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IACAPAP Textbook of Child and Adolescent Mental Health••of pressure considered acceptable when helping a child to increase
speaking behavior
In the delivery of psychosocial treatment, it varies from country tocountry whether health personnel are permitted or willing to help
children at home or at school
Concerning pharmacotherapy, there is great variation in how readilypeople are willing to use medication for SM. In many countries, suchtreatment is considered “off label”—meaning that physicians prescribe
it without official approval from health regulators, usually because
there is not enough evidence of effectiveness.

KEY POINTS
•
•

•
•

•
•
•

•

•
•

•

SM is a relatively rare childhood disorder that causes significant
impairment of social and academic functioning
The cardinal symptom of SM is a consistent failure to speak in specificsettings (e.g., school, social situations) despite speaking normally inother settings (e.g., at home)
SM runs in families and is associated with the temperamental trait
behavioral inhibition
Comorbid conditions are prevalent, especially other anxiety disorders
and neurodevelopmental disorders, and it is important to assess thechild for these
Assessment requires experience, sensitivity, and detailed informationfrom parents and teachers as well as evaluating the child
Psychoeducation and behavioral management are usually the first steps
A structured treatment approach focusing on gradual exposure to thefeared task (speaking) with reward contingency is the treatment ofchoiceMedication may be useful when there is no, or partial response topsychosocial treatment. Medication can be considered earlier where
psychosocial treatment is not available
If at all possible medication should be used in concert with psychosocial
treatment for SM, not as a monotherapy
Currently, no medication is approved for children and adolescents with
SM. However, a growing number of studies suggest cautious optimism
regarding SSRIs
If left untreated, SM is associated with a higher risk for other psychiatricdisorders, especially anxiety disorders, as well as continued impairment
in social and academic functioning.

••

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IACAPAP Textbook of Child and Adolescent Mental Health

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Bergman LR, Keller ML, Piacentini J et al (2008). The
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sample. Journal of the American Academy of Child &Adolescent Psychiatry, 41:938-946.
Bergman RL, Gonzalez A, Piacentini J et al (2013). Integrated
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Bridge JA, Iyengar S, Salary CB (2007). Clinical response andrisk for reported suicidal ideation and suicide attempts
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Carbone D, Schmidt LA, Cunningham CC et al (2010).
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Psychology, 38, 1057-1067.
Cohan SL, Chavira DA, Shipon-Blum E et al (2008). Refining
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Cohan SL, Chavira DA, Stein MB (2006a). Practitioner review:
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47:1085-1097.
Cohan SL, Price JM, Stein MB (2006b). Suffering in silence:
Why a developmental psychopathology perspective on
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Compton SN, Peris TS, Almirall D et al (2014). Predictors
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Dunn LM, Dunn DM (2007) Peabody Picture Vocabulary TestIV. San Antonio, TX: Pearson Assessments.
Egger HL, Angold AC (2004). The preschool age psychiatricassessment (PAPA): A structured parent interview for
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Gensthaler A, Dieter J, Raisig S et al (2018). Evaluationof a novel parent-rated scale for selective
mutism. Assessment, epub ahead of print. Doi:
10.1177/1073191118787328.
Gensthaler A, Khalaf S, Ligges M et al (2016a). Selective
mutism and temperament: the silence and behavioral
inhibition to the unfamiliar. European Child &Adolescent Psychiatry. DOI: 10.1007/s00787-0160835-4
Gensthaler A, Maichrowitz V, Kaess M et al (2016b). Selective
mutism: The fraternal twin of childhood social phobia.
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Hirshfeld-Becker DR, Biederman J, Henin A et al (2007).
Behavioral inhibition in preschool children at risk is a
specific predictor of middle childhood social anxiety:
A five-year follow-up. Journal of Developmental and
Behavioral Pediatrics, 28:225-233.
Hua A, Major N (2016). Selective mutism. Current Opinion in
Pediatrics, 28:114-120.
Johnson M, Wintgens A (2016). The Selective Mutism Resource
Manual 2nd ed, Brackley, UK: Speechmark Publishing.
Kaufman J, Birmaher B, Axelson D et al (2013). Schedule for
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Klein ER, Armstrong SL, Skira K et al (2016). Social
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Kristensen H (2000). Selective mutism and comorbidity with
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Manassis K (2009). Silent suffering: understanding and treating
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Neurotherapeutics, 9:235-243.
Manassis K, Oerbeck B, Overgaard KR (2016). The use of
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Manassis K, Tannock R (2008). Comparing interventions forselective mutism: A pilot study. Canadian Journal of
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McHolm AE, Cunningham CE, Vanier MK (2005). Helping
your Child with Selective Mutism: Practical Steps toOvercome a Fear of Speaking. Oakland, CA: New
Harbinger Publications.

Ostergaard KR (2018). Treatment of selective mutism based on
cognitive behavioural therapy, psychopharmacology
and combination therapy - a systematic review. Nordic
Journal of Psychiatry 72:240-250.

Muris P, Hendriks E, Bot S (2015). Children of few words:
Relations among selective mutism, behavioral
inhibition, and (social) anxiety symptoms in 3- to
6-year-olds. Child Psychiatry & Human Development,
18:151-169.

Remschmidt H, Poller M, Herpertz-Dahlmann B et al (2001).
A follow-up study of 45 patients with elective
mutism. European Archives of Psychiatry and Clinical
Neuroscience, 251:284-296.

Muris P, Ollendick TH (2015). Children who are anxious
in silence: A review on selective mutism, the newanxiety disorder in DSM-5. Clinical Child and Family
Psychology Revie, 18:151-169.
Oerbeck B, Johansen J, Lundahl K et al (2012). Selective
mutism: A home-and kindergarten-based intervention
for children 3-5 years: A pilot study. Clinical Child
Psychology and Psychiatry, 17:370-383.
Oerbeck B, Overgaard KR, Stein MB, Pripp AH, Kristensen
H (2018). Treatment of selective mutism: a 5‑year
follow‑up study. European Child and Adolescent
Psychiatry 27:997-1009.
Oerbeck B, Stein MB, Pripp AH et al (2015). Selective mutism:
follow-up study 1 year after end of treatment.
European Child and Adolescent Psychiatry, 24:757-766.
Oerbeck B, Stein MB, Wentzel-Larsen T et al (2014). A
randomized controlled trial of a home and schoolbased intervention for selective mutism – defocusedcommunication and behavioural techniques. Childand Adolescent Mental Health, 19:192-198.

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Stein MB, Yang B-Z, Chavira DA et al (2011). A common
genetic variant in the neurexin superfamily member
CNTNAP2 is associated with increased risk for
selective mutism and social anxiety-related traits.
Biological Psychiatry, 69:825-831.
Steinhausen H-C, Juzi C (1996). Elective mutism: An analysis of
100 cases. Journal of the American Academy of Child &Adolescent Psychiatry, 35:606-614.
Strawn JR, Welge JA, Wehry AM et al (2015). Efficacy andtolerability of antidepressants in pediatric anxiety
disorders: A systematic review and meta-analysis.
Depression and Anxiety, 32:149-157.
Toppelberg CO, Tabors P, Coggins A et al (2005). Differential
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World Health Organization (2018). International Statistical
Classification of Diseases and Related Health Problems(11th Revision).

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix F.5.1
Overview of the 20 sessions in the Bergman Integrated Behavioral Therapy for children withselective mutism
TOPIC

CONTENT

1

Introduction

Overview of treatment and begin to increase the child’s comfort with the new situation

2

Feelings chart,
reward system

Introduce and practise using the ‘‘feelings chart,’’ a developmentally friendly,
subjective distress measure. Introduce child and family to the use of a behavioral
reward system to reinforce speaking behavior and help them to develop a tailoredsystem3

Class list andhierarchy building

Gather details about child’s verbal behavior in class. Construct a ‘‘talking ladder’’ orhierarchy (graded list of situations involving verbal communication that the child will beworking on)

4

Exposure practice*

Review rationale behind exposure interventions and begin with in-session exposuresthat guide future in and out of session exposures

5-9

Initial (mild)
exposures*

Develop, execute, and assign exposure exercises for situations where the child has
difficulty speaking in-session and elsewhere (school, extended family, community,
etc.)

10

Treatment midpoint
session

Focus on review of progress to date and solve obstacles to success (e.g., teacher orparent non-compliance, problems with reward program, lack of generalization, child’s
oppositionality)1114

Intermediate(moderate)
exposures*

Continue working on exposures from child’s hierarchy (‘‘talking ladder’’) with input
from family and teachers

15

Continued
exposures* andintroduction oftransfer of control

Continue exposure tasks and introduce the concept of transfer of control whereby
responsibility for ongoing work is handed over to parent and child. Begin to elicit ideas
from parent/child for out of session exposures

1617

Advanced exposuresand additional focus
on transfer of control

Routinely working on more advanced exposure tasks and more focus on transferring
control and responsibility for treatment to family as well as teacher if appropriate

1819

Review of progress;
advanced exposuresand transfer ofcontrol

Recognize areas where progress has occurred and identify situations where difficulty
speaking remains. Develop strategies to continue working in these areas, particularly
if functional impairment remains. Allow family and teacher to offer suggestions of
exposure tasks to target remaining symptom areas

20

Relapse prevention
and graduation

Present child with progress chart to acknowledge and reinforce gains. Develop listof remaining challenges and together brainstorm ideas to continue working on theseareas. Review relapse prevention strategies. Present graduation certificate and, if time
permits, have small celebration* When appropriate to the developmental level of the child, simple cognitive restructuring techniques can be added during
these stages of the intervention

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix F.5.2
Example of a form used to conduct a structured assignment according to the Bergman manual
Assignment:
Reward expected:
Outcome:[1] Not attempted - not possible[2] Not attempted - child did not tolerate it[3] Attempted not completed[4] Completed as assigned[5] Completed with modifications

Child’s rating after exposure (from 1-5; varying intensity of smiley and upset faces)

Check here _____ if child rating not obtained.
Explain outcome:Appendix F.5.3
Stages in the SM-Social Communication Comfort Scale (Elisa Shipon-Blum)
Stage 0: Child does not respond or initiate (seems frozen)
Stage 1: Child communicates using nonverbal (non-spoken) communication and responds or initiates bypointing, nodding, gesturing, writing, or making non-speech noises
Stage 2: Child is transitioning into verbal (spoken) communication and responds or initiates responses
by making sounds or using a verbal intermediary that may include whispering or using arecording device
Stage 3: Child communicates by speaking and responds or initiates using words in their typical, quiet, or
altered voice from a rehearsed script or spontaneous speech.

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix F.5.4
Overview of the home and school based intervention for SM, by Hanne Kristensen and her group•

One pre-treatment psychoeducational session is held with parents and teachers together.
Selective mutism often gives rise to etiological speculations (e.g., the child deliberately withholds speech or is a result of
trauma). This session is important to ensure a common evidence based understanding of SM, and how to best help thechild.

•

Three weekly home-based sessions with the child and parent(s)Session 1. Explain (adjusted to child’s age) the purpose of the visit, that other children also struggle with inability to speakoutside home, that most do not know why, and that they really want to speak but don’t know how to do it. Explain that
it is possible to improve by practicing in small steps, that they will be prepared for what to do and receive small gifts forspeaking. Introduce a work-book (talking map, stickers, drawing sheets) and an audio-tape (to play with and hear theirsounds/voice), both for optional use and as a tool to enhance rapport. Choose together a favorite game—with speechdemands (e.g., counting, naming)—as well as favorite rewards. Show the child how this game (exposure task) will be
conducted in the 2nd session in easy and more difficult stages (see session 2).
Session 2. Review session 1 and check the workbook/audiotape if these were used between sessions. Carry out theplanned exposure task in six stages with increasing difficulty: (1) parent and child play a game; with the therapist outside
the room and the door closed; (2) therapist outside the room with the door open; (3) therapist visits the room during the
game; (4) therapist in the room, not playing; (5) therapist sitting beside but not playing; (6) therapist participates in thegame with child and parent.
Session 3. Review session 2 and continue the exposure task from where the child left off in session 2. Prepare the childfor the next sessions to be conducted at school using the same exposure task and play material, initially accompanied by
the parent (s), then training with teacher (s).

•17 weekly school sessions (if possible divide into two 30 minutes sessions to keep the child “warm”):
Similar content as in sessions 2-3 but in another location (school). The program follows six modules with predetermined
and increasingly difficult goals (see below). Children with SM can be described as starting at level zero (not speaking toadults)Goal
1

Speaks to the therapist in a separate school room with parent present

2

Speaks to therapist in a separate school room without parent present

3

Speaks to one teacher in a separate school room with therapist present

4

Speaks to other teachers (and children) in a separate school room with therapist present

5

Speaks to teachers (and children in some settings without therapist present (speaks to some but not
all teachers; speaks in some but not all groups at school)

6

Speaks to teachers (and children) in all settings without therapist present (normal/near normal
speech)Selective Mutism

F.5

23