Transcript Selective Mutism in the Public School Setting: A Case Study

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
 An ability to speak and comprehend
spoken language
(DSM-III, 3rd 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
 The disturbance interferes with educational or
occupational achievement or with social communication
 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 disturbance is not better accounted for by a
Communication Disorder
(DSM-IV-TR, 2000, p. 127)

Our Student: Initial Profile:
CA: 11.8
 Classified as a student with special
education needs…multiply disabled
 Placed in a 12:1:1 classroom 9/03
 Received counseling, speech/language
services, occupational therapy services
 Received informal diagnosis of “selective
mutism” from previous school district

Communication behaviors on intake:
Limited eye contact with classmates and
adults
 Tendency towards solitary play behaviors
 Pointing gestures to indicate requests
 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 SocioCommunication Intervention Model for
Selective Mutism (Hungerford, et al, 2003)
 Email consultation with program author
 Setting up a collaborative approach with
classroom teacher and parents

Social-Communication Intervention
Model for Selective Mutism

1.
2.
3.
4.

Accounts for nonverbal and verbal components
of social interaction as well as speech &
situation variables, including
Eye contact
Non-verbal turn taking
Non-verbal indicators of joint attention
Writing
Encourages a scaffolded approach when
manipulating variables during social interaction
(Hungerford, et al, 2003)
The Implementation of Therapy:
Employed a scaffolded, task-analyzed
approach, including:…
 Communication modality
 Characteristics of communication
 Physical environment

Communication Modality:

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
 Less familiar adult…
 Familiar peer
 Familiar peer group
 Familiar peer group with unfamiliar peer
 Classroom

Physical Environment:
Communication lab therapy room
 Empty classroom
 Empty hallway
 Crowded hallway
 Structured classroom
 Free-time: classroom

Pragmatic language treatment in
group setting:
Social language skills targeted:
 Identifying common categories
 Identifying comment types (opinion,
compliment, suggestion, insult, threat)
 Using the telephone
Progress was assessed utilizing baseline and
post-treatment checklists…
COMMUNICATION LAB PROGRESS CHART: A.B.--identifying common categories
84%
83%
percentage of correct responses
82%
80%
78%
76%
Series1
74%
73%
72%
70%
68%
Oct-03
Nov-03
dates skill assessed
Dec-03
COMMUNICATION LAB PROGRESS CHART: A.B .--identifying types of comments
120%
percentage of correct responses
100%
100%
80%
60%
Series1
40%
30%
20%
0%
Oct-03
Nov-03
Dec-03
dates skill assessed
Jan-04
Feb-04
1/2
9/
1/3 200
0/ 4
2
1/3 004
1/
20
2/1 04
/2
2/2 004
/2
0
2/3 04
/2
2/4 004
/2
2/5 004
/2
0
2/6 04
/2
2/7 004
/2
2/8 004
/2
0
2/9 04
/
2/1 2 00
0/ 4
2/1 2004
1/
2/1 200
2/ 4
2
2/1 004
3/
2/1 200
4/ 4
2/1 2004
5/
2
2/1 004
6/
2/1 2004
7/
2/1 200
8/ 4
2
2/1 004
9/
2/2 2004
0/
20
04
percentage of correct responses
COMMUNICATION LAB PROGRESS CHART: A.B.--telephone skills
60%
50%
50%
40%
30%
33%
Series1
20%
10%
0%
dates skill assessed
To encourage increased breath
support and more “forceful”
whispering—individual treatment
sessions including:
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

During these activities, clinician and student
would each have a whistle, taking turns
blowing and making sounds
COMMUNICATION LAB PROGRESS CHART: A.B.--producing noise with tube noisemaker
100%
90%
percentage of successful noise productions
87%
80%
70%
60%
50%
Series1
40%
30%
20%
10%
0%
0%
Mar-04
Apr-04
May-04
Jun-04
Jul-04
dates skill assessed
Aug-04
Sep-04
Oct-04
Also during individual treatment
sessions:
One-word whispers were modeled
and practiced—louder whispers with
increased breath support encouragedA.B. whispered one word utterances
standing 10 ft. from the clinician
Intelligibility was assessed as
percentage of words whispered
correctly interpreted by the clinician…
dates skill assessed
10
/2
8/
20
10
/2
7/
20
10
/2
6/
20
10
/2
5/
20
10
/2
4/
20
10
/2
3/
20
10
/2
2/
20
10
/2
1/
20
10
/2
0/
20
10
/1
9/
20
10
/1
8/
20
10
/1
7/
20
10
/1
6/
20
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
40%
10
/1
5/
20
10
/1
4/
20
percentage of intelligible whisper productions
COMMUNICATION LAB PROGRESS CHART: A.B.--percentage of intelligible one-word whisper productions
80%
70%
70%
60%
50%
40%
Series1
30%
20%
10%
0%
The transition to vocalization…
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
 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”
 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
 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
 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 (4th 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, 40-43.
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, 127-133.
Harris, H.F. (1996). Elective mutism: A tutorial. Language, Speech and Hearing Services
in Schools, 27, 10-15.
Hungerford, S., Edwards, J., Iantosca, A. (2003, November). A Socio-Communciation
Model for Selective Mutism. Paper presented at the meeting of the American SpeechLanguage-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, 304-315.
Schum, R.L. (2003). Selective mutism: An integrated treatment approach. The ASHA
Leader Online, 1-11.