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DIRFloortime in
Assessing and Treating

Selective Mutism
Joleen R. Fernald, MS CCC-SLP, PhD(c)

www.JoleenFernald.com
JFernaldSLP@comcast.net
Free Powerpoint Templates Page 1

What Is Selective Mutism?
Selective Mutism is the inability to

communicate in select social
settings despite being able to
verbally communicate in others
For example, a child who speaks

freely at home with his/her family,
but verbally is completely shut
down every day at school
Diagnostic criteria for 313.23
Selective Mutism
oConsistent failure to speak in specific social

situations (in which there is an expectation for
speaking, e.g., at school) despite speaking in
other situations).
oThe disturbance interferes with educational or
occupational achievement or with social
communication.
o The duration of the disturbance is at least 1
month (not limited to the first month of school)
DSM-IV TR, 2000

Diagnostic criteria for 313.23
Selective Mutism
oThe failure to speak is not due to a lack of

knowledge of, or comfort with, the spoken
language required in the social situation.
oThe disturbance is not better accounted for by a

Communication Disorder (e.g., Stuttering) and
does not occur exclusively during the course of a
Pervasive Development Disorder, Schizophrenia,
or other Psychotic Disorder.
DSM-IV TR, 2000
Shyness vs. Selective Mutism
Shyness Selective Mutism
Slow warm up Warm-up time MUCH
period longer than expected
Can often respond Cannot respond at all
with a nod or small -may appear frozen
smile Dual personality
Same demeanor restrained at school
everywhere quiet and talkative at home
and reserved

What causes
Selective Mutism?
inhibited temperaments
decreased threshold of
excitability in the amygdala
Genetic predisposition to anxiety
NO evidence that the cause of
Selective Mutism is related to
abuse, neglect or trauma

Behavioral
Conceptualization of SM
Scary situation
Increased
likelihood of Avoidance
avoidance
Reinforcement Decreased
of behavior anxiety
Prevalence
4-7 year-olds .03-.72% England (1975, 1979)
7-8 year-olds 2% Finland (1998)
7-15 year-olds .18% Sweden (1997)
5-8 year-olds .71% California (2002)
1.5-2.6 / 1 female / male Garcia et al

(2004)
Bergman et al., (2002)

Most children with SM
have more than 1
diagnosis
Speech SM
and (Anxiety)
Language
Social
Sensory
Phobia or
Dysfunction
Anx NOS
Specific
Enuresis
phobias

SM Connections
Given Selective Mutisms
relationship to anxiety, most
consider these co-morbid disorders
to be psychiatric in nature including
depression, panic disorders,
dissociative disorders, obsessive-
compulsive behavior, and
Aspergers disorder
Sharp et al., 2006

SM and
Autism Spectrum Disorders
Kopp and Gillberg (1997) found
that 7.4 percent of children with
Selective Mutism also met criteria
for Aspergers disorder.
More recently, Stein et. al. (2010)
found a partially shared etiology
between Autism Spectrum
Disorders and Selective Mutism.

DIR/Floortime
developmental and interdisciplinary

framework that helps clinicians,
parents and educators conduct a
comprehensive assessment and
develop an intervention program
tailored to the unique challenges
and strengths of children
(Greenspan & Wieder, 2006)
http://www.icdl.com/DIRFloortime.shtml
D Developmental
I Individual Differences
R Relationship-based

D (Developmental)
describes the developmental

milestones that every child must
master for healthy emotional and
intellectual growth

Symbolic
Emotional
Thinking
(30-48 months)
Representation of
Affect and Ideas
(18-30 months)
Complex Communication
(9-18 months)
Two-way Circles of Communication

(4-9 months)
Engagement
(2-6 months)
Shared Attention and Regulation

(0-3 months)
I (Individual Differences)
describes the unique biologically-

based ways each child takes in,
regulates, responds to, and
comprehends sensations such as
sound, touch, and the planning and
sequencing of actions and ideas.

SM and Individual
Differences
Receptive language processing
Expressive language
Sensory reactivity
Motor planning
Visual spatial processing
Bio-medical differences

SM and
Speech-Language Disorders
Cleator and Hand (2001) estimate
that 80% of children with SM also
have speech and language
disorders
Steinhausen et al., (1996) suggest
that about 38% have pre-morbid
speech and language problems.

These findings are consistent with
theories that children with SM
avoid speaking out of fear of being
teased for mispronouncing a word
(Krysanski, 2003).
McInnes et al. (2004) suggests
that children with Selective Mutism
have shorter, linguistically simpler
narratives with less detail than
children with social phobia.

Children with SM may also have
normal receptive language and
cognitive skills, but they show
subtle expressive language deficits
not attributable to social anxiety
(McInnes et al., 2004).
Kristensen (2000) showed children
with SM may show developmental
delay as often as they show anxiety
disorders (68.5% for co-morbid
developmental delay compared to
74.1% for co-morbid anxiety).
Percentage of 33 Children with SM who Exhibited
S/L Disorders
(Total > 100% because some children had more than
one area of disability)
Fluency
27%
Articulation
42%
Receptive and
Expressive
Language
Expressive
12%
Language
27%
Klein, E, (2010) Selective Mutism Research Institute, Jenkintown,PA

Thanks to Sherri Cawn, MA CCC-SLP
Occupational Therapy
Focus on sensory processing
Sensory Modulation
ability to take in sensory stimuli from the
environment and then filter out ambient stimuli ->
just right arousal, alertness, and attention to the
salient stimuli
Sensory Regulation
strategies one uses to assist in maintaining
attention
Sensory Discrimination
involves the perception of information from a
singular sensory system as well as multi-sensory
perception
Praxis (Motor Planning)
Focus on responses to sensory stimulation
- Tactile, Vestibular, Proprioceptive
Self Portrait
6/07

Self Portrait
10/07

R (Relationship-based)
describes the learning relationships

with caregivers, educators,
therapists, peers, and others who
tailor their affect based interactions
to the childs individual differences
and developmental capacities to
enable progress in mastering the
essential foundations
"In order to develop normally, a child
requires progressively more
complex joint activity with one or
more adults who have an irrational
emotional relationship with the
child. Somebodys got to be crazy
about that kid. Thats number one.
First, last and always.
Urie Bronfenbrenner,
Developmental Psychologist

EVALUATION AND
ASSESSMENT

Parents may not be aware of the
childs mutism or difficulty away
from the childs comfort zone
Professionals may incorrectly view
behavior as simple shyness
Professionals may incorrectly
attribute mutism to family
dysfunction or oppositional
behavior in the child
Team Approach
Parent Psychiatrist
Classroom Teacher Speech/Language
School Psychologist/ Pathologist
Guidance Counselor Occupational
School Therapist
Administration Mental Health
Pediatrician/Family Treating
Practitioner Professional
(Clinical
Psychologist,
LICSW, Play
Therapist)
Often Misdiagnosed
difficulty initiating and

may be slow to respond even when it
comes to nonverbal communication.
may lead to falsely low test scores and
misinterpretation of the child's cognitive
abilities

School-based SLP
As delineated in the ASHA Scope of
Practice in Speech-Language
Pathology and federal regulations,
SLPs work with students exhibiting the
full range of communication disorders,
including those involving language,
articulation (speech sound disorders),
fluency, voice/resonance, and
swallowing. Myriad etiologies may be
involved.
American Speech-Language-Hearing Association. (2010). Roles and
Responsibilities of Speech-Language Pathologists in Schools
Free Powerpoint
[Professional Issues Templates
Statement]. Page 37
The speech and language evaluation
(for a child with suspected SM) seeks
information on:
expressive language ability (e.g., parents
may have to help lead a structured
storytelling or bring from home, a
videotape with child talking if he or she
does not do so with the SLP)
language comprehension (e.g.,
standardized tests and informal
observations)
verbal and non-verbal communication /
pragmatics
www.asha.org/public/speech/disorders/SelectiveMutism.htm
SLP Assessments
CLINCIAL OBSERVATIONS
Pragmatic Profile of the CELF-4
(Criterion Referenced)
Selective Mutism Questionnaire (Norm
referenced), Bergman et al (2008)
Social Communication Anxiety
Inventory-2
Social Skills Rating System (Pearson)
(Norm referenced)
Social Skills Improvement System
(SSIS) Rating Scales (Norm referenced),
linked to target
Free goals
Powerpoint Templates Page 39
The Intentionality Model
Bloom and Tinker, 2001

Name of Child:____________________________ Completed by:_________________________ Date:________
Selective Mutism Questionnaire* (SMQ)

(to be filled out by parents)
Please consider your childs behavior and activities of the past month and rate how frequently each
statement is true for your child.
AT SCHOOL
3
Always
2
Often
1
Seldom
0
Never
To determine Stages
1. When appropriate, my child talks to most peers at school. X
2. When appropriate, my child talks to selected peers
(his/her friends) at school.
3. When called on by his or her teacher, my child answers.
X
X
of Communication
4. When appropriate, my child asks his or her teacher
questions.
5. When appropriate, my child speaks to most teachers or
X
X
Comfort, check
staff at school.
6. When appropriate, my child speaks in groups or in front
of the class.
How much does not talking interfere with school for your
X visually to see where
child? (please circle) Not at all Slightly Moderately Extremely
the majority of the
WITH FAMILY
Always Often Seldom Never

Xs are located.
7. While at home, my child speaks comfortably with the
X
other family members who live there.
8. When appropriate, my child talks to family members
X
while in unfamiliar places.
9. When appropriate, my child talks to family members that
dont live with him/her (e.g. grandparent, cousin).
10. When appropriate, my child talks on the phone to his/her
X
X
School = Stage 0
parents and siblings.
11. When appropriate, my child speaks with family friends.
12. My child speaks to at least one babysitter.
How much does not talking interfere with family
X
X Home = Stage 2
Relationships? (please circle) Not at all Slightly Moderately Extremely
Other = Stage 0
IN SOCIAL SITUATIONS (OUTSIDE OF SCHOOL)
Always Often Seldom Never

13. When appropriate, my child speaks with other children
X
who s/he doesnt know.
14. When appropriate, my child speaks with family friends
X
who s/he doesnt know.
15. When appropriate, my child speaks with his or her doctor
X
and/or dentist.
16. When appropriate, my child speaks to store clerks and/or
X
waiters.
17. When appropriate, my child talks when in clubs, teams or
X
organized activities outside of school.
How much does not talking interfere in social situations
for your child? (please circle) Not at all Slightly Moderately Extremely
Josh on the swing

"Children who are unable to
communicate effectively through
language or to use language as a
basis for further learning are
handicapped socially, educationally
and, as a consequence,
emotionally.
Byers-Brown & Edwards, 1989

Family Intervention
Psycho-education (what is SM, etiology,

prognosis)
What might the parent be doing or not
doing that is inhibiting social
communication (enabling)?
Is there pressure placed upon the child to
speak?
Does the parent need assistance
managing the childs anxious behaviors?
Does the parent require support in
managing other problem behaviors (sleep
disturbances, toileting issues etc.)?

A habit cannot be tossed
out of the window. It must
be coaxed down the stairs
a step at a time
Mark Twain

Treatment: Key Points
SM is about a fear of the

expectation to speak
Dont force the child to speak
No negative reinforcement for being
mute
Focus on positive reinforcement

Treatment: Key Points
Know your client young children may

benefit from a more play-based
approach, older children or adolescents
may benefit from a cognitive behavioral
approach
Know your setting do you have access
to toys, equipment for the child to
engage without expectation to speak
Focus on engaging non-verbally, then
bridging to verbal communication

SLP Treatment Hierarchy
Get the child to engage
Get the child to communicate (gestural or
with AAC)
Get the child to make noise (clapping or
stomping)
Get the child to say sounds, syllables,
words, phrases, sentences
Get the child to converse with key worker
Expand narratives with key worker while
broadening other communication
partners
Vary social problem solving and social
pragmatic opportunities
Goals and Objectives
Longterm goal examples:
Child will progress from Stage 0
through Stage 2, with multiple
conversation partners in a variety of
settings
Child will progress from Stage 1
through Stage 3, with multiple
conversation partners in a variety of
settings
Child will verbally convey wants and
needs to adults and peers
Short term objectives (Stage 0 - Stage 1):
Child will use gestures intentionally, in
order to communicate
Child will take turns with the key
worker
(Stage 1 Stage 2):

Child will make voiceless sounds
intentionally
Child will make animal sounds during
play

Short term objectives (Stage 2 - Stage 3):
Child will speak at normal volume when
alone, and allow the key worker to enter the
room while still speaking
Say single words at normal volume in the
key workers presence
Remember to consider responding &

initiating throughout the therapy process
Generalization to more people in more settings
should also be incorporated in goals

Treatment for Stage 0 - 1
Improve engagement and social comfort
Use a small environment
1:1 ratio
Not a lot of stimuli or distractions
Consider rolling a ball back and forth
Taking turns with pushing a truck back
and forth
Taking turns playing a game (board
games)

Puzzles
Arts and crafts
Stamping and stencils
Eye Spy books
Playground equipment (sliding
down the slide or swinging on the
swing set)
Guessing games to practice
nodding or shaking the head (Hide
something in the room Is it in the
drawer?)
Matching musical instruments (take
turns making a sound behind a
screen child/ key worker holds up
the matching instrument)
Miming to make requests (animal puzzle
may be used child/ key worker
acts out the animal to request it)
Simon Says
(www.speakingofspeech.com/materials
_exchange.html)

Sounds that dont involve the body
(instruments)
Body sounds that dont involve
talking (clapping, snapping,
tapping)
Oral motor noises (blowing,
whistling, tongue clicking,
popping cheeks)
Voiceless sounds (/s/ for snake, /sh/
for sleeping baby, tongue click for
horseFreegallop)
Powerpoint Templates Page 58
Environmental noises (phone
ringing, vroom vroom for car)
Animal noises (moo, baa, woof)
Laughter
Clockwatcher
Handover/takeover
Interview game (yes, no, writing
responses, asking questions)

Hangman
Battleship
Interview (favorites)
Augmentative Communication
(AAC) Go Talk, talking photo
albums, recordable pens, iPad
Verbal intermediary (puppets,
peers)

Tools to Transition from
Stage 2 - 3
Using childs feelings as a GUIDE, use person or
object who child can speak to:
Whisper close up (toilet paper roll)
Whisper at fist length away
whisper at half arm length away (paper towel
roll)
Whisper at full arm length away
Whisper across table (wrapping paper roll)
Look in direction of person
Dr. Elisa Shipon-Blum

Stage 2 - 3
Use Sounds
This is great for kids who are speech
phobic or who are already using sounds
in play like animal sounds or audible
laughing
Begin making tapping noises, finger
snapping noises.
2 snaps/taps=YES & 1 snap/tap=NO
Mouth Popping SOUND
Free Powerpoint Templates Dr. Elisa Shipon-Blum Page 65
2 pops=Yes & 1 Pop=No
Stage 2 - 3
When child/teen able to make Pop sound, let
them know they made a P sound (Ritual Sound
Approach)
Child CROSSES OFF letters of the alphabet
AB C D E FGH I JKL
MNOPQRSTUVW
XYZ
H sound = DEEP BREATH in/OUT

Stage 2 - 3
Use P sound and SHAPE into other
sounds. i.e., B sound
Then,bbbbbbbbb=BYE
hhhh=Hi,
As work thru sounds of letters,
ssssssssssss=YES
nnnnnnnnn=No.
Put beginning and ending sounds
together.
Y+S = YES and N+o =No
Importance of Early
Intervention
Minimize negative impact on the child
Prevent situation from becoming worse
Prevent mutism from becoming engrained
Prevent repeated ineffective attempts to

elicit speech
Minimize emotional and physical strain

caused to parents and teachers

When you smile at me,
I learn that I am lovable
When you understand me,
you help me to understand the
world
- Hatkoff, 2007

References
American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition-TR. 4th ed. Washington DC: American
Psychiatric Association, 2000.
American Speech Hearing Association. Web.
<http://www.asha.org/>.
Bergman, RL, ML Keller, J. Piacentini, and AJ
Bergman. "The Development and Psychometric
Properties of the Selective Mutism Questionnaire." J
Clin Child Adolesc Psychol. 37.2 (2008): 456-64.
Bergman, R. L, Piacentini, J., & McCracken, J. T.
Prevalence and description of selective mutism in a
school-sased sample. Journal of the American
Academy of Child & Adolescent Psychiatry - August
2002. Vol. 41, Issue 8, Pages 938-946.
Cleator, H., and L. Hand. "SM: How a Successful Speech
and Language Assessment Really Is Possible.
International Journal of Language and Communication
Disorders 36 (2001): 126-31.
Dunn, L. M., and D. M. Dunn. Peabody Picture
Vocabulary Test. 4th ed. Minneapolis: Pearson, 2007.
Gresham, F., and S. N. Elliott. Social Skills Improvement
System Rating Scales. Minneapolis: Pearson, 2010.
Johnson, M., and A. Wintgens. The Selective Mutism
Resource Manual. Milton Keynes, UK: Speechmark, 2010.
Klein, E., and J. Gordon. "Assessing Communication in
Children with Selective Mutism: Past, Present and Future.
Proc. of --SM Conferences: Assessment and Treatment of
Selective Mutism; Beyond the Basics (2010), Phila., PA.
Kopp S, Gillberg C. Selective mutism: a population-based
study: a research note. J Child Psychol Psychiatry. 1997
Feb;38(2):257262.
Kristensen H. Selective mutism and comorbidity with
developmental disorder/delay, anxiety disorder, and
elimination disorder. J Am Acad
Free Powerpoint Child Adolesc Psychiatry.
Templates Page 74
2000;39(2):249256.
Kristensen, H., and B. Oerbeck. "Is SM Associated with
Deficits in Memory Span and Visual Memory?: An
Exploratory Case-control Study." Depression and Anxiety
23 (2006): 71-76.
Krysanski VL. A brief review of selective mutism literature.
J Psychol. 2003;137(1):2940
Letamendi, A M, DA Chavira, CA Hitchcock, SC Roesch,
E. Shipon-Blum, and MB Stein. "Selective Mutism
Questionnaire: Measurement, Structure and Validity." J
AM Acad Child Adolexc Psychiatry 47.10 (2008): 1197-
204..
Manassis, K., R. Tannock, EJ Garland, K. Minde, A.
McInnes, and S. Clark. "The Sounds of Silence:
Language, Cognition and Anxiety in SM." Journal of the
American Academy of Child and Adolescent Psychiatry
46 (2007): 1187-1195.
McInnes, A., D. Fung, K. Mannassis, L. Fiksenbaum, and
Rosemary Tannock. "Narrative Skills in Children with
Selective Mutism: an Exploratory Study." American
Journal of Speech-Language Pathology, 13.4 (2004):
304-315.
"Roles and Responsibilities of Speech-Language
Pathologists in Schools." ASHA Practice Policy. Web.
<http://www.asha.org/docs/html/PI2010-00317.html>.
Semel, E., E. H. Wiig, and W. A. Secord. Clinical
Evaluation of Language Fundamentals. 4th ed.
Minneapolis: Pearson, 2003.
Sharp WG, Sherman C, Gross AM. Selective mutism and
anxiety: A review of the current conceptualization of the
disorder. J Anxiety Disord. 2006 Aug 30.
Shipon-Blum, E. Selective Mutism-Stages of Social
Communication Comfort Scales. Jenkintown, PA:
Selective Mutism Anxiety Research andTreatment Center,
2006.
Stein, M. B., B. Z. Yang, et al. (2010). A Common Genetic
Variant in the Neurexin Superfamily Member CNTNAP2
Is Associated with Increased Risk for Selective Mutism
and Social Anxiety-Related Traits. Biol Psychiatry, A 2010
Society of Biological Psychiatry. Published by Elsevier Inc
Steinhausen HC, Juzi C. Elective mutism: an analysis of
100 cases. JFree
Am Powerpoint
Acad ChildTemplates
Adolesc Psychiatry. Page 76
1996;35(5):606614

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DIRFloortime in

Assessing and Treating

Joleen R. Fernald, MS CCC-SLP, PhD(c)

Free Powerpoint Templates Page 1

Selective Mutism is the inability to

For example, a child who speaks

oConsistent failure to speak in specific social

DSM-IV TR, 2000

oThe failure to speak is not due to a lack of

oThe disturbance is not better accounted for by a

Free Powerpoint Templates Page 5

Free Powerpoint Templates Page 6

4-7 year-olds .03-.72% England (1975, 1979)

7-8 year-olds 2% Finland (1998)

7-15 year-olds .18% Sweden (1997)

5-8 year-olds .71% California (2002)

1.5-2.6 / 1 female / male Garcia et al

Free Powerpoint Templates Page 8

Free Powerpoint Templates Page 9

Free Powerpoint Templates Page 10

Free Powerpoint Templates Page 11

developmental and interdisciplinary

Free Powerpoint Templates Page 13

describes the developmental

Free Powerpoint Templates Page 14

Two-way Circles of Communication

Shared Attention and Regulation

describes the unique biologically-

Free Powerpoint Templates Page 16

Free Powerpoint Templates Page 17

Free Powerpoint Templates Page 18

Free Powerpoint Templates Page 19

Klein, E, (2010) Selective Mutism Research Institute, Jenkintown,PA

Free Powerpoint Templates Page 29

Free Powerpoint Templates Page 30

describes the learning relationships

Free Powerpoint Templates Page 32

Free Powerpoint Templates Page 33

difficulty initiating and

Free Powerpoint Templates Page 36

Bloom and Tinker, 2001

Selective Mutism Questionnaire* (SMQ)

Always Often Seldom Never

Always Often Seldom Never

Free Powerpoint Templates Page 43

Byers-Brown & Edwards, 1989

Psycho-education (what is SM, etiology,

Free Powerpoint Templates Page 45

Free Powerpoint Templates Page 46

SM is about a fear of the

Free Powerpoint Templates Page 47

Know your client young children may

Free Powerpoint Templates Page 48

(Stage 1 Stage 2):

Free Powerpoint Templates Page 51

Remember to consider responding &

Free Powerpoint Templates Page 52

Free Powerpoint Templates Page 54

Free Powerpoint Templates Page 56

Free Powerpoint Templates Page 59

Free Powerpoint Templates Page 61

Free Powerpoint Templates Page 62

Dr. Elisa Shipon-Blum

Prevent situation from becoming worse