A Socio-Communication Intervention Model for
Selective Mutism
American Speech-Language-Hearing Association Convention,
Chicago, IL
November, 2003
Suzanne Hungerford, Ph.D., CCC/SLP Plattsburgh State University of New York
Jessie Edwards, M. A., CFY Multilingual Therapy Associates, NY, NY
Alissa Iantosca, B.A. Plattsburgh State University of New York
Theoretical Perspective. The American Psychiatric Association defines selective mutism as a disorder in which a
child does not speak in situations in which speech in normally expected, but speaks normally in other situations
(Diagnostic and Statistical Manual of Mental Disorders-IV-TR, 2000). This definition has led to assessment and
therapy approaches that focus on two variables: absence/presence of speech, and situations, i.e., contexts in which
speech occurs (e.g., Cline & Baldwin, 1994; Drewes & Akin-Little, 2002). Many clinicians, following this bi-variate
approach, have found the treatment of children with selective mutism to be particularly challenging, lengthy, and even
frustrating. Therapy progress may seem slow when speech is the only short- and long-term goal, and improvements in
non-verbal communicative and pragmatic behaviors are not addressed and are not recognized as therapy progress. In
fact, selective mutism, viewed from this perspective, has been described as “particularly treatment resistant” (Krohn,
Weckstein, & Wright, 1992, p.711).
Furthermore, even when treatment models for selective mutism attempt to go beyond the “speech only” approach, and
do include non-verbal behaviors, the behaviors targeted may not be related to communication, as viewed from a sociocommunicative model. For example, Pecukonis and Pecukonis (1991), following a behavioral model, recommended
first training non-verbal attending by reinforcing eye contact following the request “look at me.” Subsequent therapy
targets included behaviors such as clapping, standing, and touching toes which were “gradually shaped through
successive approximations to specific facial movements instrumental in producing speech” (p.10). Interestingly, these
authors conceded that “…it is debatable whether non-verbal imitation training either accentuates or facilitates
generalization to later verbal imitative training” (Pecukonis & Pecukonis, 1991, p.10).
We propose a model for assessment and intervention of selective mutism that comes not from the psychiatric and
operant conditioning literature, but stems from models of socio-communicative development and pragmatics (e.g.,
Baltaxe, 1993; Baltaxe, 1994; Prizant, Wetherby, & Rydell, 2000; Prutting & Kirchner, 1987). This model not only
incorporates speech and situation variables, but takes into account variables related to non-verbal and verbal indicators
of social engagement, which are often deficit in children with selective mutism (e.g., proxemics, kinesics, eye gaze,
non-verbal turn-taking, participation in joint activity routines, nonverbal indicators of joint attention). Other factors we
consider are: alternative methods of communication (e.g., writing), the functions of communication, and
communicative variables on the personal-impersonal continuum. Such a model may provide the clinician with a
method for determining appropriate therapy targets that are not too difficult for the child to achieve, a method for
documenting therapy progress (even before speech emerges), and a model that gives us a better understanding of the
pervasive verbal and nonverbal communicative problems seen in many children with selective mutism.
Overview of Selective Mutism
Possible associated features:
 Excessive shyness (and shyness/anxiety in family)
 Anxiety disorder (social phobia)
 Fear of social embarrassment
 Social isolation and withdrawal
 Compulsive traits
 Negativism
 Temper tantrums
 Controlling or oppositional behavior
 Accompanying (underlying) communication disorder (DSM IV, Cline & Baldwin, 1994)
Less well-documented possible associated features and possible predisposing factors: bilingualism and/or
immigration, familial or geographical isolation, mouth injury, speech/language difference/disorder, hospitalization,
controlling personality, existence of “family secret,” social immaturity, hypersensitivity, aggressiveness, compulsive,
resistant to change, encopresis and enuresis, severe warnings against talking to strangers, marital problems in family,
chaotic family environment, mother aligns with child against father, sibling rivalry, twin, idiosyncratic eating habits
(e.g., only likes a few foods), psychological or physical trauma, child holds self-image as a mute, family members
convey expectation that child will remain mute (Cline & Baldwin, 1994; Hodge, 1998).
Current Thinking: Selective Mutism is a manifestation of an underlying anxiety disorder or social phobia (Schum,
2001).
The way that we think/talk about Selective Mutism affects what how we treat the child and the problem:
We think/say:
Consequence:
“She won’t talk.”

Anger, frustration, a “war of the wills.”
“She can’t talk.”

“How can we enable her to do
what she is not currently able to do?”
Team Management is Essential
Is this a psychological disorder?
Is this a psychiatric disorder?
Yes
Yes
Is this a learning disorder?
Yes
Is this a family problem?
Yes
Is this a communication disorder? Yes
Team member: school psych.
Team member: psychiatrist,
pediatrician
Team member: teachers
Team member: parents
Team member:
speech/language pathologist
Things To Avoid
 begging or cajoling the child to speak
 trying to rationalize with the child
 pressuring the child to speak
 punishing, blaming, isolating, ignoring the child
 drawing a lot of attention to the child when he/she makes a communicative attempt
(may make a shy and anxious child even more uncomfortable) [reinforce in other ways]
 teasing and enabling from peers
Things That Help
 not blaming the child, but viewing the problem as an opportunity to make a very significant difference in a
child’s life
 treating the child as equally as possible to other children
 allowing the child to use any mode of communication possible (but always reinforcing higher levels): picture
exchange, writing, pointing, whispering, drawing
 being patient and calm; not letting your frustration become counterproductive; know that the process may take
6 mo. – 2+ years
 knowing that treatment is often described as “difficult” and one study found that despite treatment, 50% of
cases have not shown major improvement (Steinhausen and Juzi, 1996, cited in Blum, et al., 1998)
 using a social-pragmatic hierarchy in choosing goals; emphasizing social interaction at increasing levels of
complexity
 NEVER GIVING UP
Typical Therapies. Therapies for selective mutism fall into three general categories:
 psychodynamic  behavioral 
psychopharmacologic (e.g., Zoloft)
A combination of therapy approaches may be used, but the research shows that the more effective combinations include
a behavior modification component (e.g., Kehle, et al., 1998). We suggest that combinations of therapies should be
used, but the overall framework for goal selection and intervention should emphasize participation in social
engagement (nonverbal and verbal) at increasingly more difficult levels.
Case Presentation. The case presented is that of a girl, who, when first assessed in the second grade, had never spoken
in school and had never received therapy. When she was referred for assessment, she was not only mute, but the
absence of non-verbal interaction behaviors gave her the appearance of a statue. She walked slowly in the presence of
others, had to be physically maneuvered at times to sit in a chair, made no eye contact, and had very little spontaneous
bodily movement. She did not participate in joint activity routines, did not play in the presence of the clinicians, and
did not participate in any alternative modes of communication presented by the clinicians (picture pointing, picture
exchange, writing, etc.). The severity and pervasiveness of the verbal and nonverbal aspects of her communication
disorder shown in the video clips demonstrate the inadequacies of previous models in describing the communicative
needs of such children.
While borrowing from several previous approaches to therapy that have been reported to have some success, such as
stimulus fading and audio feed-forward (Blum et al., 1998; Kehle et al.,1998), the overall theoretical approach to
intervention was social-pragmatic and emphasized turn-taking, reciprocity, shared focus, and participation in joint
activities. Examples are presented that demonstrate progress in communication/pragmatics, even before speech
emerges, and demonstrate the importance of a socio-communicative approach rather than a “speech only” approach in
selecting treatment targets and measuring therapy progress for children with selective mutism.
Example Goals and Milestones Using a Social-Pragmatic Framework.
NOTE: these are not sequential – they are integrated. I.e., when you change communicative partners or contexts, you
may need to go back to simpler levels in other hierarchies. These are examples based on our case. Therapy goals
should be individualized to meet the social/communicative needs of the child.
Nonverbal participation in joint activities
 Tolerates physical manipulation of arm and hand to “take” objects to take a turn in routine with clinician (e.g.,
“Don’t Spill the Beans”)
 Tolerates physical manipulation of arm/hand to give or take or show objects to another person in order to
participate in game (more social)(e.g., shows cards in Uno game). Fade support.
 Spontaneously moves one arm/hand to participate in routines and games with clinician (first under table, then
on table in view of clinician)
 Spontaneously moves both hands/arms to participate in social routine, activity or game (catches/tosses ball
with 2 hands; holds paper with one hand, draws with other)
 Takes or holds object/toy, manipulates object/toy, gives objects to another person during activity (e.g., water
coloring)
 Takes, gives, or chooses objects needed for social routine on verbal request
 Shows objects to participate in social routine (e.g., shows cards in Uno game)
 Indicates joint attention nonverbally by orienting or looking
 Takes turns and reverses roles in activities
Nonverbal communication
 Reaches for objects to make a choice
 Points to picture or object to make an activity choice
 Circles a word on a page to make an activity choice
 Writes first letter of word to make a choice (first with hand-over-hand manipulation, then with reduced
support, then spontaneous).
 Writes a word to make a choice, answer questions about a story, answer impersonal questions about self, then
personal…
 Shows or gives objects to clinician
 Follows a variety of verbal requests during activities
 Nods yes/no or uses shoulder shrug
 Expresses affect through facial expression
o Smile, lips closed
o Smile, lips open
o Laughing, mouth closed, no voicing
o Laughing, mouth open, no voicing
o Voiced laugh
Production of non-speech sounds, speech sounds and voicing; 1st in non-communicative (but interactive game) contexts
– then shaped into words used for communication.
 Plays toy stringed instrument in “band”
 Plays kazoo in band (uses voice)
 Produces isolated and repeated speech sounds in context of game
o Stop-plosives (e.g., / tΛ tΛ tΛ tΛ / going up the ladder in “Chutes and Ladders” (first voiceless, then
voiced)
o Continuants going down the chutes in “Chutes and Ladders” (first voiceless (e.g., /s:/, then voiced,
e.g,. /z:/)
o Consonant-vowel sequences shaped into functional words (e.g., “no” and “yes”) made in noncommunicative contexts; then used to make choices/answer questions in communicative contexts
 Note: these goals may be achieved through shaping and reinforcement (behavioral techniques) in the context
of interactive (social) routines (often games) using natural reinforcers – a social/pragmatic framework.
Personal-impersonal continuum
 Answers questions about story
 Answers “non-personal” (non-invasive) questions about self , e.g., “What color is your dress?”
 Answers increasingly “personal” questions, e.g., “Do you like carrots?” “What are the names of your
brothers?” “Where did you go on vacation?” “What is the name of your best friend?”
 Answers prepared written questions that are pulled from a basket, then answers questions directly from
therapist
 Asks questions using same hierarchy
 Note: we found this to be an essential variable that significantly influenced performance; it needed to be
systematically addressed.
Context variable: People
 Communicates with
o Clinician, parent, other clinicians, other children, teacher, males and females, familiar and unfamiliar
people
Context variable: Places/situations
 Communicates in
o Therapy room (university), adjacent therapy room
o School library alone with clinician
o School library with librarian in room; with other adults in room; with peers in room; with teacher…
o Classroom with clinician before school
o Classroom with teacher nearby before school
o During school in one-on-one situations; in small groups; in front of class…
Communicative function variables
 Uses communication for:
o Regulating another’s behavior (e.g., request object or action from another person)
o Social interaction (e.g., request comfort, request permission, show off, greet)
o Joint attention (e.g., comment, request information)
Manages conversation appropriately (contexts: barrier games, spontaneous conversations)
 Participates in discourse over multiple turns
 Repairs conversations
 Selects, maintains and terminates topics appropriately
 Takes listener’s perspective
 Takes initiator and responder roles
Other areas of need may include proxemics, kinesics, eye contact, paralinguistics (volume, rate, pitch), and
speech/language if delays are found.
Concluding Remarks. Our case is ongoing. This child has made significant functional gains. She now is very normal
in verbal and nonverbal interactions in many contexts in which she was previously uncommunicative and noninteractive. In the university clinic she communicates and interacts appropriately in and out of the therapy room, with
different therapists, with faculty, and with groups of “strangers” (other speech/language pathology students). In her
school, she communicates normally with the therapist, her teacher, and some peers while in the school library and gym.
In the classroom, she is raising her hand to answer questions with a whisper, she now whispers in small group activities,
and talks using voicing with a few peers in and out of the classroom. She continues to make progress on a daily basis,
and never regresses during therapy breaks.
Controlled research should be done to verify the efficacy of a pragmatic approach in the treatment of selective mutism.
In our case, a pragmatic approach, focusing first on nonverbal indicators of social engagement, presented our client with
goals that she could achieve, formed a foundation for later communication training, and provided us with a method for
documenting clinical growth, even before speech emerged. In addition to a pragmatic emphasis on goal selection and
therapy contexts, we recommend an eclectic approach that includes reinforcement (albeit natural), shaping, stimulus
generalization, etc. Another approach that may be useful as an adjunct to social/pragmatic therapy is the “audio
feedforward” technique that uses audio or video tapes from home to desensitize a child to the sound of their own voice
in contexts in which the child normally does not speak (Blum et al., 1998; Kehle et al., 1998). Therapy techniques
should be chosen on an individual basis according to the needs of the individual with selective mutism.
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