Running head: SELF MODELING & SELECTIVE MUTISM

Intervention Integrity of Self-Modeling for Selective Mutism

EDPS 658 L01
Tina Parsons
Amanda Medland

Running head: SELF MODELING & SELECTIVE MUTISM

Intervention Integrity of Self-Modeling for Selective Mutism

Selective Mutism
Selective mutism, although only recently termed as such, has been identified in
the literature for over a century. In 1877 Adolf Kussmal identified similar features, calling
his findings aphasia voluntaria or voluntary mutism (Dow, Sonies, Scheib, Moss, &
Leonard, 1995; Arshad & Fitzgerald, 2013). Years later, Moritz Tramer changed the label
to elective mutism, as he deemed these children were electing not to speak (Arshad &
Fitzgerald, 2013). In 1994, the Diagnostical and Statistical Manual of Mental Disorders
changed the term from elective to selective creating the foundations and criteria for
what we now know as selective mutism (American Psychological Association, 2013),
launching an increase in literature in the area.
Typically diagnosed upon entry to school and extending until approximately 9
years of age, children with selective mutism appear to be shy, withdrawn, anxious, and
dependent children who have the potential to show oppositional behaviour or tantrums.
(Kehle, Madaus, & Baratta, 1998; Arshad & Fitzgerald, 2013). The absence of speech
must occur for a minimum of 1 month in a particular environment while speech remains
typical in other environments. The lack of speech must not be better explained by a
communication disorder or lack of ability with the language expected in a specific
situation (Cohan, Chavira, & Stein, 2006). This failure to speak will pose interferences in
educational, occupational or social achievements if left untreated (Arshad & Fitzgerald,
2013). The enrollment in school results in the emergence of cases of selective mutism
due to the increased importance of verbal skills, although the diagnosis should not be
made within the first month of school. In addition, it has been recommended that

Running head: SELF MODELING & SELECTIVE MUTISM

children who are bilingual should show signs of mutism across both languages, as well
as symptoms should persist for at least six months in their non-native language (Cohan,
Chavira, & Stein, 2006). Although rare, occurring in less than 1% of referred cases to
clinicians, studies have shown that only 60% receive intervention for their concerns and
the longer duration of the symptoms, the more resistance to intervention typically occurs
(Arshad & Fitzgerald, 2013; Blum et al., 1998).
History has painted a grave picture for those diagnosed with selective mutism,
describing it as intractable and exceptionally resistance to intervention (Dow et al.,
1995; Kehle, Madaus, & Baratta, 1998). This may occur due to the fact that children are
negatively reinforced when teachers or classmates either withdraw requests or allow the
child to rely on prompts or gestures to communicate despite having fully functional
language (Kehle, Bray, & Byer-Alcorace, 2012). Treatments typically take on a
behavioural approach, but have also included cognitive-behavioural therapy, family
therapy interventions, behavioural language training, pharmacological, and
psychodynamic interventions (Cohan, Chavira, & Stein, 2006). The meta-analysis
conducted by Cohan, Chavira, & Stein (2006) concluded that 1) some treatment was
better than no treatment, 2) behaviorally-oriented treatment approaches were better
than no treatment, and 3) two different behavioral models were not differentially
effective in treating children with selective mutism. In the eyes of a behaviourist,
selective mutism is seen as a learned behaviour to fulfill a function, which also means
that the behaviour can also be unlearned. Of particular emerging interest within the
behavioural treatment is self-modeling to increase vocalizations within the previously
mute setting.

Running head: SELF MODELING & SELECTIVE MUTISM

Self-Modeling with Selective Mutism

Self-modeling has the potential to occur through auditory or visual recordings of a
child speaking which can be altered in order to depict the desired behaviours and then
viewed in order to re-learn expectations around certain situations (Kehle, Madaus, &
Baratta, 1998). The expectation is that through repeated exposure, the children will
become comfortable hearing themselves speaking within these settings, and this will
increase their belief in the ability to do so (Cohan, Chavira, & Stein, 2006). Due to
infrequent availability of subjects and the need for tailored interventions, most past
studies have been single-study case designs. Self-modeling is believed to be an
underused technique that is unobtrusive, time and resource friendly, and effectiveness
has been seen in both children with stuttering and selective mutism (Bray & Kehle,
2012). In addition to using self-modeling alone, studies have also shown results when
pairing self-modeling with reinforcement (Cohan, Chavira, & Stein, 2006). Positive
results have been reported almost immediately, but typically occur within a month or so
although it could take longer (Bray & Kehle, 2012).
In order to create the behaviourally desirable recordings for the child to view,
recordings (either video or audio) are taken in a situation where the child still has
functional speech. The child may be asked questions by a parent where they feel safe
to communicate, either in their home or the mute environment with only the parent
present. An adult in the environment will then record the same set of questions where
the selective mutism occurs. These two videos would then be edited together to appear
as if the non-parent adult was asking the questions and the child was answering them
directly (Bray & Kehle, 2012). Research has shown that videos ranging in length from

Running head: SELF MODELING & SELECTIVE MUTISM

one to seven minutes in length have been used to display the expected behaviour to the
child and viewings ranged from twice daily for one week to five times over a period of a
month (Kehle, Madaus, & Baratta, 1998; (Kehle, Bray, & Byer-Alcorace, 2012; Blum, et
al., 1998).
Treatment Integrity of Self-Modeling with Selective Mutism
When looking to address the treatment integrity of self-modeling, the 12 steps outlined
by Upah & Tilly (2002) have been used below.
Behavioural Definition. The classification of selective mutism in itself is
objective, being that it can be heard or not heard. The criteria for selective mutism
provides a clear and complete understanding of the behaviour that is occurring.
Children must experience zero vocalizations for a period of 1 month in a setting during
which vocalizations are expected, and despite having the ability to vocalize in other
settings. This all or nothing definition of selective mutism provides a clear and concise
understanding of the behavioural definition.
Baseline data. In order to identify baseline data for behaviour, it must be
measurable within the natural setting during which behaviour occurs. By using the
behavioural definition to determine the specificities of behaviour, researchers must also
identify how measurement of data should occur prior to collection of data. When looking
at possible dimensions of data, it can be helpful for researchers to consider the acronym
FLITAD; frequency, latency, intensity, topography, accuracy, duration (Upah & Tilly,
2002). In the case of selective mutism, the absence of speech must occur all of the time
within a certain setting, making data recording strictly observational on the part of the
observers within the mute environment. If occasional vocalizations occur, frequency

Running head: SELF MODELING & SELECTIVE MUTISM

data recording could be of benefit, as well as Antecedent-Behaviour-Consequence

(ABC) data to determine what impacts the infrequent vocalizations. Depending on the
study, the professionals may direct specific questions to the child and record responses
or non-responses, or they may gather frequency data within the childs natural setting
without structured involvement from the professional.
Problem validation. In order to identify and validate the problem, baseline data
for the behaviour should be summarized and scrutinized. In order to determine if there
is a discrepancy, data should be compared both to typical age expectations as well as
to the students ability level. Before proceeding with any further steps, professionals
need to determine whether the discrepancies are large enough to support intervention
within the child. In the case of selective mutism, children have expressed vocal abilities
in other situations, while withholding in others. This creates a large discrepancy not only
between typical peers, but within the childs own ability. As stated above, researchers
Cohan, Chavira, & Stein (2006) found that some treatment provided better results than
no treatment, providing support for intervention strategies for children with selective
mutism.
Problem analysis steps. Problem analysis allows the professionals to delve
deep into the behaviour of concern and formulate hypotheses around the behaviour.
Initially, identification of information starts this process, often through structured and
non-structured interviews, observations, and examination of data collected. Since the
child is non-verbal in a particular setting, often times the parents and teachers are the
best source of information on the behaviours that occur. It is also possible to discuss
with the child in a safe setting, although typically with selectively mute children an

Running head: SELF MODELING & SELECTIVE MUTISM

interview with a professional has the potential to elicit the mutism as well. Despite this,
the professional has the opportunity to observe the childs temperament, the ability to
communicate verbally and nonverbally as well as the quality of interactions (Dow et al.,
1995). Information may also be gathered by formalized questionnaires or testing
particularly to rule out or identify comorbid disorders that may be effecting the
vocalizations within the child. Despite gathering of information, many of the studies
addressing selective mutism fail to generate an independent hypothesis of their own,
and piggyback onto the concept that selective mutism results from shyness and
anxieties within a particular setting. Information is typically limited around decisions to
choose one intervention design over another, which is an obvious shortcoming of
research in this area. Development and validation of a hypothesis on why the behaviour
is occurring would serve to help identify children who would potentially respond better to
the varying treatment options to increase vocalizations.
Goal setting. In theory, the goal is created to return children to a vocalization
level that is comparison to their peers, or their ability level in non-mute settings. That
said, any increase in vocalizations is seen as an improvement, whether it be a request
for an object, a comment or any other vocalization that could occur. Based on past
research, some children have shown increase in vocalizations almost immediately,
while others may take several months, so timelines in which to expect results may vary.
Intervention plan development. When developing a treatment plan based off
of the hypothesis of behaviour, it is important to that plan is developed in a way that is
clear enough that another person could replicate the intervention and produce the same
results. As selective mutism interventions are typically single-case studies, these may

Running head: SELF MODELING & SELECTIVE MUTISM

vary from child to child, but it is important to the application of the intervention remains
the same within the childs treatment. Once the video or audio recording is created, it is
important that all professionals involved are aware of the process in which the
recordings are to be viewed. In some cases, the children were to use the recordings 2
times a day for 1 week, and in others the children were exposed to the recordings over
a longer period of a month. This must be outlined specifically within the intervention
plan, as well as the conditions around it. Where should the child be exposed to the
recording? Who should be around for it? What is to occur before or after the recording is
viewed or heard? All of these questions need to be formalized so that consistency is
followed and so that any professional could read the treatment plan and implement the
intervention. For some studies, exposure to the recording was all that occurred, while
others augmented the exposure with the opportunity to vocalize for a preferred treat.
The more complex the treatment intervention the greater the plan development is
needed.
Measurement strategy. Measurement strategies are an important step to
analyze if the intervention is working. The professionals need to know how will data be
collected, if any specific materials are needed, in which settings data is to be collected,
who is responsible, and how often and when data is to be collected. For treatment of
selective mutism, the data will be collected in the setting during which the mutism
occurs and is typically a frequency recording of vocalizations. Some studies have
structured question and answer periods to match the questions observed during the
recordings. Other measurements were less objective and professionals recorded
whether or not vocalizations occurred more naturally.

Running head: SELF MODELING & SELECTIVE MUTISM

Decision making plan. When implementing an intervention it is important to

outline guidelines for decision making once the intervention is underway in regards to
evaluation. The frequency of data collection should have been addressed above, but it
is also important to acknowledge how this data is going to be summarized. How many
data points are sufficient to start analyzing effect? What is the team to do if the data
starts to take on certain patterns? It may also be helpful to identify the procedure when
or if the data starts to represent an unfavorable pattern, and when termination should be
considered in the intervention plan.
Progress monitoring. For more complex interventions, progress monitoring may
involve checklists, observation procedures, percentages, frequency counts, and
permanent products in order to continue to verify the intervention is the correct fit for the
behaviour. When using self-monitoring with children with selective mutism, it is
important to ensure the modeling recordings are being viewed as designed as well as to
check in with the frequency recording of vocalizations within the target setting. This data
can be used for the formative evaluation of the intervention.
Formative evaluation. Throughout the intervention it is essential that the
professionals check in and visually analyze the data, as well as compare this to the
baseline data the child exhibited. This is the period of time where they must assess if
the intervention is working or if it is not. In some studies where researchers counted the
number of words spoken per hour, this would be compared to baseline in order to
develop an opinion on the effectiveness. This step is crucial, as ineffective treatment
options may need to be altered or abandoned altogether. Within the realm of selective
mutism, with the baseline vocalizations most commonly existing at zero, this should no

Running head: SELF MODELING & SELECTIVE MUTISM

10

the more than a simple, quick observation of the data. For more in-depth and complex
interventions, this evaluation may take some careful scrutiny and investigation to ensure
that the treatment plan is well suited and has the potential for effectiveness.
Treatment integrity. In order to determine whether the intervention is effective,
the intervention needs to be implemented as planned. As the recordings are a
permanent product, these remain constant but other aspects of the treatment have the
potential to allow room for error. Unfortunately in many of the studies, the reports
around procedures were absent or lacked the detail to be able to identify proper
implementation or to replicate a similar study. Regardless of whether the interventions
were implemented as planned, there seem to be external factors that make it difficult to
correlate the improvement in vocalizations directly to the self-modeling treatment. Often
times the self-modeling intervention are combined with other behavioural strategies
such as reinforcement or stimulus fading, making it difficult to identify the effect of selfmodeling independently (Cohan, Chavira, & Stein, 2006), as well as parents informally
continue to reinforce and offer rewards for talking.
Summative evaluation. In all simplicity, professionals want to know did the plan
work? Within the scope of selectively mute children, there is either improvement or
there is not. The successful range of this may vary as the children may increase
vocalizations but still remain quiet and withdrawn, or the children may become fully
communicational within the previously mute setting. In the most effective cases,
generalization of the ability to speak occurred even without creation of a new
intervention tape to address a different setting (Blum et al., 1998). In other cases,
viewing of the tapes increased anxiety in the children and had to be terminated. This

Running head: SELF MODELING & SELECTIVE MUTISM

11

could mean that the hypothesis created around the behaviour needs to be revised and
an alternate treatment plan created. If all previous steps are completed correctly, the
professional team should have an idea whether the intervention is increasing
vocalization or not, even before the conclusion of the intervention.
Conclusion
Despite the seemingly effective interventions using self-modeling to increase
vocalizations in selectively mute children, there appears to be areas for growth and
expansion in order to address the integrity of these interventions. Although not typically
possible to move past the single-participant experiments, the lack of descriptions of
diagnostic procedures used and the poor data and outcome measures in most studies
creates difficulty in assessing the efficacy of the intervention. Also due to unknown
influence of other strategies, particularly praise and reinforcement outside of treatment
sessions, the effectiveness of self-modeling independently is difficult to discern. When
looking at the positives, self-modeling allows for a seemingly effective intervention that
is quick, simple to implement and leaves room for variances in application in order to
tailor to each child. As the literature evolves, this intervention leaves room for
improvement, but has created a solid foundation for which to build on with future
research.

Running head: SELF MODELING & SELECTIVE MUTISM

12

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