Conquering Challenges of Interprofessional Treatment for Selective Mutism How can school-based SLPs best collaborate with colleagues in treating selective mutism? School Matters
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School Matters  |   August 01, 2017
Conquering Challenges of Interprofessional Treatment for Selective Mutism
Author Notes
  • Suzanne Hungerford, PhD, CCC-SLP, is a professor of communication sciences and disorders at the State University of New York at Plattsburgh, specializing in auditory processing, language acquisition and behavioral disorders in children. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; and 2, Neurogenic Communication Disorders. suzanne.hungerford@plattsburgh.edu
    Suzanne Hungerford, PhD, CCC-SLP, is a professor of communication sciences and disorders at the State University of New York at Plattsburgh, specializing in auditory processing, language acquisition and behavioral disorders in children. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; and 2, Neurogenic Communication Disorders. suzanne.hungerford@plattsburgh.edu×
Article Information
Speech, Voice & Prosodic Disorders / School-Based Settings / School Matters
School Matters   |   August 01, 2017
Conquering Challenges of Interprofessional Treatment for Selective Mutism
The ASHA Leader, August 2017, Vol. 22, 34-35. doi:10.1044/leader.SCM.22082017.34
The ASHA Leader, August 2017, Vol. 22, 34-35. doi:10.1044/leader.SCM.22082017.34
“The school district said it wasn’t the speech department’s job to work with her. The school psychologist refused to see her, so the school counselor worked with her [but] refused any input from me. By the end of the school year she had whispered one word to the teacher … [then she] moved before the next school year.”
—Meghan, a school-based speech-language pathologist
Have you experienced a similar situation to the one described above from a school-based SLP? Selective mutism is a disorder in which a child does not speak in some situations—typically school—but does speak in others, such as at home.
Professional consensus designates anxiety as the core of this disorder, with an array of other variables interacting with anxiety and contributing to the mutism. These variables can include a reticent or withdrawn temperament, second-language learning, environmental stressors and underlying articulation or language disorders.
The disorder’s believed psychological underpinnings, unique social and communication impairments, and negative academic consequences make psychologists, SLPs and teachers logical partners in intervention. Interprofessional collaboration can potentially provide the highest quality of care and improve outcomes for students with this disorder. Before this collaborative treatment can begin, however, interprofessional education must take place. This presents certain challenges for SLPs assessing and treating selective mutism.

Interprofessional teamwork is key to giving students with selective mutism their best chance at successful treatment, while a lack of it can significantly delay identification and treatment.

Educating the team
Interprofessional education—forming the foundation of successful collaboration—involves role clarification. Each team member should understand the potential contributions and responsibilities of everyone on the team. Clarification of an SLP’s role in treating selective mutism can be challenging. Misconceptions still exist about what SLPs do and few outside our profession understand our complex scope of practice. And many professionals still perceive selective mutism as an exclusively psychiatric disorder, so your school faculty might feel treatment lies outside our purview.
Use such an opportunity to teach your colleagues what you do. Draw on ASHA’s 2016 Scope of Practice to help clarify your roles and responsibilities in collaborative intervention for selective mutism. Pragmatic skills, such as language use and social aspects of communication, are listed in our scope of practice. These relate to treating selective mutism, because in addition to anxiety, the disorder involves language use in social contexts—also considered a pragmatic language disorder.
Our scope of practice also includes communication disorders with psychiatric causes. For example, SLPs can address a student’s negative emotions and thoughts related to communication. This is an essential component of cognitive-based interventions for selective mutism. SLPs also provide experience and specialized knowledge about shaping communication behaviors. These skills all contribute to behavior-based interventions for selective mutism.
SLPs can also work to open lines of communication among potential team members. Other professionals respond well to a willingness to share information, leadership and decision-making. Such teamwork is key to giving students their best chance at successful treatment, while a lack of it can significantly delay identification and treatment, making the mutism more difficult to treat.

Numerous studies show behavioral and cognitive—and combined behavioral-cognitive—approaches can effectively treat selective mutism.

Collaborating for treatment
School-based SLPs can also help evaluate a child with selective mutism to offer a more specific treatment approach. For example, an SLP can screen the child’s hearing to rule out hearing loss as a cause. An in-depth pragmatic analysis can document the situations, speakers and communicative contexts that promote and inhibit the child’s speech. The SLP can also evaluate receptive language—if the child can participate in testing that does not require speaking—as well as expressive language and articulation by analyzing audio recordings of speaking samples from home. Once thorough assessments are complete, the SLP can share information and a proposed treatment plan with the entire team.
Good interprofessional team members recognize any limitations in their own knowledge, skills and abilities for a low-incidence case like selective mutism. SLPs can turn to ASHA’s Practice Portal to update their knowledge and improve their team contribution. The Practice Portal page on selective mutism includes information on signs and symptoms, assessment, treatment, and the roles and responsibilities of SLPs for treating this disorder.
The average age at onset of selective mutism ranges from 2 to 5 years, but children often are not diagnosed until they enter school—or even later. Pediatricians and teachers might think the child is just shy. Parents might not realize the extent of a child’s muteness in school, because their child talks at home. Even once identified, students might not receive effective evidence-based treatment and may maintain their mutism into adulthood, leading to a host of social, economic and emotional problems.
Numerous studies show behavioral and cognitive—and combined behavioral-cognitive—approaches can effectively treat selective mutism. Behavioral strategies often include shaping and stimulus-fading. In shaping, SLPs reinforce the student for small steps toward speaking and communicating—pointing, making unvoiced sounds, making voiced sounds, saying nonsense words, and so forth. In stimulus-fading, a stimulus the child associates with speaking—a parent, for example—is brought into the environment in which the child does not speak—typically school—and when the child speaks to the parent at school, the SLP slowly introduces new stimuli. For example, the teacher slowly makes his or her presence known while the child and parent are talking.
Cognitive strategies include “cognitive restructuring”—replacing a child’s negative or fearful thoughts about speaking with more positive thoughts to reduce anxiety and make speaking easier. Cognitive restructuring involves exposure activities, in which the child learns to gain control over their speaking fear through incremental exposure to speaking situations. The combination of cognitive retraining and behavioral exposure aims to help the student manage speaking anxiety and tolerate feared speaking situations.
It’s a hallmark of interprofessional practice for team members to motivate one another, resulting in a cohesive, evidence-based intervention for selective mutism. Interprofessional practice is becoming an expectation in many service-delivery settings. Although collaborative practice has its challenges, it also offers opportunities for professional growth, new and productive partnerships, and improved patient outcomes. In the case of helping children with selective mutism, there is an urgency for professionals to share these responsibilities.
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August 2017
Volume 22, Issue 8