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School Mental Health
DOI 10.1007/s12310-016-9198-8
ORIGINAL PAPER
Reinforce, shape, expose, and fade: a review of treatments
for selective mutism (20052015)
Brittany N. Zakszeski1 George J. DuPaul1
Springer Science+Business Media New York 2016
Abstract Selective mutism (SM) is a rare anxiety disorder
that impairs childrens daily functioning, often during critical
periods of early development. Given that schools are a
common setting for mutism, it is vital that school-based
practitioners are knowledgeable of recent advances in the SM
treatment literature. Unfortunately, the literature base is
comprised primarily of case studies and limited single-case
designs, and no published narrative review has included
treatment studies published after 2005. This review served to
describe the SM treatment approaches, methodologies, and
outcomes of 21 studies published between 2005 and 2015.
Treatments most commonly utilized behavioral and systems
approaches, including behavioral strategies such as contin-
gency management, shaping, hierarchical exposure, and
stimulus fading and systems strategies such as adult skills
training, psychoeducation, and consultation. Although treat-
ments were most frequently provided in schools, they were
most often provided by researchers or clinicians rather than
school-based professionals. Reviewed treatments were gen-
erally effective, although effect sizes were rarely provided. In
general, methodological limitations noted in prior reviews
applied to these studies; however, the presence of random-
ized controlled trials demonstrates efforts to address these
criticisms. Future research directions and implications for
school-based practitioners are described.
Keywords Selective mutism
Context-dependent speech

Childhood anxiety disorders
Treatment
Intervention

Behavior modification
& Brittany N. Zakszeski
brk213@lehigh.edu
1
Department of Education and Human Services, Lehigh
University, 111 Research Dr., Bethlehem, PA 18015, USA
Introduction
The latest edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5; American Psychiatric
Association [APA], 2013) has reclassified selective mutism
(SM) as an anxiety disorder, which is corroborated by the
literature supporting both the role of anxiety as a prominent
symptom in SM as well as similarities in etiology and
treatment between SM and other anxiety disorders (e.g.,
Muris & Ollendick, 2015). SM is characterized by the
consistent failure to speak in specific social situations in
which there is an expectation for speaking (e.g., at school)
despite speaking in other situations (APA, 2013, p. 195).
This context-dependent absence of speech significantly
impairs ones ability to function on a daily basis.
SM is typically a disorder of childhood, with average
age of onset occurring before age 5 (APA, 2013); however,
most cases of SM do not attract attention prior to childrens
entry into school, and instead continue for lengthy periods
of time before entering treatment (Ford, Sladeczeck,
Carlson, & Kratochwill, 1998). School is a context for
mutism for a majority of children with SM (Kehle & Bray,
2009) and is often the setting in which impairment is most
severe (Steinhausen, Wachter, Laimbock, & Metzke,
2006). A child with SM may not speak at all to teachers or
classmates at school, but speak fluently with family
members and friends in the home (Viana, Beidel, &
Rabian, 2009). This absence of speech in the school setting
may result from a need to adjust to new settings and learn
new expectations as well as from anxiety about separating
from parents and initiating social relationships (e.g.,
Crundwell, 2006). Although these types of adjustment and
anxiety may be typical and developmentally appropriate
for children entering new schools, the lack of speech
constitutes a diagnosis of SM when it extends beyond a
123

month, not including the first month in the new school
environment, and when it cannot be accounted for by other
explanations (e.g., limited language proficiency; APA,
2013).
Childrens failure to verbally communicate is critically
concerning, as children who do not interact verbally in the
school environment often exhibit greater difficulty engag-
ing in learning and social activities (Busse & Downey,
2011). Children exhibit higher levels of academic and
social skills development when they engage in high-quality
interactions with their teachers and peers; by contrast,
difficulty engaging in structured learning environments
predicts lower academic outcomes and greater disconnec-
tion from peers (Bulotsky-Shearer, Fantuzzo, & McDer-
mott, 2008). For example, childrens development of
literacy skills is largely dependent on their verbal com-
munications (Phillips, Clancy-Menchetti, & Lonigan,
2008). Absent speech in the early years, when SM is most
prevalent, is particularly harmful considering the degree to
which early learning and social experiences provide the
foundation upon which later competence develops. Given
that spontaneous improvement is rare for SM (Bergman,
Piacentini, & McCracken, 2002), these considerations
point to the importance of effective treatments tailored to
the needs of children with SM to reduce the associated
functional impairment.
To minimize potential detrimental effects of SM on
childrens academic and social development, it is essential
that school-based practitioners are equipped to effectively
intervene with children with SM. As existing helpers
within school environments, professionals such as teachers,
guidance counselors, social workers, and school psychol-
ogists are in good position to develop, implement, and
evaluate school-based treatment programs for students with
SM. In fact, prior studies reported that children with SM
participate in treatments provided by school-based practi-
tioners more than any other type of treatment provider
(Dummit et al., 1997), and that parents find school-based
practitioners the most helpful of treatment providers (Ford
et al., 1998). Unfortunately, however, most school profes-
sionals report limited knowledge about SM and experience
with SM interventions (Kehle, Bray, Byer-Alcorace,
Theodore, & Kovac, 2012). Accordingly, it is critical that
school professionals are informed regarding evidence-
based treatment approaches for SM in order to best serve
their students.
Treatment of SM
As Sanetti and Luiselli (2009) have noted, SM has devel-
oped a reputation of being especially nonresponsive to
intervention (p. 28), due, in part, to such factors as adults
decreasing verbal communication demands and peers
123
School Mental Health
speaking on behalf of children with SM (Kehle & Bray,
2009). The systematic development and evaluation of
treatments for SM have been difficult given that SM is a
relatively rare disorder affecting \1 % of the population
(APA, 2013; Viana et al., 2009). In fact, the SM treatment
literature primarily consists of clinical case studies and
single-case designs (Anstendig, 1998; Cohan, Chavira, &
Stein, 2006), which is problematic when attempting to
generalize results or analyze pooled outcomes.
Published SM treatment evaluation studies have gener-
ally described strategies falling into four different cate-
gories of approaches: behavioral, psychodynamic,
psychopharmacological, and systems (Anstendig, 1998;
Cohan et al., 2006). Behavioral approaches either directly
or indirectly target the underlying function of speech being
withheld (e.g., to escape anxiety or demands, to gain
attention) using strategies stemming from applied behavior
analysis, cognitive behavioral, and/or social learning
frameworks. Definitions and examples of various behav-
ioral strategies are available in Table 1 (see electronic
resources). In contrast, approaches that are psychodynamic
in nature attempt to understand the origins of SM in the
childs unconscious and commonly employ techniques
such as play and art therapies. Psychopharmacological
approaches provide medication to ameliorate SM symp-
toms, and systems approaches are those that target the
knowledge, skills, and/or behavioral patterns of individuals
significant to children with SM (e.g., families, school
personnel, peers) with techniques such as psychoeducation,
consultation, adult skills training, and cross-setting com-
munication. This focus on systems approaches and depar-
ture from family approaches (i.e., a term used in prior
reviews; Anstendig, 1998; Cohan et al., 2006) acknowl-
edges (a) the prominent roles that individuals and envi-
ronments play in shaping a childs experiences
(Bronfenbrenner, 1979) as well as (b) growing attention to
the importance of familyschool collaboration in address-
ing childrens mental health needs (e.g., Auster, Feeney-
Kettler, & Kratochwill, 2006).
In general, behavioral treatments have been recom-
mended as the treatment of choice for SM (e.g., Viana et al.,
2009). A meta-analysis of 114 SM treatment studies (Pio-
nek Stone, Kratochwill, Sladezcek, & Serlin, 2002) indi-
cated that behavioral interventions for SM are more
effective than no treatment at all; however, outcome com-
parisons among various SM treatment approaches were
unattainable due to a lack of quantifiable data reported in
studies with non-behavioral treatment approaches. The
limitations of large-scale meta-analyses (e.g., non-com-
prehensive effect size comparisons and incorporation of
limited descriptions of reviewed treatments; as demon-
strated by Pionek Stone et al., 2002) compel the need for
reviews that narratively describe the SM treatment literature
School Mental Health

Table 1 Definitions and examples of common behavioral strategies for selective mutism
Strategy Definition Example

Cognitive Teaching the child to identify and challenge maladaptive Supporting the child in identifying his or her reason for not
restructuring thoughts and reasoning speaking and in understanding how withholding speech
may not be rational in the context of this reason
Contingency Providing positive reinforcement for appropriate behaviors Offering the child praise, tangible reinforcers (e.g., sticker),
management (e.g., verbalizations) or activity reinforcers (e.g., iPad time) for speaking
Defocused Providing opportunities for communicating in a way that is Avoiding eye contact, sitting beside rather than across from
communication comfortable to the child the child, maintaining distance between self and the child
Goal setting Identifying, communicating, and supporting behavioral Collaborating with a child to have him or her establish a goal
goals, often in a progressive fashion for speaking (e.g., speaking with one peer during a
classroom activity) and helping the child identify what will
need to occur for that goal to be met
Hierarchical Developing a gradient of feared situations and having the Having the child practice speaking in the classroom (a) to the
exposure child encounter each situation sequentially beginning with teacher with the parent present, (b) to the teacher with the
the least feared and ending with the most feared parent in the hallway, (c) to the teacher alone, (d) to the
teacher and a student, and (e) to the teacher and his or her
class
Modeling Displaying the desired behavior; in self-modeling, having the Video-recording a child speaking in a classroom with his or
child repeatedly view him or herself enacting the desired her parent, and then playing this recording for the child to
behavior observe
Priming Allowing the child to preview an activity or expectation prior Informing the child that you will ask him or her to answer a
to its occurrence certain question during large-group instruction
Prompting Using verbalizations or gestures to encourage enactment of a Calling on a child to speak; pointing to your ear to encourage
target behavior the child to speak or to speak at a louder volume
Role-playing Creating a scenario and having the child take on a role in the Asking the child to practice speaking to you as if you were a
scenario in order to practice a desired behavior classmate
Shaping Reinforcing progressive approximations of a behavior (e.g., Offering the child praise, tangible reinforcers (e.g., sticker),
volume or frequency of verbal response) or activity reinforcers (e.g., iPad time) for mouthing a
response
Social skills Teaching the child skills to use in interpersonal situations Instructing the child on how to initiate an interaction with a
training peer or how to ask the teacher for help
Stimulus fading Gradually transitioning a comfortable context into a feared Incrementally increasing the number of people present or
situation reducing the distance at which people are located when the
child is speaking

to assist practitioners in identifying evidence-based inter-
ventions that appear promising for use with their clientele as
well as in understanding the features and strategies of these
interventions for effective implementation.
Syntheses of the SM Treatment Literature
Previously, Standart and Le Couteur (2003) as well as
Viana et al. (2009) provided descriptive overviews of the
broader SM literature, including a summary of select
treatment evaluation studies. In addition, Anstendig (1998)
and Cohan et al. (2006) provided narrative reviews specific
to the treatment of SM. In her review of 24 treatment
studies published between 1980 and 1996, Anstendig
identified differences in the ways that the various approa-
ches conceptualized and targeted SM, concluding that
treatment success may be more closely connected to the
clinicians thorough assessment of the treated childs his-
tory, present environment, and personal and familial
dynamics than the treatment modality (p. 390). Cohan
et al. (2006) reviewed 23 treatment studies published
between 1990 and 2005, and concluded that behavioral/
cognitive-behavioral interventions were the best supported
treatment modality. Further, Cohan and colleagues identi-
fied four substantial limitations of the SM treatment liter-
ature base, including a lack of (a) widely used assessment
techniques, (b) group-design treatment studies with control
groups, (c) standardized treatments and treatment integrity
reporting, and (d) guidance as to which specific treatment
strategies are most effective.
The narrative literature reviews offer necessary and
meaningful contributions by synthesizing the procedures
and conclusions of the literature on a particular topic
(Baumeister & Leary, 1997). Because no narrative reviews
have been conducted for SM treatment studies published
after 2005, it is unclear whether the SM treatment literature
is still subject to the limitations identified in the prior
reviews of Anstendig (1998) and Cohan et al. (2006).

123

Given, for example, ongoing developments in the con-
ceptualization (e.g., Muris & Ollendick, 2015) and
assessment (e.g., Cohan et al., 2008) of SM, efforts to
narratively review the SM treatment literature should be
conducted on an ongoing basis to synthesize recent findings
and trends and thereby best inform practice. Results of such
a narrative review can be used to identify important future
research directions as well as to develop evidence-based
recommendations for practice.
Purpose of Review
This review serves to expand upon those of Anstendig
(1998) and Cohan et al. (2006) by identifying and sum-
marizing SM treatment studies published between 2005
and 2015; examining these studies to describe their treat-
ment approaches, strategies, settings, and providers as well
as study designs, sample characteristics, and outcome
measures; and synthesizing findings to describe the evi-
dence base of SM treatments. Specifically, this review
sought to summarize identified studies with relation to the
following questions. For SM treatment studies published
between 2005 and 2015: (1) What treatment approaches
and strategies were incorporated? (2) In what settings and
through what types of providers were treatments imple-
mented? (3) What were the characteristics of the treatment
samples? (4) What study designs and methodologies were
used? (5) What outcome measures were used and types of
outcomes were yielded? By describing the recent SM
treatment literature in this manner, we aimed to follow the
lead of Anstendig (1998) and Cohan et al. (2006) by dually
(a) identifying the strengths and weaknesses of recent SM
treatment studies as well as (b) supplying practitioners with
foundational knowledge to enhance development and
implementation of SM interventions.
Method
Article Selection
Empirical studies of SM treatment strategies published
between 2005 and 2015 were located in July 2016 using the
PsycINFO, ERIC, PubMed, and Web of Science databases.
The [keyword (PsycINFO, ERIC), text word (PubMed), or
topic (Web of Science)] search terms selective mutism
AND (treatment OR intervention OR therapy) were used to
provide a pool of, 168, 48, 95, and 139 potential articles,
respectively. This pool was then refined by narrowing
results to peer-reviewed journal articles published in Eng-
lish between 2005 and 2015, and in databases for which it
was possible, limiting results to only those studies with
child participants.
123
School Mental Health
For the 71 (PsycINFO), 31 (ERIC), 35 (PubMed), and 50
(Web of Science) nonexclusive articles that remained on the
databases, article titles, abstracts, and text were scanned to
consider their relevance to the current review according to
the following pre-established criteria: (a) examined treat-
ment outcomes specific to SM, (b) reported original out-
come data (i.e., reviews and meta-analyses were excluded)
with visual or statistical analysis results or reported out-
come data in such a way that treatment effects could be
visually or statistically analyzed (e.g., case studies pro-
viding only narrative descriptions were excluded), and
(c) included samples of children ages 12 years and younger
who were identified with a primary diagnosis of SM or
whose provided information indicated that they otherwise
met DSM-5 SM criteria (APA, 2013) prior to beginning
treatment, with no other profound developmental or intel-
lectual disability noted.1 This method identified 19 studies
to be included in the review, including one study (Lang
et al., 2016) that was published online in 2015 and in print
in 2016. Reference lists of the articles located through the
database search were also examined in order to identify
other relevant citations, yielding two additional studies, for
a total of 21 studies.
Article Coding
The 21 included studies were double-coded by an advanced
doctoral student (the first author) and an undergraduate
research assistant for the following set of variables: par-
ticipant characteristics (study sample size; participant age,
gender); intervention context (setting, intervention agent);
data collection procedures (study design, dependent vari-
ables, measurement of treatment integrity and social
validity); and treatment features (approach and strategies).
Operational definitions for all coded variables are available
upon request from the first author.
Treatment approaches included behavioral, psychody-
namic, psychopharmacological, and systems (Cohan et al.,
2006). Treatment strategies were broken down for a variety
of behavioral strategies (see Table 1); for art and play
therapies under the psychodynamic approach; and, under
the systems approach, for communication of progress (i.e.,
ongoing open communication between parties and collab-
oration in meeting treatment goals; e.g., home-school
notes), consultation (i.e., problem-solving process aiming
1
All but two included studies reporting SM diagnoses referenced the
use of DSM-IV-TR rather than DSM-5 criteria (APA, 2000; the
exceptions being Conn & Coyne, 2014 and Mayworm, Dowdy,
Knights, & Rebelez, 2015) due to the DSM-5 not being published
until 2013; however, no changes in the diagnostic criteria were made
from DSM-IV-TR to DSM-5 aside from SMs reclassification as an
anxiety disorder. Accordingly, the latest edition of the DSM was
consulted for diagnostic considerations as a best practice.
School Mental Health
to enhance the supports and services for a child with SM
and connected parties), parent/teacher skills training (i.e.,
directly targeting the skills and/or practices of adults con-
nected to a child with SM), and psychoeducation (i.e.,
teaching parties connected to the child about the needs and
challenges of the child with SM). Multiple treatment
approaches and/or strategies were coded for the same study
when they were described as being implemented separately
for comparison or together in a treatment package.
Inter-coder reliability in the form of percentage agree-
ment was calculated by dividing the number of articles for
which the coders agreed on each variable by the total
number of articles reviewed by both coders (i.e., all 21)
with the result multiplied by 100 %. Initial agreement
levels were 100 % across participant characteristic vari-
ables and ranged from 95.2 % (intervention agent) to
100 % (setting) for intervention context categories, from
95.2 % (measurement of treatment integrity) to 100 % (all
other variables) for data collection procedure categories,
and from 90.5 % (cognitive restructuring, defocused
communication, hierarchical exposure) to 100 % (treat-
ment approach; multiple strategies) for treatment features,
such that disagreements were found for no more than two
studies per coded variable. For categorical variables,
Cohens kappa was also computed as a more stringent
measure of inter-coder agreement (Kazdin, 1982). Across
variables, this coefficient averaged .94 and ranged from .74
(defocused communication) to 1.00 (all participant char-
acteristic, setting, study design, dependent variables, and
treatment approach categories; multiple treatment strate-
gies), indicating moderate to strong agreement, but strong
overall agreement, according to the criteria of Landis and
Koch (1977) and Altman (1991). The two coders resolved
disagreements by rereading the studies and discussing the
codes provided, which resulted in a final agreement level of
100 % (j = 1.00) for all coded variables.
Results
Characteristics of the samples, treatments, designs, and
outcomes of the 21 included studies are described in
Table 2. Identified articles are summarized according to
the specific guiding questions previously posed.
What Treatment Approaches and Strategies Were
Incorporated?
Of the reviewed studies, eight (38.10 %) incorporated one
treatment approach (i.e., behavioral for n = 7, psy-
chopharmacological for n = 1), 12 (57.14 %) incorporated
two approaches (i.e., all combinations being behavioral and
systems), and one (4.76 %) incorporated three approaches
(i.e., behavioral, psychodynamic, and systems). A behav-
ioral approach was incorporated in all but one study
(95.24 %; in Manassis & Tannock, 2008, the information
provided was inadequate to categorize the therapeutic
approaches). Some behavioral strategies were more com-
mon than others. Contingency management was incorpo-
rated in 19 studies (90.48 % of all reviewed articles),
shaping was used in 12 (57.10 %), hierarchical exposure
was used in 10 (47.62 %), and stimulus fading was used in
9 (42.86 %). Other behavioral strategies reviewed included
goal setting and cognitive restructuring (respectively,
n = 6 studies, 28.57 %); prompting (n = 5, 23.81 %);
defocused communication, modeling, and social skills
training (respectively, n = 4 studies, 19.05 %); and prim-
ing and role-playing (respectively, n = 2, 9.52 %).
Systems was the second most common approach,
incorporated in 11 studies (52.38 %). Of these, seven
(63.64 %) used skills training, six (54.55 %) provided
psychoeducation, four (36.36 %) provided consultation,
and two (18.18 %) embedded cross-setting communication
into treatment. In addition, all studies incorporating sys-
tems approaches included parents in treatment, and all but
one (n = 10, 90.91 %) also incorporated school personnel.
Only three studies (14.29 %) incorporated psychopharma-
cological approaches, with Manassis and Tannock (2008)
evaluating fluoxetine and sertraline, and Plener, Gatz,
Schuetz, Ludolph, and Kolch (2012) and Ooi, Raja, Sung,
Fung, and Koh (2012) separately evaluating fluoxetine
only. Finally, the psychodynamic approach was found in
just one reviewed study, as Jackson, Allen, Boothe, Nava,
and Coates (2005) incorporated psychodynamic play ther-
apy strategies in a multimodal treatment.
In What Settings and Through What Types
of Providers Were Treatments Implemented?
Treatments were implemented in one setting for 15 studies
(71.43 %), in two settings for five [23.81 %; combinations
being school and home (n = 3), clinic and school (n = 1),
and clinic and home (n = 1)], and in three settings (clinic,
school, and home) for one (4.76 %). The most common
treatment setting was school (n = 12, 57.14 %), followed
by clinic (n = 9, 42.86 %), then home (n = 6, 28.57 %),
and community (n = 1, 4.76 %). Similarly, one type of
provider primarily delivered the treatment in 17 studies
(80.95 %), and two types delivered the treatment in three
studies [14.29 %; combinations being clinician/experi-
menter and school personnel, family, or computer (n = 1,
respectively)]. The most common treatment provider was a
clinician or experimenter (i.e., individual employed by a
setting such as a clinic, healthcare setting, or university/
research center who was not employed or contracted by the
childs school) (n = 17, 80.95 %), followed by school
123
 Table 2 Treatment studies for selective mutism: 20052015
Investigators Approach and treatment strategies Setting and Sample Design Outcome measures Outcomes
interventionist

123
Beare et al. Behavioral School: EBD N = 1, Single-case: multiple baseline Number of verbal A functional relationship was
(2008) Contingency management, classroom, 12 years, (ABB) responses and rate of demonstrated for both increased
prompting, stimulus fading study room, male words spoken verbal responses and increased rate
general of words spoken.
education
classroom
General education
teacher, special
education
teacher,
paraprofessional
Bergman Behavioral, systems Clinic N = 21, 4 Group: RCT with treatment SMQ, SSQ, SASC-P/T, Both parent and teacher reports
et al. (2013) Contingency management, goal Ph.D.- or 8 years, versus WLC (analyzed with SNAP revealed significant improvements
setting, hierarchical exposure; Masters-level gender not mixed factorial ANOVAs) in verbalizations.
parent skills training therapists provided
Conn and Behavioral Head Start N = 1, Case study: pre-/post-tests (no CBCL/1.55 (PRF, TRF) Maternal and teacher ratings that
Coyne Contingency management, preschool 3 years, analyses reported) indicated significant concern at
(2014) hierarchical exposure, shaping, classroom male baseline (e.g., pervasive
social skills training, stimulus Clinical developmental problems,
fading psychology withdrawn, somatic complaints)
graduate student were all at subclinical levels post-
treatment.
Howe and Behavioral, Systems Head Start N = 1, Single-case: AB Social interactions, Each outcome variable was found to
Barnett Contingency management, preschool 4 years, initiating conversation have a greater mean and increased
(2013) prompting, shaping; consultation classroom male with teacher/peer, slope (also increased initial effect
Two classroom multi-word phrases for initiating conversation with
teachers peer, and increased initial effect
and no overlapping data for social
interactions) in the treatment
condition.
Jackson et al. Behavioral, Psychodynamic, Clinic N = 1, Case study: pre-/post-testing Interactions with therapist Significant increases were observed
(2005) Systems Therapist 6 years, (analyzed with paired coded using CSC-SM in vocal/verbal behaviors.
Cognitive restructuring, contingency male t tests)
management, goal setting,
hierarchical exposure; play
therapy; consultation
Kern et al. Behavioral Teacher N = 2, 11 Single-case: changing Independent and Significant increases were observed
(2007) Contingency management, priming, General (male) and criterion design prompted vocal in independent vocalizations across
prompting education/ 13 years responses intervention and maintenance
special (female)a phases.
education
classrooms
School Mental Health
 Table 2 continued
Investigators Approach and treatment strategies Setting and Sample Design Outcome measures Outcomes
interventionist

Lang et al. Behavioral Community N = 1, Single-case: multiple baseline Prompt, audible verbal Increases in responses and initiations
(2011) Contingency management, Therapist 9 years, design across three social responses; verbal as well as decreases in
female situations initiations; communication breakdowns were
School Mental Health

modeling, role-playing
communication observed.
breakdowns
Lang et al. Behavioral, Systems Clinic N = 24, ages Group: pre-/post-test design ADIS-IV, CGI, SMQ At a 2-year follow-up, participants
(2016) Cognitive restructuring, contingency Therapist 312 years maintained their treatment
management, hierarchical at baseline, improvement, and most (84 %) no
exposure, modeling, shaping, gender not longer met DSM-IV-TR criteria for
stimulus fading; parent available SM.
psychoeducation, parent skills
training, parent/teacher
communication
Manassis and Psychopharmacological Varied: home, N = 17, Group: medication only SMQ, CGAS Children taking SSRIs showed
Tannock SSRI (fluoxetine for n = 8, clinic/private mean age (n = 6) versus therapy only greater improvement in scores on
(2008) sertraline for n = 2) or any type of practice of (n = 6) versus both (n = 4) the CGAS and SMQ school and
therapy (i.e., psychotherapy or Varied: 7.83 years, versus neither (n = 1); other scales. No significant
speech language therapy, neither psychiatrist, 12 female pre-/post-testing (analyzed differences were found related to
further described) psychologist, with paired t tests) nonmedicated intervention.
speech therapist
Mayworm Behavioral General education N = 1, Case study: pre-/post-test Non-verbal and verbal Increased levels of responding and
et al. (2015) Contingency management, classroom 6 years, design responses and initiations initiations as well as increased
hierarchical exposure, shaping, School female across settings levels of verbal relative to non-
stimulus fading psychology verbal responding and initiations
graduate were observed.
student,
classroom
teacher
Mitchell and Behavioral, Systems Clinic, then home N = 4; 5, 6, Single-case: combined series Number of words spoken A statistically significant response
Kratochwill Contingency management, shaping, and school 7, 10 years; multiple baseline design coded using the speech rate was observed for the
(2013) stimulus fading; consultation Clinician, parent, 2 female across participants RBOCSM, CBCL, TRF treatment phase compared to
teacher (analyzed with baseline. Child anxiety as reported
nonparametric on the CBCL and TRF did not
randomization tests) change significantly over the
course of the treatment.
OReilly et al. Behavioral School resource N = 2, 5 and Single-case: multiple baseline Audible vocalizations Significant effects were
(2008) Contingency management, room 7 years, design across participants demonstrated by immediate and
modeling, priming, prompting, Educational female dramatic changes in vocalization
role-playing, social skills training psychology levels, which were maintained at a
graduate 3-month follow-up.
student, teacher

123
 Table 2 continued
Investigators Approach and treatment strategies Setting and Sample Design Outcome measures Outcomes
interventionist

123
Oerbeck et al. Behavioral, Systems Home, then N = 7, Group: pre-/post-tests SSQ, SMQ, CBCL/1.55 Increased verbalizations following
(2012) Contingency management, school 35 years, (analyzed with repeated (PRF, TRF), CGI, intervention implementation were
defocused communication, goal classroom 5 female measures ANOVA) Speaking level found at both 3 and 6 months post-
setting, shaping, stimulus fading; Therapist implementation. The parent-rated
psychoeducation, parent/teacher SMQ confirmed data from the SSQ.
skills training
Oerbeck et al. See Oerbeck et al. (2012) See Oerbeck et al. N = 24, Group: RCT with treatment SSQ, SMQ Intervention effects for speech
(2014) (2012) 39 years, versus WLC (analyzed with production were demonstrated by a
16 female mixed effects models) significant time-by-group
interaction for SSQ scores as well
as SMQ scores.
Oerbeck et al. See Oerbeck et al. (2012) See Oerbeck et al. See Oerbeck See Oerbeck et al. (2014) See Oerbeck et al. (2014) At 1-year follow-up of Oerbeck et al.
(2015) (2012) et al. (2014), no significant decline of
(2014) effects was found; rather,
significant increases in scores were
found on both the SSQ and SMQ.
Ooi et al. Behavioral, Psychopharmacological Home N = 5; 6, 8, Case study: pre-/post-test SMQ Post-treatment, three participants had
(2012) Cognitive restructuring, social skills Computer, 9, 10, higher SMQ-Total scores; four had
training; SSRI (1020 mg psychiatrist 11 years; 4 higher SMQ-Home/Family scores;
fluoxetine) female three had higher SMQ-Public/
Social scores; and one had a higher
SMQ-School score, with higher
scores representing more frequent
speech.
Plener et al. Behavioral, Psychopharmacological Clinic N = 1, Single-case: AB design ESKM, GAF Across 8 months of treatment,
(2012) Contingency management, Therapist 7 years, ESKM scores (of SM symptoms)
hierarchical exposure; SSRI female decreased from 33 to 12, and the
(10 mg fluoxetine) participant began speaking with
more individuals.
Reuther et al. Behavioral, Systems Clinic N = 1, Single-case: AB design CBCL, TRF, MASC, fear CBCL, TRF, and MASC ratings
(2011) Cognitive restructuring, contingency Therapist 8 years, hierarchy ratings were nonclinical by Session 11.
management, hierarchical male Fear hierarchy ratings decreased
exposure, shaping social skills across sessions. Treatment gains
training; psychoeducation were maintained at 6 months post-
treatment.
Sanetti and Behavioral, Systems School classroom N = 1, Single-case: changing Number of words spoken The child spoke more words and
Luiselli Contingency management, goal and office 8 years, criterion design and frequency of more frequent verbalizations across
(2009) setting, hierarchical exposure, Teachers female verbalizations across the intervention.
shaping, stimulus fading; parent goal levels
communication (school-home
notes)
School Mental Health
 Table 2 continued
Investigators Approach and treatment strategies Setting and Sample Design Outcome measures Outcomes
interventionist

Sharkey et al. Behavioral, Systems Clinic N = 5; 5 Group: Pre-/post-testing CGI, CGAS, SDQ, SMQ, Significant improvements were
(2008) Cognitive restructuring, contingency Three child (n = 2), 6 (analyzed using t tests) CRS, SCAS, clinician found for all outcome measures
(n = 2), ratings of verbal and analyzed with large effect sizes
School Mental Health

management, defocused psychiatrists

communication, hierarchical and one speech and non-verbal observed.
exposure, shaping; parent and language 8 years; communication,
psychoeducation and skills training therapist female initiation, and confident
speaking
Vecchio and Behavioral Clinic, school N = 9; 4 to Single-case: alternating Words spoken per day in Eight children met criteria for
Kearney Treatment A: settings 9 years, treatment design public, CBCL, TRF positive end-state functioning for
(2009) Therapists, mean age: (ABBABAAB for n = 5, words spoken. CBCL and TRF
Hierarchical exposure, modeling,
Parents 6.6 years; 7 BAABABBA for n = 4) scores generally improved and
prompting, shaping
female Group: pooled remained stable at 3-month follow-
Treatment B: Contingency up
baseline ? average
management
treatment data point Children displayed significantly
(analyzed with three paired- greater speech during Treatment A
sample t tests) than Treatment B based on child,
parent, and teacher reports.
a
Participant was included in review despite not meeting the age criterion because she participated in a similar intervention and displayed similar outcomes to the other participant, who did meet
the age criterion
ADIS-IV Anxiety Disorders Interview Schedule for DSM-IV for Children and Parents, CBCL child behavior checklist, CBT cognitive-behavioral therapy, CGAS Childrens Global Assessment
Scale, CGI Clinical Global Impression Scale, CRS Communication Rating Scale, CSC-SM communication skills checklist-selective mutism, EBD emotional and behavioral disorders, ESKM
Evaluationsbogen fur das Sozialinteraktive Kommunikationsverhalten Bei Mutismus, GAF global assessment of functioning, IBTSM integrated behavior therapy for selective mutism, IE
independent evaluator, MASC Multidimensional Anxiety Scale for Children, PRF parent report form, RCT randomized controlled trial, SRBOCSM revised behavioral observation code for
selective mutism, SASC-P/T Social Anxiety Scale for Children-Revised, Parent and Teacher Versions, SCAS Spence Childrens Anxiety Scale, SDQ Strengths and Difficulties Questionnaire,
SMQ Selective Mutism Questionaire, SNAP strong narrative assessment procedure, SSQ School Speech Questionnaire, SSRI selective serotonin reuptake inhibitor, TRF teacher report form,
WLC wait list control group

123

personnel (i.e., individuals who were employed or con-
tracted by the childs school such that they were available
for consultation on an ongoing basis in the school envi-
ronment) (n = 6, 28.57 %), parent (n = 2, 9.52 %), and
computer (n = 1, 4.76 %).
What Were the Characteristics of the Treatment
Samples?
Excluding a follow-up study (Oerbeck, Stein, Pripp, &
Kristensen, 2015) that provided data on 24 children for
whom data were previously reported (Oerbeck, Stein,
Wentzel-Larsen, Langsrud, & Kristensen, 2014), 129
children were included in the 20 presumably non-over-
lapping samples. Sample sizes ranged from 1 (n = 9) to 24
(n = 3), with a rounded mean of 7 children and median of
2 children. For single-case designs, samples ranged from 1
to 9, with a rounded mean of 2 children and median of 1
child; for group designs, samples ranged from 7 to 24, with
a rounded mean of 20 children and median of 23 children.
In 18 of the 21 studies, child participants were not
described as having been diagnosed with any psychiatric
disorder or disability other than SM. By contrast, Bergman,
Gonzalez, Piacentini, and Keller (2013) reported that par-
ticipants had an average of 2.38 diagnoses but did not
describe the comborbid diagnoses. In addition, Vecchio and
Kearney (2009) listed secondary diagnoses of social phobia
for all nine participants (100 %); of separation anxiety
disorder for two participants (22.22 %); and of attention-
deficit/hyperactivity disorder, enuresis, generalized anxiety
disorder, and oppositional-defiant disorder for one partici-
pant, respectively (11.11 %). Finally, Lang et al. (2016)
reported that, at baseline, all 24 original participants
(100 %) had a comorbid diagnosis of social anxiety disorder
and 11 (45.8 %) had a comorbid diagnosis of specific pho-
bia, with less prevalent comorbidities including enuresis,
attention-deficit/hyperactivity disorder, night terrors, sepa-
ration anxiety disorder, oppositional-defiant disorder, panic
disorder, and dysthymia (precise statistics not available).
Consistent with the article selection procedures, partic-
ipant ages at time of treatment ranged from 3 to 12, except
for one participant, aged 13, who was included in a study
with an 11-year-old participant (Kern, Starosta, Cook,
Bambara, & Gresham, 2007). Most children fell between
the ages of 3 and 8, though inconsistent reporting across
articles, such as only providing an age range, limited the
degree to which age could be further analyzed descrip-
tively. Participants were more often female (n = 79,
61.24 %) than male (n = 50, 38.76 %). For the 83 partic-
ipants in 13 studies (61.90 %) for whom ethnicity infor-
mation was provided, 28 (33.73 %) were European/
European American, 18 (21.69 %) were Middle Eastern,
11 (13.25 %) were Asian/Asian American, seven (8.43 %)
123
School Mental Health
were biracial, five (6.02 %) were Hispanic/Latino(a), one
(1.20 %) was African American, and 13 (15.66 %) were
described as being of an other or unspecified ethnic-
ity. In addition, eight studies (38.10 %) reported informa-
tion related to participants socioeconomic status. Four of
these studies (50.00 %, n = 55 participants) reported
average parental educational attainment levels falling
between high school diploma and some college education.
Three studies (37.50 %, n = 4 participants) reported par-
ticipants as coming from low-income or socially disad-
vantaged backgrounds, and one study (n = 9 participants)
specifically reported a mean household income of just
under $68,000.
What Study Designs and Methodologies Were Used?
Four studies (19.05 %) were case studies using pre- and
post-testing to evaluate outcomes. Of the nine studies
(42.86 %) employing single-case designs, only two (22.22,
9.52 % of all reviewed articles; Beare, Torgerson, & Cre-
viston, 2008; Vecchio & Kearney, 2009) utilized a design
capable of demonstrating functional control (i.e., estab-
lishing a consistent effect of the treatment on the outcomes;
Cooper, Heron, & Heward, 2007). Eight studies (38.10 %)
incorporated group designs, with three of these (37.5,
14.29 % of all reviewed articles; Bergman et al., 2013;
Oerbeck et al., 2014, 2015) being randomized controlled
trials (RCTs). Ten of the 21 studies (47.62 %) used sta-
tistical analyses, with five (50, 23.81 % of all reviewed
articles) using a t test or a form of ANOVA, respectively,
and one (10, 4.76 % of all reviewed articles) using a
nonparametric randomization technique to analyze single-
case data. In addition, only six studies (28.57 %) reported
treatment integrity and social validity data, respectively.
What Outcome Measures Were Used and Types
of Outcomes Were Yielded?
Among the various outcome measures used in the reviewed
studies, the most common was some form of observed
verbal response or initiation (n = 12, 57.14 %). Rating
scales were also used to evaluate treatments either on their
own (n = 9, 42.86 %) or in combination with observa-
tional data (n = 4, 19.05 %). Common rating scales rep-
resented included the Selective Mutism Questionnaire
(SMQ; Bergman et al., 2008; n = 7, 33.33 %), ASEBA
preschool- or school-age parent- and teacher rating scales
(Achenbach & Rescorla, 2000, 2001; n = 5, 23.81 %), and
the School Speech Questionnaire (SSQ; Bergman et al.,
2001; n = 4, 19.05 %).
All reviewed studies provided data reflecting promising
treatment effects, with a range of functional control or sta-
tistical significance evidence for a variety of outcomes (e.g.,
School Mental Health
observed verbal and social behaviors; child-, parent-, and
teacher-reported speech behaviors and anxiety symptoms).
Effect sizes were reported in just four of the 21 studies
(19.05 %). Bergman et al. (2013) reported a partial eta-
squared value of .50 for both SMQ and SSQ scores, and
Oerbeck, Johansen, Lundahl, and Kristensen (2012) repor-
ted eta-squared values of .782 and .965, respectively, for
SSQ score improvement at 3 and 6 months. Sharkey,
McNicholas, Barry, Begley, and Ahern (2008) reported
effect sizes for several observational and rating scale mea-
sures, with Cohens d values ranging in magnitude from
.409 (Strengths and Difficulties Questionnaire; Goodman,
1997, indicating decreased child difficulties observed post-
treatment) to -4.56 (verbal communications, indicating
increased verbal communication observed post-treatment).
Vecchio and Kearney (2009) provided effect sizes for the
incremental effects of Treatment A (hierarchical exposure,
shaping, modeling, and prompting) over Treatment B
(contingency management; child report, d = .83; parent
report, d = .41; and teacher report, d = .25). Overall, these
effect sizes suggest small to large intervention effects.
Inconsistent methodologies and reporting of results pro-
hibited the analysis of effectiveness according to treatment
approach and strategies, such that it remains unclear whether
the most commonly identified approaches and strategies
yielded the most promising treatment effects.
Discussion
This review synthesized 21 studies published between 2005
and 2015 identified in four databases, and thereby uncov-
ered a similar number of studies to those (n = 23) identi-
fied across a 15-year period (i.e., 19902005) by Cohan
et al. (2008) who used three of the four databases utilized
in the current study (ERIC excluded). Review findings
suggest that small-sample, single-case designs evaluating
combined behavioral-systems approaches to SM treatment
continue (from Cohan et al., 2008) to be the most common
among SM treatment studies between 2005 and 2015. The
rarity of studies employing psychodynamic approaches was
not surprising due to the representation of behavioral
strategies as being more predominant in prior syntheses
(Cohan et al., 2006), but the identification of just three
studies (i.e., Manassis & Tannock, 2008; Ooi et al., 2012;
Plener et al., 2012) incorporating psychopharmacological
treatment was unexpected in the context of growing
attention to the psychopharmacological treatment of
childhood anxiety disorders (e.g., Nail et al., 2015).
Most reviewed treatments were delivered in schools and
by clinicians or experimenters, the former of which is
promising given that schools are a context of mutism for
most children with SM (Kehle & Bray, 2009). In similar
fashion, the finding that clinicians and experimenters, and
not school personnel, were typically the ones providing SM
treatment contrasts the earlier findings of Dummit et al.
(1997) and may reflect low clinical representativeness of
the literature (Weisz, Doss, & Hawley, 2005). Finally,
consistent with Anstendig (1998) and Cohan et al. (2008),
all reviewed treatments were linked with positive out-
comes, though outcome measures varied slightly and
analyses varied significantly across studies.
Accordingly, despite this review being limited to a
10-year publication range, conclusions regarding, for
example, most prevalent intervention type, level of treat-
ment effect, and methodological limitations were similar to
those reached by reviews covering prior publication peri-
ods (Anstendig, 1998; Cohan et al., 2006), suggesting that
the current reviews conclusions may be generalized in
providing research and practice recommendations. More-
over, although this narrative review did not, for example,
include publications in languages other than English (as
would be done in a systematic review) or quantitatively
analyze pooled outcome data (as would be done in a meta-
analysis; cf. Pionek Stone et al., 2002 for limitations of
meta-analyzing the SM treatment literature), the current
review provides descriptive information useful in providing
recommendations for future research and practice in the
treatment of SM.
Limitations in the Research and Future Research
Directions
As similarly found in previous reviews of SM treatment
studies (Anstendig, 1998; Cohan et al., 2006), the reviewed
articles methodological limitations are considerable. In
general, studies employed limited research designs using
restricted data analysis techniques (if any) to examine data
collected for small samples. Further, with the exception of
Vecchio and Kearney (2009), study methods did not allow
the isolation of treatment strategies with regards to out-
comes. Even in the case of Vecchio and Kearney (2009),
one condition combined several treatment strategies (i.e.,
hierarchical exposure, shaping, modeling, and prompting).
The integration of multiple behavioral strategies has been
suggested as being more successful than single techniques
(e.g., Watson & Kramer, 1992); however, the systematic
comparisons of individual and combination techniques
would further validate the oft-cited understanding that
more is better.
Although studies have begun to consistently employ
several of the same rating scales (i.e., SMQ, SSQ, ASEBA
rating scales) much to the credit of Bergman et al.s
(2001, 2008) assessment development, variability in
instrumentation remains, most prominently for the obser-
vational procedures by which speaking and interaction
123

behaviors are sampled (e.g., operational definitions,
recording methods, relationship of coder with target child).
Although it may be useful to individualize observation
procedures on a case-by-case basis, these practices limit the
degree to which data from case studies and single-case
designs may be pooled to provide more generalizable
estimates of outcomes. Shriver, Segool, and Gortmaker
(2011) recommend using 15-s partial interval recording
(i.e., recording whether the target behavior occurs at any
time during a 15-s interval) to measure both non-vocal
behaviors and vocalizations as well as the stimulus con-
dition of the communication [i.e., opportunity (with
prompts) or initiation (without prompts); operational defi-
nitions provided on p. 400]. This recommendation may
guide practitioners and researchers in designing observa-
tional procedures, and thereby serve to standardize out-
come measurement procedures used in SM treatment
studies.
Across treatment modalities, the need for large-scale,
well-controlled group designs that enable statistical con-
clusions and the generalizability of findings is quite apparent.
Due at least in part to the rarity of SM, treatment research is
riddled with practical challenges (e.g., Barlow & Hersen,
1984). For example, group designs are often unattainable due
to difficulties in recruiting participants and in securing
research funding based on the limited market that appears
for selective mutism treatments (Carlson, Mitchell, &
Segool 2008, p. 367). One suggestion made by Carlson and
colleagues is to examine treatments with children presenting
with a variety of anxiety disorders, which could overcome
the described recruitment and funding problems.
Specifically, it remains critical for future studies to
(a) include control groups or single-case designs demon-
strating functional control, (b) report effect sizes and
treatment integrity, and (c) compare individual treatment
strategies, as few studies were found to address each con-
cern. Alternatively, given that there was only one SM
treatment study including a control group published prior
to this period (Sluckin, Foreman, & Herbert, 1991), the
inclusion of control groups in four currently reviewed
studies (Bergman et al., 2013; Oerbeck et al., 2014, 2015;
Vecchio & Kearney, 2009) suggests growing interest in
conducting evaluation studies with more rigorous
methodologies. Despite these advancements, reporting of
SM treatment outcome effect sizes remains uncommon
(19.05 % of reviewed studies). It is important that
researchers routinely report effect sizes to aid readers in
assessing magnitude of treatment impact as well as to assist
meta-analysts in conducting quantitative syntheses of the
treatment literature. Although the reporting of treatment
integrity also remains rare (28.57 % of reviewed studies),
there appears to be growing interest in standardizing
treatment procedures as evident in the RCTs of Bergman
123
School Mental Health
et al. (2013) and Oerbeck et al. (2014, 2015). In addition,
research is needed to identify what treatment components
are necessary (e.g., to reduce resources) or in need of
improvement (e.g., to modify utilized strategies). For
example, future studies might follow Vecchio and Kear-
neys (2009) lead in comparing individual or combinations
of behavioral strategies.
There is also a clear need for additional trials examining
the efficacy of medication for children with SM. In their
reviews of psychopharmacological SM treatments (using
unique sets of article inclusion criteria, as well as criteria
that differed from those of the current study), Carlson et al.
(2008) identified 21 publications with a pooled sample of
57 children, and Manassis, Oerbeck, & Overgaard (2016)
identified 10 publications (case studies excluded) with a
pooled sample of 83 children. The groups of researchers
arrived at similar conclusions, in Manassis and colleagues
words that although there is some evidence for symp-
tomatic improvement in SM with medication, especially
SSRIs, it is limited by small numbers, lack of comparative
trials, lack of consistent measures, and lack of consistent
reporting on tolerability (p. 571). Given the limited evi-
dence base for this type of treatment for children with SM
as well as the early age of onset for SM, it is important that
studies evaluate the benefits and risks of various medica-
tions, in various dosages, for children of different ages and
backgrounds. Although psychopharmacological evaluation
is generally outside the realm of school-based practitioners,
it is necessary for this information to be available to these
professionals, who might encounter children medicated for
SM and thus should be aware of medication considerations
(e.g., symptom reduction efficacy, prevalence of side
effects).
Finally, this review described the prevalence of SM
treatment components as they have been presented in
empirical peer-reviewed publications, and might not
accurately reflect the use of treatment components in
community (i.e., non-research) settings (Weisz et al.,
2005). One way to form conclusions regarding this type of
question is for researchers to distribute surveys on practi-
tioners use of SM treatments. Survey studies might also be
used to probe school-based practitioners perceptions of
preparedness to implement SM interventions and prefer-
ences for various SM treatment approaches and strategies
(see Schwartz, Freedy, and Sheridan, 2006 for results of a
parent survey of acceptability for various SM treatment
modalities).
Implications for School-Based Practitioners
Several studies included in this review report promising
results for school-based interventions in increasing the
verbal initiations and interactions of children with context-
School Mental Health
dependent speech, demonstrating the unique and opportune
position of school-based practitioners to support behavior
change and success for students with SM. Even those
treatment strategies that have been evaluated outside of the
school setting should be considered in designing a treat-
ment package that adequately addresses a students needs
and a schools resources. Although the reviewed studies
have been largely criticized for their methodological lim-
itations, the case study format to which many of them
adhere is advantageous in that it often offers rich descrip-
tions of case conceptualization; treatment selection,
development, and implementation; and interprofessional
collaboration that may be useful in guiding practice.
Additionally, given that treatments in the reviewed
studies were most often designed and implemented by non-
school-personnel clinicians rather than school personnel
(i.e., natural helpers in the school environment who are
available for consultation on a consistent and ongoing
basis), it could be that existing interventions may not have
been designed for implementation by school-based per-
sonnel, and/or these personnel may not feel competent in
addressing the needs of students with SM (Kehle et al.,
2012). Specialized training may be necessary to equip
practitioners such as school psychologists, social workers,
and guidance counselors with the skills and strategies
necessary to successfully intervene and consult with
teachers who intervene with students with SM (Adelman &
Taylor, 1999), such as by modifying existing SM treat-
ments for use in school settings. It is recommended that
this type of training is both offered in graduate-level
courses and available to school practitioners through pro-
fessional development. Given the low prevalence of SM
(APA, 2013) as well as the economic and opportunity costs
associated with training, pre- and in-service training related
to SM could be embedded within broader training oppor-
tunities related to identification and intervention for stu-
dents internalizing problems, which are often overlooked
by educators (Loades & Mastroyannopoulou, 2010).
Strategically incorporating combinations of the treat-
ment strategies identified in this review to individualize SM
treatment based on comprehensive conceptualizations of
child characteristics, strengths, difficulties, and school and
home contextual factors (cf. Cleave, 2009, pp. 242244)
allows practitioners to maximize the likelihood of effec-
tiveness. For example, younger children may require more
adult supports in the forms of priming, prompting, and/or
modeling, whereas older children may differentially benefit
from child-directed goal-setting procedures. Children with
social anxiety may need assistance with cognitive restruc-
turing and explicit relaxation training embedded within
hierarchical exposure techniques. For children whose SM is
perpetuated by teacher, parent, and/or peer reinforcement of
nonverbal communication, it is particularly important to
include systems-level strategies to target contextual
demands for a childs speech.
Further, it is critical that practitioners closely monitor
students progress, such as by following the observation
recommendations of Shriver et al. (2011) previously
described (i.e., 15-s partial interval recording of non-vocal
behaviors, vocalizations, and the stimulus condition of the
communication). Progress monitoring data can then be
reviewed and evaluated on an ongoing basis to make
decisions related to increasing or decreasing supports or
goals. Practitioners are also encouraged to share their
experiences in using SM intervention strategies through a
variety of outlets not limited to peer-reviewed journal
publications, such as on professional organization online
forums and through informal communication with col-
leagues, to further spread awareness and knowledge related
to SM.
Conclusions
The extant research base supports the use of behavioral and
combination strategies in treating childhood SM. In gen-
eral, it also recognizes the benefits of treatment occurring
in a context of mutism (e.g., school) and involving sig-
nificant individuals in the childs life (e.g., teachers, par-
ents). Given the methodological limitations associated with
published empirical studies, further evaluation of SM
treatments is strongly warranted. With the DSM-5s (APA,
2013) recent shift to including SM as an anxiety disorder, it
is expected that interest in the treatment of SM will grow,
as will, in turn, its corresponding literature base. This
review underscored the importance of continued efforts to
develop, refine, and evaluate SM treatment strategies,
particularly school-based interventions, that most effec-
tively target context-dependent speech and anxiety and
thereby best support the adaptive development and school
functioning of children with SM. Optimal SM treatment
outcomes are only achievable, however, when school
practitioners develop the knowledge and skills to effec-
tively implement evidence-based practices promoting stu-
dents context-irrelevant speech.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
interest.
Human and Animals Rights The article does not contain any
studies with human participants or animals performed by any of the
authors.
123

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