And finally, using a logistic regression analyses, clusters A, B, and C (Fig.3.1) were found to be associated with diagnosis, with the odds of ‘pure’ selective mutism or primary selective mutism diagnoses being 5.6 (95% CI: 2.3–14.1,p< 0.001) times higher in cluster A compared to clusters B + C.
As implied from the aforementioned examples, and based on clinical observation and preliminary research evidence, the Steps to Talking tool shows promise as a user-friendly tool that could, in a single one-hour encounter, assist clinicians and researchers in distinguishing selective mutism from social anxiety disorder in young children, and could potentially be used to monitor children’s progress in using their voice to speak during treatment or intervention studies.
Appendix 3.1
Child’s Name/ID ________________________________ Date: ________________________
PRE-SCHOOL SCREEN FOR CHILDHOOD ANXIETY RELATED DISORDERS (Pre-SCARED) Parent Form
Monga, S. & Benoit, D. (2017)
Below is a list of items that describe how children may feel. Read each statement carefully and place a check mark ( ) in the box that best reflects how often your child displays each of the behavior described below. Please answer all items as well as you can, even if some do not seem to concern your child.
Never Almost
never Sometimes Almost always Always 1 When my child is frightened or scared, I notice that it is hard for
him/her to breathe and/or he/she breathes rapidly 2 My child gets headaches when he/she is at school, daycare, or
other organized activities
3 My child quickly feels comfortable with people he/she doesn’t know well
4 My child speaks to teachers or other caregivers when needed 5 My child worries about other people liking him/her
6 When my child gets frightened or scared, I notice that he/she looks flushed
7 My child is nervous
8 My child follows me wherever I go (he/she is like my shadow) 9 People tell me that my child looks nervous
10 My child feels nervous with people he/she doesn’t know well 11 My child gets stomach aches at school, daycare, or other
organized activities
12 My child worries about things that might happen in the future 13 My child is able to fall asleep on his/her own
14 My child worries about being as good as other kids 15 When my child gets frightened or scared, I notice that he/she acts
out or has an angry meltdown
16 My child has nightmares about something bad happening to his/her parents (e.g., getting lost/ kidnapped, injury, accident, death)
17 My child worries about going to school, daycare, or other organized activities
Never Almost
never Sometimes Almost always Always
22 When my child gets frightened or scared, I notice that he/she sweats a lot
23 My child is a worrier
24 My child gets really frightened or scared for no reason at all
25 My child is afraid to be alone in an area of the house (e.g., basement, bedroom)
26 It is hard for my child to talk with people he/she doesn’t know well
27 When my child gets frightened or scared, he/she feels like he/she is choking
28 People tell me that my child worries too much
29 My child doesn’t like to be away from his/her family
30 My child worries that their own voice will be too loud
31 My child gets upset when I leave him/her with another caregiver (e.g., babysitter, grandparent, teacher)
32 My child worries that something bad might happen to his/her parents
33 My child feels shy with adults he/she doesn’t know well
34 My child feels shy with children he/she doesn’t know well 35 My child needs to be given a lot of explanations and/or
reassurance about things that are going to happen 36 When my child gets frightened or scared, he/she feels like
throwing up
37 My child worries that their own voice will sound funny
38 My child worries about how well he/she does things 18 When my child gets frightened or scared, I notice that his/her
heart beats fast
19 When my child gets frightened or scared, I notice that he/she shakes or trembles
20 My child has nightmares about something bad happening to him/her (e.g., getting lost/kidnapped, injury, accident, death) 21 My child worries more about things than most children his/her
age
Never Almost
never Sometimes Almost always Always
47 My child dislikes having attention drawn to him/her 48 My child worries about trying a new activity
49 My child is scared to go to school, daycare, or other organized activities
50 My child has trouble controlling his/her worries
39 When my child meets new people, he/she becomes quieter than usual for a while after first meeting the new people, but then warms up
40 My child worries about things that have already happened
41 When my child meets new people, he/she becomes quieter than usual for the whole time he/she is with the new people 42 My child feels nervous when he/she is with other children or
adults and has to do something while they watch him/her (for example: read aloud, speak, play a game, or play a sport) 43 My child feels nervous about going to birthday parties or any
place where there will be people that he/she doesn’t know well 44 My child worries that adults and/ or children will laugh at
him/her 45 My child is shy
46 My child speaks to many peers without difficulty
Appendix 3.2
Child’s Name/ID ________________________________ Date: _________________________
Mutism Accommodation Scale (MARS: Parent Version) Monga, S. & Benoit, D. (2017)
Below is a list of items that describe what parents do when their child does not speak or speaks very little in various social situations. Read each statement carefully and place a check mark ( ) in the box that best reflects how often you do each item. If an item does not apply to you, please place a check mark ( ) in the N/A (Not Applicable) box. Please answer all items as well as you can, even if some do not seem to concern you.
Never Almost
never Sometimes Almost
always Always N/A 1 I avoid social situations because my child will become
upset or “shut down.”
2 I arrange play dates and other social interactions for my child
In various social situations (e.g., school, play dates, birthday parties, extra-curricular activities, camps, visits with extended
family): Never Almost
never Sometimes Almost
always Always N/A 3 I speak for my child
4 I allow my child’s siblings to speak for him/her 5 I become anxious when my child does not speak, so I
don’t expect or encourage him/her to speak 6 I tell people my child is shy
7 I allow my child to whisper to others 8 I tell my child that he/she does not have to speak 9 I encourage other children (e.g., classmates, peers) to
speak for my child
10 I praise or reward my child when he/she speaks
11
I become angry, annoyed, or frustrated when my child does not speak so, I don’t expect or encourage him/her to speak
12 I tell teachers, coaches, and other adults that my child does not speak
13 I am surprised (shocked) when my child speaks to adults he/she does not know well
14 I am surprised (shocked) when my child speaks to children he/she does not know well
15
I know my child will become upset or “shut down”
when he/she has to speak, so I don’t expect or encourage my child to speak
16 I allow my child to nod, use other gestures, or facial expressions instead of his/her voice
17 I encourage other adults (e.g., nanny, babysitter, grandparents) to speak for my child 18 I allow my child to whisper answers to me 19 I become embarrassed when my child does not speak, so
I don’t expect or encourage my child to speak
In various social situations (e.g., school, play dates, birthday parties, extra-curricular activities, camps, visits with extended family):
Never Almost
never Sometimes Almost
always Always N/A 20 I apologize to adults or children for my child not
talking
21 I allow my child to say parts of words or sounds instead of saying a full word
22 I whisper to my child
Appendix 3.3
Child’s Name/ID ________________________________ Coder: ________________ Date: _______________
TALKING BEHAVIOR ASSESSMENT TOOL Benoit, D. & Monga S. (2017)
Languages spoken at home: English___ Other: ___________________________________
Main language spoken at home: English___ Other: ___________________________________
Language child most comfortable speaking: English___ Other: ___________________________________
Concern about speech, articulation, etc.: ____________________________________________________________________
Place a checkmark to indicate the child’s best performance with respect to ability to communicate in the following settings:
Home:
Nothing (no gesture and no voice)
Gestures Whisper Soft voice
Normal volume voice
How long a warm up period is needed before speaking Parents
Siblings Extended family Family friends Babysitter Visitors (strangers) Other
Community:
Nothing (no gesture and
no voice)
Gestures Whisper Soft voice
Normal volume
voice How long a warm up period is needed before speaking Neighbors – children
Neighbors – adults Play date – close friend Play date – parent(s) of close friend Extra-curricular activity – close friend
Extra-curricular activity – other children
Extra-curricular activity – coach Restaurant – waiter / waitress Stores – cashier / store employee Park – children
Park – adult
Doctor / dentist / optometrist Other
Other Day care:
Nothing (no gesture and no voice)
Gestures Whisper Soft voice
Normal volume voice
How long a warm up period is needed before speaking Close friends
Children Primary caregiver Other caregiver Other
School:
Nothing (no gesture and no voice)
Gestures Whisper Soft voice
Normal volume voice
How long a warm up period is needed before speaking Close friends
Children Classroom teacher Other adult Concert/play/ show & tell Other
Other
Appendix 3.4
Child’s Name/ID ________________________________ Coder: ________________ Date: _______________
Selective Mutism vs. Social Anxiety Disorder Criteria Checklist Monga, S. & Benoit, D. (2017)
Score 3 2 1 0
True or Yes
Variable (sometimes true, sometimes
false)
False or No
Don’t know, not specified, or not applicable
Selective Mutism if most/all of criteria #1 – 3 are True or Variable
1 Will not speak to a specific person or specific people, or in one (or more) specific setting(s), even after a warm-up period
2
During activities (e.g., extra-curricular activities, gym class, performances), participates non-verbally without difficulty, but remains non-verbal when speech is expected
3 With peers, interacts socially, but non- verbally
Count the totals of each column Total Selective Mutism Score
aSocial Anxiety Disorderif most/all of criteria
#4 – 6 are True or Variable
4 Will interact, participate, (or speak), but only after a warm-up period
5
Conveys self-consciousness (e.g., worries about being embarrassed, made fun of, laughed at, in the spotlight, or having attention focused on him/her, whether perceived or actual)
6
Displays physical signs of tension (e.g., shoulders hunched, wringing hands, downward gaze, hiding behind parent) in most social encounters, whether in groups or one-on-one, including with assessor
Count the totals of each column Total Social Anxiety Disorder Score
a Anxiety about being observed or scrutinized must be present with adults and peers.
Appendix 3.5
Child’s ID ________________________________ Coder: ________________ Date: _______________
STEPS TO TALKING for Selective Mutism and Social Anxiety Disorder
Monga, S. & Benoit, D. (2017)
How long was today’s assessment? ________ hours
(i.e., how long was the observation that yielded the ratings below)
This checklist is to be completed by an assessor after spending at least one hour completing an assessment with the child, in the presence of the child’s primary caregiver(s). Circle the number corresponding to the highest step achieved by the child during interactions with the assessor (unless otherwise specified) within each time point during the period of observation.
Steps to
talking Immediately
upon greeting
Within the first 30 minutes
of encounter
Any time after 30 minutes 11 Spontaneously asks questions or volunteers information (soft
or normal voice) to assessor 16 16 16
10 Responds to questions (≥ 5 words normal voice) to assessor 15 15 15
9 2-4 word response(s) with normal voice to assessor 14 14 14
8 1 word response(s) with normal voice (e.g. only yes, no) to
assessor 13 13 13
7 > 1 word spoken in soft voice with assessor 12 12 12
6 > 1 word response(s) in (soft / normal – circle one) voice with
(parent / other:_______ - circle one) 11 11 11
5 1 word responses in soft voice only (e.g., yes, no) to assessor 10 10 10 4 1 word responses in soft voice only (e.g., yes, no) to parent /
other 9 9 9
3 ≥ 1 word(s) whispered audibly to assessor 8 8 8
2 ≥ 1 word(s) whispered audibly to parent/ other 7 7 7
1 Mouths ≥ 1 word(s) 6 6 6
Nods or gestures, spontaneously or upon request, to respond to
the assessor’s questions 5 5 5
Sustains eye contact with the assessor 4 4 4
Makes fleeting eye contact with the assessor 3 3 3
Positions self to be face to face with assessor 2 2 2
Willing to be in the same room with assessor 1 1 1 0
Notes: _________________________________________________________________________________________________
References
Birmaher, B., Brent, D. A., Chiappetta, L., Bridge, J., Monga, S., & Baugher, M. (1999). Psycho- metric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study.Journal of the American Academy of Child and Adolescent Psychiatry, 38(10), 1230–1236.https://doi.org/10.1097/00004583-199910000-00011.
Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., & Neer, S. M. (1997). The Screen for Child Anxiety Related Emotional Disorders (SCARED): Scale construction and psy- chometric characteristics.Journal of the American Academy of Child and Adolescent Psychiatry, 36(4), 545–553.https://doi.org/10.1097/00004583-199704000-00018.
Calinski, T., & Harabasz, J. (1974). A dendrite method for cluster analysis.Communications in Statistics, 3(1), 1–27.
Genolini, C., Alacoque, X., Sentenac, M., & Arnaud, C. (2015). Kml and kml3d: R packages to cluster longitudinal data.Journal of Statistical Software, 65(4), 1–34. URLhttp://www.jstatsoft.
org/v65/i04/.
Monga, S., Birmaher, B., Chiappetta, L., Brent, D., Kaufman, J., Bridge, J., & Cully, M. (2000).
Screen for Child Anxiety-Related Emotional Disorders (SCARED): Convergent and divergent validity.Depression and Anxiety, 12(2), 85–91.https://doi.org/10.1002/1520-6394(2000)12:2%
3c85::aid-da4%3e3.0.co;2-2.
Monga, S., Rosenbloom, B. N., Tanha, A., Owens, M., & Young, A. (2015). Comparison of child- parent and parent-only cognitive-behavioral therapy programs for anxious children aged 5 to 7 years: Short- and long-term outcomes.Journal of the American Academy of Child and Adoles- cent Psychiatry, 54(2), 138–146.https://doi.org/10.1016/j.jaac.2014.10.008.
Silverman, W. K. & Albano, A. M. (1996).The Anxiety disorders interview schedule for children for DSM-IV: Clinician manual (Child and parent versions).
Spence, S. H., & Rapee, R. (1999). The preschool anxiety scale. Retrieved fromhttp://www.
scaswebsite.com/docs/scas-preschool-scale.pdf.
Thompson-Hollands, J., Kerns, C. E., Pincus, D. B., & Comer, J. S. (2014). Parental accommoda- tion of child anxiety and related symptoms: Range, impact, and correlates.Journal of Anxiety Disorders, 28(8), 765–773.https://doi.org/10.1016/j.janxdis.2014.09.007.