3.2 Tools to Assess Selective Mutism and Social Anxiety
3.2.4 Steps to Talking
The Steps to Talking (Appendix3.5) is a novel clinician-administered instrument that can be used by clinicians and researchers in the assessment of four- to seven- year-old children presenting for ‘not speaking’ or possible selective mutism and/or social anxiety disorder. The Steps to Talking quantify a child’s nonverbal and ver- bal communication with an assessor during an encounter. The level of nonverbal and verbal interaction is measured at three time points during a clinical encounter:
(1) immediately upon greeting; (2) within the first 30 minutes of the encounter; and
(3) any time after the first 30 minutes of the encounter. As seen in Appendix3.5, the clinician or researcher indicates in the first column the child’s highest or best (between 1 and 16) verbal or nonverbal performance immediately when first greet- ing the child. The clinician or researcher then indicates in the second column the child’s highest or best (between 1 and 16) verbal or nonverbal performance with the assessor within the first 30 minutes of an encounter. The clinician or researcher then uses the third column to indicate the child’s highest or best (between 1 and 16) verbal or nonverbal performance with the assessor any time after the first 30 minutes of the encounter.
For example, a child who comes in for an assessment might only nod to the assessor in the waiting room when first greeted and not move beyond nodding within the first 30 minutes and beyond. As seen in Appendix3.5, that child would receive a score of 5 in the ‘Immediately upon greeting’ column, a score of 5 in the ‘Within the first 30 minutes.’ column, and a score of 5 in the ‘Any time after 30 minutes.’
column, and thus would not demonstrate any change over the course of the encounter in the level of verbal (or nonverbal) interaction. This child would likely have selective mutism as clinical experience with the Steps to Talking tool suggests that the ratings for children with selective mutism appear to remain flat across the three time points during an encounter with an assessor.
Conversely, a child might hide behind a parent’s leg and only make fleeting eye contact when first greeted in the waiting room and might be able to nod and use various gestures in response to questions during the first 30 minutes. With further warm up time beyond the first 30 minutes, that same child, who was not speaking at the start of the interview, may respond to questions from the assessor using two- to four-word responses with a normal volume voice. On the Steps to Talking this child’s scores would be 3 in the ‘Immediately upon greeting’ column, 5 in the ‘Within the first 30 minutes.’ column, and 14 in the ‘Any time after 30 minutes.’ column. This child likely has social anxiety disorder as clinical experience with the Steps to Talking suggests that children with social anxiety disorder show an upward progression of scores over the course of the encounter as the child warms up.
To formally test the hypotheses (derived from the aforementioned clinical expe- rience) that a flat line (or near flat line) across the three time points on the Steps to Talking is characteristic of young children with selective mutism, while an upward progression of scores across the three time points is characteristic of young children with social anxiety disorder, we conducted a cluster analysis on the data collected in the sample of 94 four- to seven-year-old children (M age5.44 years;SD 1.0; 28 males) with selective mutism and/or anxiety disorder who consented to par- ticipate in the recently completed randomized control trial and for which data were available (Sect.5.3.5). To identify a priori profiles and following implementation of the k-means algorithm (Genolini, Alacoque, Sentenac, & Arnaud,2015) and the Calinski and Harabasz criterion (1974), three clusters were identified (Fig.3.1): Clus- ter A included patients with consistently low scores (N 41), Cluster B included those with overall increasing scores (N 36), and Cluster C included those with consistently high scores (N17).
Fig. 3.1 Cluster analysis of mean Steps to Talking scores (standard deviation) over three time points;Minsminutes
Fig. 3.2 Cluster analysis of mean Steps to Talking scores (standard deviation) over three time points by diagnostic group;SADsocial anxiety disorder;SMselective mutism;Minsminutes
Additionally, a cluster analysis using data from the same sample was performed based upon four diagnostic groups: (1) ‘pure’ selective mutism; (2) primary selective mutism plus social anxiety disorder; (3) primary social anxiety disorder plus selective mutism; and (4) ‘pure’ social anxiety disorder (Fig.3.2).
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.