Fulltext

J Abnorm Child Psychol (2010) 38:1057–1067
DOI 10.1007/s10802-010-9425-y

Behavioral and Socio-emotional Functioning in Children
with Selective Mutism: A Comparison with Anxious
and Typically Developing Children Across Multiple
Informants
Diana Carbone & Louis A. Schmidt &
Charles C. Cunningham & Angela E. McHolm &
Shannon Edison & Jeff St. Pierre & Michael H. Boyle

Published online: 23 May 2010
# Springer Science+Business Media, LLC 2010

Abstract We examined differences among 158 children, 44 implications for clinical practice, whereby social skills
with selective mutism (SM; M=8.2 years, SD=3.4 years), 65 training merits inclusion in intervention for children with
with mixed anxiety (MA; M=8.9 years, SD=3.2 years), and anxiety disorders as well as children with SM.
49 community controls (M=7.7 years, SD=2.6 years) on
primary caregiver, teacher, and child reports of behavioral Keywords Selective mutism . Mixed anxiety . Children .
and socio-emotional functioning. Children with SM were Social skills . Social anxiety . Parent and teacher reports .
rated lower than controls on a range of social skills, but the Internalizing problems
SM and MA groups did not significantly differ on many of
the social skills and anxiety measures. However, children
with SM were rated higher than children with MA and Selective mutism (SM) is a disorder marked by a consistent
controls on social anxiety. Findings suggest that SM may be failure to speak in certain social situations (e.g., at school)
conceptualized as an anxiety disorder, with primary deficits despite the presence of speech in other social situations
in social functioning and social anxiety. This interpretation (e.g., at home; American Psychiatric Association 2000).
supports a more specific classification of SM as an anxiety SM is largely considered rare with prevalence rates
disorder for future diagnostic manuals than is currently estimated to be between 0.03% and 0.2% (Bergman et al.
described in the literature. The present findings also have 2002; Brown and Lloyd 1975; Elizur and Perednik 2003;
Kolvin and Fundudis 1981; Kopp and Gillberg 1997;
Kumpulainen et al. 1998), with higher rates identified in
D. Carbone : L. A. Schmidt
immigrant populations (Elizur and Perednik 2003). Preva-
McMaster Integrative Neuroscience, Discovery, & Study
(MiNDS), McMaster University, lence rates for SM are variable in the literature and appear
Hamilton, ON, Canada to be influenced by the origin of research, diagnostic
criteria, age of children, immigrant status, and setting in
L. A. Schmidt (*)
which SM is sampled (e.g., clinic versus school setting)
Department of Psychology, Neuroscience & Behaviour,
McMaster University, (Bergman et al. 2002; Kumpulainen 2002; Sharp et al.
Hamilton, ON L8S 4K1, Canada 2007). There is little consensus as to the sex ratio of the
e-mail: schmidtl@mcmaster.ca disorder, with clinically-referred samples reporting a slightly
C. C. Cunningham : A. E. McHolm : S. Edison : M. H. Boyle
higher prevalence of SM in females than males (e.g.,
Department of Psychiatry & Behavioural Neurosciences, Cunningham et al. 2004; Dummit et al. 1997; Kristensen
McMaster University, 2000). Other studies investigating community- and school-
Hamilton, ON, Canada based samples suggest comparable occurrence between the
sexes (e.g., Bergman et al. 2002; Elizur and Perednik 2003).
J. St. Pierre
Child and Parent Resource Institute (CPRI), Although SM has a typical onset before the age of five,
London, ON, Canada the disorder often does not become evident until school

1058 J Abnorm Child Psychol (2010) 38:1057–1067

entry, when expectations (and related pressures) to speak cooperation, than controls. More recently, Cunningham et
increase (Cunningham et al. 2004; Garcia et al. 2004; al. (2006) used the SSRS again and found that both
Giddan et al. 1997). Despite this early onset, children are teachers and parents rated children with SM to be lower on
not commonly referred for clinical assessment until they are verbal and nonverbal social skills than control children, but
between approximately 6.5 to 9 years of age (Ford et al. the two groups were not different on measures of nonverbal
1998; Kumpulainen et al. 1998; Standart and Le Couteur social cooperation.
2003). SM may persist for a few months to several years, In addition to the work by Cunningham and colleagues
and adults diagnosed with SM as children often continue to (2004, 2006), a study by Vecchio and Kearney (2005)
suffer with social anxiety and deficits in social communi- found that children with SM and children with anxiety
cation, in addition to displaying other problems with socio- disorders were rated by teachers and parents to have greater
emotional and daily adjustment (Remschmidt et al. 2001). internalizing behaviors than controls. Vecchio and Kearney
Despite being diagnostically well-documented (Dummit et also found that children with SM and children with anxiety
al. 1997; Kopp and Gillberg 1997; Sharp et al. 2007), the disorders did not differ from children in a control group on
etiology of SM remains equivocal. externalizing behaviors. Furthermore, children with SM had
Currently, SM is ambiguously classified under ‘Other significantly greater total comorbid diagnoses and anxiety
Disorders of Infancy, Childhood and Adolescence’ in the disorder diagnoses than children with anxiety disorders,
current Diagnostic and Statistical Manual (DSM-IV-TR, based on child, but not parent, report.
American Psychiatric Association 2000). This classification There are, in addition, other studies, which have used
is largely disputed as the greater consensus in the literature clinician, parent, and children’s self-report measures to
classifies SM as an anxiety disorder (Anstendig 1999; compare children with SM to children with SP (Yeganeh
Sharp et al. 2007; Standart and Le Couteur 2003). The basis et al. 2003, 2006). For example, Yeganeh et al. (2003,
for the designation of SM as an anxiety disorder comes 2006) found that children with SM did not report greater
from four main findings. First, strong comorbidity with and levels of social anxiety than children with SP, despite
characteristic similarities between SM and anxiety disor- clinician and observer ratings of greater or equal levels of
ders, specifically social phobia (SP), have been identified in social anxiety in the SM and SP groups. Yeganeh and
the literature (e.g., Black and Uhde 1995; Dummit et al. colleagues (2003, 2006) suggested that children with SM
1997; Sharp et al. 2007; Vecchio and Kearney 2005). There do not report as large a degree of anxiety, since their
is even the suggestion that SM may be a subtype (Black & inability to talk may serve as a compensatory strategy to
Uhde, 1992) or developmental precursor (Bergman et al. reduce their anxiety.
2002) to SP in some cases. Second, there is evidence Studies that have examined the socio-emotional charac-
showing a greater prevalence of anxiety disorders amongst teristics of SM have been limited by several factors,
relatives of children with SM than among typically including small sample sizes (e.g., Vecchio and Kearney
developing children, which further implicates genetic 2005; Yeganeh et al. 2003, 2006) and a lack of other
factors in the etiology of the disorder (Black and Uhde clinical group comparisons (e.g., anxious children;
1995; Cohan et al. 2006b; Kristensen and Torgerson 2002). Cunningham et al. 2004, 2006). Furthermore, few studies
Third, both SM (Ford et al. 1998) and anxiety disorders have examined social skills in children with SM. Studies
(e.g. Hirshfeld-Becker et al. 2007) have been associated that address these issues are needed, given the argument
with similar temperaments, namely, behavioral inhibition. that 1) SM would be better classified as an anxiety disorder
Lastly, SM and anxiety disorders both share common (Anstendig 1999; Sharp et al. 2007; Standart and Le
psychotherapeutic and pharmacological treatments (Cohan Couteur 2003), 2) there are conceptual and behavioral
et al. 2006a; Standart and Le Couteur 2003). similarities between SM and SP, and 3) the reported
Recent research has examined the socio-emotional char- findings of children (e.g., Bernstein et al. 2008) and adults
acteristics of children with SM. For example, Cunningham (e.g., Voncken et al. 2008) with SP suffer from social skills
and colleagues (2004; Cunningham et al. 2006) have deficits.
suggested that children with SM exhibit lower social A further limitation concerns the issue that most studies
competence compared to their typically developed peers. examining SM have largely been informed by parent report
Using the Social Skills Rating System (SSRS; Gresham and despite the recommendation that a multi-method, multi-
Elliot 1990), Cunningham et al. (2004) found that children informant approach be utilized in the assessment of anxiety
with SM were rated significantly lower than controls on disorders (Schniering et al. 2000) and SM (Mclnnes and
the parent report of social assertion, social responsibility, Manassis 2005). Given the personal nature of fears, self-
social cooperation, and social control subscales. Compar- report is a recommended component of the multi-modal
atively, teachers considered children with SM to exhibit battery (Schniering et al. 2000). Teacher ratings of a child’s
less social assertion, but not social control or social socio-emotional behavior, in addition to parent and self-

J Abnorm Child Psychol (2010) 38:1057–1067 1059

report, are also imperative, since children spend substantial mental health agencies in Southern Ontario and
amounts of time in the classroom during their formative children from the McMaster Child Database. Children
years (Clarizio 1994). Moreover, there exist anxiety- classified as controls were also obtained from the
provoking situations unique to the school setting about McMaster Child Database only, and all were healthy
which only a teacher may be apt to report. Accordingly, without mental health problems. The McMaster Child
teacher assessments are essential for children who typically Database contains the names of children from the
do not speak in the school setting. There is, however, scant community who were recruited at birth from the McMas-
research on SM that has included teacher reports. ter University Medical Centre and St. Joseph’s Healthcare,
Hamilton, Ontario. Parents consented for their infant’s
inclusion in the McMaster Child Database if they were
The Present Study interested in participating in future research studies.
Participant demographics can be found in Table 1.
In order to extend the recent work of Cunningham and
colleagues (2004, 2006) and clarify other previous findings, Selective Mutism (SM) Group
we compared a relatively large sample of children with SM
to children with mixed anxiety (MA) disorders and The SM group comprised 44 children (female n=23, male
typically developing children on teacher, primary caregiver, n=21), with a mean age of 8.2 years (SD=3.4 years). The
and child self-report measures of social and emotional children were included in the SM group if their primary
functioning. Based on the prior findings by Cunningham caregivers or teachers indicated that the child did not speak
and his colleagues (e.g., Cunningham et al. 2004, 2006), we in two or more situations on the Speech Situations
predicted that children with SM would exhibit significantly Questionnaire—Parent Version (SSQ—Parent; or the
lower verbal and nonverbal social competence than Speech Situations Questionnaire—Teacher version (SSQ-
typically developing children as rated by both primary Teacher; Cunningham et al. 2004, 2006). Classification in
caregivers and teachers. Given that SM appears to be the SM group also required that the absence of speaking
associated with internalizing rather than externalizing was not due to a communication disorder, and that the
factors (e.g. Black and Uhde 1995; Dummit et al. 1997; absence of speaking persisted for a minimum of one month.
Ford et al. 1998; Kristensen 2000; Steinhausen and Juzi The same criteria used to classify children with SM in the
1996; Vecchio and Kearney 2005), we also anticipated that present study have also been used elsewhere (Nowakowski
children with SM would be significantly higher on et al. 2009).
internalizing behaviors and lower on externalizing, hyper- Primary caregiver report on the internalizing section of
active and problem behaviors than typically developing the Computerized Diagnostic Individual Schedule for Child
children. Since it may be the case that children with SM do (C-DISC IV; Shaffer et al. 2000) was used to examine the
not report as great a degree of anxiety as indicated by other number of internalizing disorders for which the participants
informants (Yeganeh et al. 2003, 2006), we expected that met criteria. The C-DISC IV was not used to classify
self-report of social anxiety by children with SM would not children with SM, since its reliability has been established
differ from children with MA and typically developing for anxiety disorders but not for SM. There were seven
children, but primary caregivers of children with SM would (15.9%) children classified as SM for which the C-DISC IV
indicate higher levels of social anxiety than children with could not be obtained because primary caregivers could not
MA and typically developing children. We further hypoth- be reached via telephone to conduct the questionnaire.
esized that social skills and anxiety would not be different Twenty-eight of the 37 (63.6%) children classified as SM
between the SM and MA groups, if SM is conceptualized were diagnosed with one or more anxiety disorders as per
as an anxiety disorder. the C-DISC IV. The most common anxiety disorder
diagnosis was specific phobia (29.5%), followed by social
phobia (18.2%), agoraphobia (15.9%), separation anxiety
Method (13.6%), generalized anxiety disorder (GAD; 2.3%),
obsessive-compulsive disorder (OCD; 2.3%), and post-
Participants traumatic stress disorder (PTSD; 2.3%).

Participants were 158 (81 males, 77 females; M=8.4 years, Mixed Anxiety (MA) Group
SD=3.1 years) children. Children with SM consisted of
referrals from children’s mental health agencies in The MA group included 65 children (female n=29, male
Southern Ontario. Children classified as mixed anxiety n=36), with a mean age of 8.9 years (SD=3.2 years). The
(MA) were a combination of referrals from children’s children were classified in the MA group if they had one or


Table 1 Demographic Information

Selective mutism Mixed anxiety Community control Statistic p-value
(n=44) (n=65) (n=49)

Percent female 52.3 44.6 51.0 X2(2) = 0.7 0.682
Mean (SD) age of child in years 8.2 (3.4) 8.9 (3.2) 7.7 (2.6) F(2,155) = 2.2 0.166
Percent in regular classroom 97.7 95.3a 100a X2(4) = 2.9 0.577
Age range of primary caregiver <19 (n=1) 19–39 (n=25) 19–39a (n=21) X2(4) = 2.9 0.570
19–39 (n=17) 40–64 (n=40) 40–64 (n=27)
40–64 (n=26)
Approximate total income of X2(12) = 35.5 0.0005
household, in prior year,
before taxes
Less than $15 000 1a 2a 0a
$ 15 000–$30 000 3 10 1
$ 30 000–$45 000 6 5 0
$ 45 000–$60 000 0 11 2
$ 60 000–$75 000 12 5 8
$ 75 000–$90 000 11 14 21
Greater than $100 000 10 17 13
a
indicates group with missing data for that demographic variable

more anxiety disorder diagnoses on the C-DISC IV (social comprehend the questions. A questionnaire package was
phobia, separation anxiety, specific phobia, panic disorder, also sent out to the child’s teacher in which he/she reported
GAD, PTSD, OCD, or agoraphobia), and no diagnosis of on the child’s social skills and problem behaviors.
SM as per teacher and primary caregiver report on the The measures collected in the present study were part of
Speech Situations Questionnaires. Of the 65 children in the a larger study examining the etiology, academic abilities,
MA group, 40 (61.5%) had one anxiety disorder, and 25 familial characteristics, and behavioral and psychophysio-
(38.5%) had two or more anxiety disorders as per the C- logical correlates of children with SM. Data collection took
DISC IV. The most common anxiety disorder diagnosis place at the Child Emotion Laboratory at McMaster
among the MA group was specific phobia (67.7%), University. All procedures were approved by the McMaster
followed by social phobia (27.7%), separation anxiety University Health Sciences Research Ethics Board. The
(23.1%), GAD (16.9%), OCD (10.8%), panic disorder child received a toy or gift certificate as a token of our
(6.2%), and PTSD (1.5%). appreciation at the end of the visit.

Community Control Group Primary Caregiver Report Measures

The typically developing group comprised 49 children Diagnostic Questionnaires The Speech Situations Ques-
(female n=25, male n=24), with a mean age of 7.7 years tionnaire—Parent Version (SSQ-Parent; Cunningham et al.
(SD=2.6 years). Children were classified as typically 2004, 2006) assesses a child’s speech patterns in a number
developing if they had no diagnoses as per the CDISC IV, of situations and to several different people as reported by
and if they did not meet criteria for SM based on primary the primary caregiver. High internal consistencies of 0.82
caregiver and teacher report on the Speech Situations (Cunningham et al. 2006) and 0.92 (Nowakowski et al.
Questionnaires. 2009) have been found in prior studies. An internal
consistency of 0.92 was found in the present study.
Procedure Additionally, primary caregiver report on the internaliz-
ing section of the computer assisted Diagnostic Interview
Following arrival at the Child Emotion Laboratory, the Schedule for Children (C-DISC IV; Shaffer et al. 2000) was
parent and child were briefed about the procedures and obtained by a trained research assistant via telephone
written consent was obtained. The primary caregiver then following the initial laboratory visit. The C-DISC IV is a
filled out a number of questionnaires. Child self-report of structured diagnostic interview that evaluates the presence
anxiety was also obtained if the child was old enough to of 34 psychiatric disorders in children based on the DSM-


IV (Shaffer et al. 2000). Panic disorder, GAD, social Teacher Report Measures
phobia, specific phobia, separation anxiety, OCD, PTSD,
agoraphobia, and major depression are assessed on the Teacher Diagnostic Questionnaires The Speech Situations
internalizing section of the C-DISC IV. Only the internal- Questionnaire—Teacher Version (SSQ-Teacher; Cunningham
izing section of the C-DISC IV was administered due to et al. 2004, 2006) assesses a child’s speech patterns in a
time contraints. number of situations at school and to several different people
as reported by the teacher. A high internal consistency of 0.95
Social Competence and Problem Behavior Measures was reported recently (Nowakowski et al. 2009) and was 0.95
Primary caregivers completed the Social Skills Rating in the present study.
System (SSRS)—Parent Version (Gresham and Elliot
1990), which is comprised of nine different scales. There Social Competence and Problem Behavior Measures
are four scales that examine social skills: social assertion, Teachers also completed a version of the SSRS that yields
social cooperation, social responsibility, and self-control; identical scales to that of the parent version with the
these four sum to a total social skills scale. exception of a social responsibility scale.
The SSRS has three scales that pertain to externaliz-
ing, internalizing, and hyperactive (only grades K-6) Verbal and Nonverbal Social Interactions We also com-
behaviors subscales, which sum to a total problem puted subscales developed by Cunningham et al. (2006) to
behaviors scale. Internal consistency among the scales assess verbal social interactions, nonverbal social interactions
of the SSRS—Parent Version has been reported between and nonverbal classroom cooperation and competence.
0.87 and 0.90 (as cited in Cunningham et al. 2004). The Internal consistency among the scales of SSRS—Teacher
internal consistencies for grades K-6 in the present study Version has been reported between 0.93 and 0.94 (as cited in
were between 0.62 and 0.88, and for grades 7–12 were Cunningham et al. 2004). The internal consistencies for
between 0.74 and 0.91. grades K-6 in the present study were between 0.87 and 0.96,
and for grades 7–12 were between 0.72 and 0.93. Cunning-
Verbal and Nonverbal Social Skills We also computed three ham et al. (2006) reported internal consistencies of 0.90,
scales developed by Cunningham et al. (2006) to assess 0.94 and 0.92 for the verbal social interaction subscale,
verbal social skills, nonverbal social skills, and nonverbal nonverbal social interaction subscale, and nonverbal class-
cooperation subscales. Cunningham et al. (2006) reported room cooperation and competence subscale, respectively. In
internal consistencies of 0.78, 0.71, and 0.78 for the verbal the present study, the internal consistencies were: 0.87 for
social skills, nonverbal social skills, and nonverbal cooper- grades K-6 and 0.80 for grades 7–12 verbal social
ation subscales, respectively. For the present study, internal interactions scales, 0.86 for grades K-6 and 0.90 for grades
consistencies were 0.70 for grades K-6 and 0.58 for grades 7–12 nonverbal social interaction scales, and 0.92 for grades
7–12 verbal social skills scales, and 0.83 for grades K-6, K-6 and 0.88 for grades 7–12 nonverbal classroom compe-
and 0.76 for grades 7–12 nonverbal social skills scales, and tence scales.
were 0.81 for grades K-6, and 0.85 for grades 7–12 for the
nonverbal social competence scales. Child Report Measures

Screen for Child Related Emotional Disorders (SCARED) Although reliability for the SCARED has been tested for
The SCARED (Birmaher et al. 1997) yields five scales children between the ages of 9 to 18 (Birmaher et al. 1997),
related to five different anxiety disorders: panic disorder/ we administered the SCARED—Child Version if the child
significant somatic symptoms, GAD, social anxiety disor- was able to comprehend the questions. The mean age for
der, separation anxiety disorder, and significant school children who completed the SCARED—Child Version was
avoidance. We also computed a measure of total anxiety, 9.4 (SD=2.9) years. The SCARED—Child Version has
which was a sum of all of the questions on the SCARED— identical questions and yields identical scales as the
Parent Version. The parent version of the SCARED has an SCARED—Parent Version. The child version of the
internal consistency of 0.74 (Birmaher et al. 1997). The SCARED has an internal consistency of 0.93 (Birmaher et
internal consistencies for subscales of the SCARED— al. 1997). We also computed a total score for the SCARED—
Parent Version in the present study were between 0.63 Child Version, which was the total sum of all of the questions
and 0.75, and for the total score was 0.92 for children on the SCARED—Child Version. The internal consistencies
below age eight. Internal consistencies for subscales of the for subscales of the SCARED—Child Version in the present
SCARED—Parent Version in the present study were study were between 0.56 and 0.82, and for the total score was
between 0.76 and 0.93 and for the total score was 0.95 0.86 for children below age eight. Internal consistencies of the
for children eight and above. SCARED—Child Version in the present study were between


0.63 and 0.83, and for the total score, it was 0.92 for children using income as a covariate. All post hoc analyses were
eight and above. Bonferroni corrected.
The total social skills scale for the SSRS-Parent and
Missing Data Teacher Versions and the total anxiety scales for the SCARED
Parent and Child Versions were not included in the MAN-
Data were missing if specific questions were not completed, COVA analyses as they represent the sum of the subscales in
questions were deemed non-applicable to the child by the each of the questionnaires. The total scales from these scales
primary caregiver or teacher, certain questions were missed, were analyzed using separate one-way ANCOVAs, with
entire questionnaires were not returned to the laboratory, or group (SM, MA, Control) as the between subject-factor and
the child was too young to understand the question(s) in the income as a covariate. All post hoc analyses were Bonferroni
case of the SCARED-Child Version. Missing questions for corrected. The total problem behaviors scale was not
the SSRS-Parent and Teacher Version were filled out in analyzed, as it is the sum of three different constructs
accordance with the protocol outlined in Gresham and (internalizing, externalizing and hyperactive behaviors) that
Elliot (1990). Missing questions for the SCARED-Parent should be analyzed and reported separately.
and Child Versions were filled in by computing the average To assess whether primary caregiver and child report of
of the questions pertaining to a specific scale that the anxiety differed within the SM and MA groups, paired-samples
missing question was relevant to and then recalculating the t-tests were conducted using the SCARED—Parent and Child
scale. Importantly, the groups did not significantly differ on Versions total anxiety score and social anxiety score.
the amount of missing data. There were a total of seven
participants missing the SSRS—Parent Version, 25 partic-
ipants missing the SSRS—Teacher Version, eight partic- Results
ipants missing the SCARED—Child Version, and five
participants missing the SCARED—Parent Version. Of the SSRS-Parent Version: Social Competence
remaining participants, there were 1.1% data missing from
the SSRS—Parent Version, 0.6% data missing from the Consistent with our predictions, the MANCOVA for the
SSRS—Teacher Version, 0.09% data missing from the social skills subscales indicated a significant multivariate
SCARED—Parent Version, and 0.06% data missing from main effect of group (Wilks’Λ, F(8,256) = 6.886, p=0.0005)
the SCARED—Child Version. that further indicated a significant main effect of group on
the social assertion, social responsibility, and self-control,
Data Analyses but not the social cooperation subscales (see Table 2). A
one-way ANCOVA also indicated that there was a
Income in the prior year before taxes differed significantly significant main effect of group on the total social skills scale
among the three groups (X2(12) = 35.5, p<0.05) and was (F(2,131) = 12.3, p=0.0005; see Table 2).
significantly correlated with all of the measures in the study Follow-up tests confirmed that the SM and MA groups
except for the SSRS—Teacher Version social assertion and had significantly lower social assertion (p<0.006) and total
verbal social skills scales, the SCARED—Child Version, social skills (all p’s<0.02) than the control group. Primary
and the SCARED—Parent Version social anxiety and caregivers also rated the SM group lower in social
school avoidance scales. Accordingly, income was consid- responsibility skills than the MA and control groups (all
ered as a covariate in all analyses. p’s<0.006). There were no significant group differences on
To examine differences among the three groups on the the self-control scale following Bonferroni correction.
various behavioral and socio-emotional functioning mea-
sures completed by the primary caregiver, teacher, and SSRS-Parent Version: Verbal and Nonverbal Social Skills
children, separate one-way multivariate analyses of covari-
ance (MANCOVA) tests were conducted, with group (SM, The MANCOVA for the verbal social skills scale, nonver-
MA, Control) as the between-subject factor and the bal social skills scale, and nonverbal cooperation scale
subscales (e.g., SSRS-Parent subscales: social cooperation, revealed a main effect of group (Wilks’Λ, F(6, 260) =
social assertion, social responsibility, self-control) as the 11.679, p=0.0005) for all of the subscales (see Table 2).
dependent variables. A similar MANCOVA was performed The SM group had significantly lower verbal social skills
with group (SM, MA, Control) as the between-subject than the MA and control groups (p’s<0.006; see Table 2
factor and the subscales (internalizing, externalizing, and and Fig. 2). Furthermore, the SM and MA groups had
hyperactive behaviors) as the dependent measures. Signif- significantly lower nonverbal social skills than the control
icant main effects were followed up with analyses of group (p’s<0.006). There were no other significant group
covariance (ANCOVA) tests on the dependent variables differences following Bonferroni correction.


Table 2 Group Differences on Social Skills Rating System (SSRS) and Verbal and Nonverbal Social Behavior Measures as Completed by
Primary Caregivers

Measure Selective mutism Mixed anxiety Controls f-ratio p

Mean SD Mean SD Mean SD

Social competence measures
Social cooperation 11.4 (3.6) 10.6 (3.8) 12.4 (3.0) 1.8 0.175
Social assertion 11.0b (3.5) 12.5a (3.9) 16.1a,b (3.3) 17.8 0.0005
Social responsibility 9.9c,d (3.7) 11.8c (2.9) 13.6d (2.9) 13.5 0.0005
Self-control 11.9 (2.8) 10.9 (3.9) 13.5 (3.8) 3.5 0.034
Total social skills 44.2e (9.1) 45.9f (10.0) 48.3e,f (11.0) 12.3 0.0005
Problem behavior measures
Externalizing behaviors 3.7 (2.1) 4.8 (2.9) 3.4 (2.4) 2.0 0.139
Internalizing behaviors 5.6g (2.2) 5.9h (3.1) 2.9g,h (2.4) 11.2 0.0005
Hyperactive behaviors 3.6 (2.5) 5.3 (2.8) 4.1 (2.7) 3.0 0.054
Verbal and nonverbal behavior measures
Verbal social skills 10.8i,j (3.2) 13.8i (3.8) 16.1j (4.0) 22.8 0.0005
Nonverbal social skills 15.4k (4.2) 15.7l (4.1) 20.2k,l (4.8) 12.5 0.0005
Nonverbal social cooperation 15.8 (3.5) 13.6 (4.0) 16.3 (4.5) 3.7 0.028

Identical superscripts indicate statistical significance between those groups

SSRS-Parent Version: Problem Behaviors SM group had lower verbal social skills than the MA and
control groups (p<0.006; see Table 3 and Fig. 2). The SM
The MANCOVA indicated a significant main effect for group was also lower in nonverbal social skills than the
group on the problem behavior subscales (Wilks’Λ, F(6, control group (p<0.006), and the MA group had lower
202) = 5.088, p=0.002), but only for the internalizing
subscale (see Table 2 and Fig. 1). Follow up analyses
supported our hypothesis that the SM and MA groups
had significantly higher internalizing behaviors than the
control group (p<0.02), but they did not differ from each
other.

SSRS-Teacher Version: Social Competence

The MANCOVA indicated a significant multivariate main
effect for group on the social skills subscales (Wilks’Λ, F(6,
194) = 9.713, p=0.0005; see Table 3). A one-way ANCOVA
also revealed a significant main effect for group on the total
social skills scale (F(2, 99) = 9.126, p=0.001). Follow-up
tests indicated that the SM and MA groups had significantly
lower self-control (p’s<0.006) and total social skills than the
control group (p’s<0.02). Teachers also rated children with
SM lower in social assertion skills than the MA and control
group (p’s<0.006). Additionally, children with MA were
considered to be lower in social cooperation skills than the
control group (p<0.006).

SSRS-Teacher Version: Verbal and Nonverbal Social Skills Note: ** p < .02 for SSRS-Parent Version
** p < .006 for SSRS-Teacher Version
The MANCOVA revealed a significant main effect of group
Fig. 1 Primary caregiver and teacher report of internalizing behaviors
(Wilks’Λ, F(6,196) = 12.406, p=0.0005) on all of the on the Social Skills Rating System (SSRS). Note: Internalizing
subscales (see Table 3). Follow-up tests showed that the behaviors were z-scored to standardize comparison across informants


Table 3 Group Differences on Social Skills Rating System (SSRS) and Verbal and Nonverbal Social Behavior Measures as Completed by
Teachers



Social competence measures
Social cooperation 14.5 (4.0) 12.9a (5.5) 16.6a (3.8) 4.8 0.010
Social assertion 5.0b,c (3.6) 10.3b (4.7) 11.9c (4.8) 22.5 0.0005
Self-control 12.6d (4.0) 12.7e (5.0) 16.3d,e (2.2) 5.8 0.004
Total social skills 32.0f (8.8) 35.8g (13.1) 44.7f,g (6.1) 9.1 0.0005
Problem behavior measures
Externalizing behaviors 0.5h (1.2) 2.9h,i (3.6) 0.6i (1.3) 8.0 0.001
Internalizing behaviors 6.6k (3.2) 4.9j (3.1) 1.7j,k (1.8) 17.5 0.0005
Hyperactive behaviors 2.2 (2.3) 4.3 (4.0) 1.8 (2.4) 5.2 0.007
Verbal and nonverbal behavior measures
Verbal social skills 2.0l,m (2.4) 6.9l (3.1) 7.8m (2.2) 33.6 0.0005
Nonverbal classroom cooperation and competence 18.1 (4.9) 16.n (7.1) 21.2n (4.2) 7.0 0.001
Nonverbal social interactions 10.9o (4.8) 12.7 (4.6) 15.7o (2.4) 5.5 0.005


classroom cooperation and competence skills compared to (Wilks’Λ, F(6,170) = 8.774, p=0.0005; see Table 3). In line
the control group (p<0.006). with our predictions, the SM and MA groups had
significantly higher internalizing behavior scores than the
SSRS-Teacher Version: Problem Behaviors control group (p <.006; see Table 3 and Fig. 1). The SM
and control groups had significantly lower externalizing
The MANCOVA revealed a significant multivariate main behaviors than the MA group (p’s<0.006). There were no
effect for group on all of the problem behavior subscales other group differences following Bonferroni correction.

Note: ** p < .006
Note: ** p < .003
Fig. 2 Primary caregiver and teacher report of verbal social skills on
the Social Skills Rating System (SSRS). Note: Verbal social skills Fig. 3 Primary caregiver report of social anxiety on the Screen for
were z-scored to standardize comparison across informants Child Related Emotional Disorders (SCARED)


SCARED—Parent Version Our findings support and extend recent research (e.g.,
Cunningham et al. 2004, 2006; Vecchio and Kearney
Anxiety Subscales The MANCOVA revealed a significant 2005), suggesting that children with SM appear less
multivariate main effect for group (F(10, 284) = 12.5, p= socially competent and more prone to internalizing behav-
0.0005) on all of the subscales (see Table 4). A one-way iors compared to controls as reported by primary caregivers
ANCOVA also showed a significant main effect for group and teachers. More specifically, children with SM were
on the total anxiety score (F(2, 146) = 28.4, p=0.0005). rated significantly lower than controls on teacher-reported
While the SM and MA groups had significantly higher social assertion, self-control and total social skills and on
GAD, separation anxiety, and school avoidance scores (all primary caregiver reported social responsibility and total
p’s<0.003) as well as higher total anxiety (p<0.02) than the social skills. Furthermore, consistent with findings by
control group, the two groups did differ from each other on Cunningham et al. (2006), children with SM were rated
levels of social anxiety and panic/somatic symptoms. More by both primary caregivers and teachers lower on verbal
specifically, the SM group had higher social anxiety scores social skills compared to both the MA and control groups.
than the MA group and the control group and the MA Consistent with our predictions, we also found that primary
group had higher social anxiety scores than the control caregivers indicated greater social anxiety levels in children
group (see Fig. 3). The MA group also had higher panic/ with SM than the children reported for themselves, which is
somatic symptoms compared to the SM and control groups supportive of the idea that children with SM may use their
(all p’s<0.003). mutism as a compensatory strategy to reduce their anxiety
(Yeganeh et al. 2003, 2006).
SCARED—Child Version As expected, given the general agreement in the literature
that SM should be better classified as an anxiety disorder (e.g.
There were no significant group differences. Anstendig 1999; Sharp et al. 2007; Standart and Le Couteur
2003), children with SM, and children with MA, did not
SCARED—Parent and Child Comparisons significantly differ on many of the social skills and anxiety
measures regardless of informant. For example, the SM and
A paired-samples t-test on the social anxiety subscale of the MA groups did not significantly differ on internalizing
SCARED indicated significantly greater report of child behaviors, social cooperation, self-control, total social skills,
social anxiety by primary caregivers (M=11.7, SD=2.7) and on teacher reported nonverbal social skills, and class-
than self-report of social anxiety by the children (M=7.7, room cooperation and competence. The SM and MA groups
SD=3.5) (t(35) = 6.1, p<0.01). additionally did not differ on primary caregiver reported
internalizing behaviors, social assertion, self-control, nonver-
Discussion bal social skills and total social skills. Also in line with our
predictions, children with SM and anxiety disorders were not
The goal of the present study was to examine group significantly different on behaviors reflecting GAD, separa-
differences among children with SM, mixed anxiety, and tion anxiety, school avoidance, and overall anxiety, although
controls on measures of behavioral and socio-emotional primary caregivers rated the SM group significantly higher in
functioning. We used a relatively large sample size, multi- behaviors reflecting social anxiety than the MA and
informant report (i.e. primary caregiver, teacher, and child control groups. Taken together, these results suggest that
self-report) and included an anxious comparison group. deficits in social abilities are evident in both children with

Table 4 Group Differences on the Screen for Child Anxiety Related Emotional Disorders (SCARED) as Completed by Primary Caregivers



Panic/significant somatic symptoms 3.1a (2.9) 7.7a,b (4.6) 3.7b (3.0) 11.3 0.0005
Generalized anxiety disorder 6.6c (4.9) 8.7d (5.5) 2.6c,d (3.2) 18.1 0.0005
Separation anxiety disorder 5.7e (3.6) 6.5f (4.3) 2.6e,f (3.1) 11.5 0.0005
Social anxiety disorder 11.7g,h (2.7) 7.7g,i (4.6) 3.7h,i (3.0) 47.6 0.0005
School avoidance 1.9j (2.0) 2.4k (2.0) 0.5j,k (1.0) 13.9 0.0005
Total anxiety 28.9l (11.4) 30.2m (16.2) 10.6l,m (9.3) 28.4 0.0005



SM and children with anxiety disorders. Furthermore, the Chair in Patient-Centred Health Care. The authors would like to thank
Lindsay Bennett, Sue McKee, Renee Nossal, Matilda Nowakowski,
findings suggest that SM may be considered an anxiety
and Jamie Sawyer for their assistance with data collection. We would
disorder characterized by social anxiety. More detailed also like to thank the many children, their primary caregivers and
observational analyses of the types of social inhibitions teachers for their participation in the study.
experienced by children and youth with social phobia but
who speak at school versus those with SM and SP versus References
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