La Salle University
School of Nursing and Health Sciences
Speech-Language-Hearing Science Program
STATEMENT OF VOLUNTARY INFORMED CONSENT
Assessing Speech-Language Skills in Children with Selective Mutism
By signing this paper, I am acknowledging my interest to take part in a study about selective mutism in children. This study is supported by the Selective Mutism Anxiety Research Treatment Center in cooperation with La Salle University Speech-Language-Hearing Science Program.
I, _____________________________ understand and willingly agree to participate in the Assessing Speech-Language Skills in Children with Selective Mutism Study. This study is intended to evaluate children suspected of selective mutism and will be conducted at the Selective Mutism Anxiety Research and Treatment Center ( Smart Center ) in Jenkintown , PA. The aims of this study are to determine if parents can be trained to effectively administer selected speech-language tests to their children and to help investigators determine if children’s speech-language difficulties are anxiety-based or an actual receptive / expressive speech-language disorder. Children and their parents will be randomly assigned to one of two groups based upon order of assessment: parent testing first followed by professional testing or professional testing first followed by parent testing. The testing materials and tasks will be the same in both situations.
All information will be kept strictly confidential. Names of participants or any identifying information will not appear in any published reports or in any documentation. Participation is completely voluntary. Parent and children will not be placed at any risk and are free to leave the study at any time. There is no penalty if you choose to withdraw from the study.
This study has crucial implications for treatment of children suffering from selective mutism and for development of appropriate school-based accommodations and intervention. Children with selective mutism become mute and have great difficulty communicating when anxiety is high and comfort level is low. Social anxiety causes children to lack initiative in speaking. Some children are sent to speech-language therapy with a diagnosis of an expressive language disorder when in reality it is the child’s anxiety that is causing the communication impairment symptoms. Differential diagnosis is needed. More accurate information is essential to determine if a child with selective mutism has an accompanying speech-language disorder that is impacting effective communication. Proper diagnosis is necessary so that the child can receive proper school accommodations and interventions. A false or missed diagnosis often leads to inappropriate school placement and misdirected treatment.
At the beginning of this study, parents will be trained by a certified and licensed speech-language pathologist or supervised graduate student to administer speech-language tests. At the same time the parent is administering these tests, the evaluator will view the testing through a one-way mirror for later comparison and scoring. For children who cannot comply with the testing on site, parents may attempt to complete the assessments at home, videotaping the session for later analysis. Parents in this study will also complete questionnaires about their child’s development and behavior in addition to providing a social communication history.
After the session is complete, parents may schedule a brief follow-up session (free of charge) to review and discuss their child’s assessment results, provided both verbally and in writing. The information will provide suggestions for enhancing communication and follow-up recommendations.
Participation in this study does not imply that the child will be undergoing specific treatment at the Smart Center. Communication with parents will take place after the study during the study follow-up visit.
If you have any questions, feel free to contact:
Evelyn R. Klein, Ph.D., CCC-SLP
Certified & Licensed Speech-Language Pathologist & Psychologist
Associate Professor
klein@lasalle.edu (email address)
215-951-1433 (office)
"I agree to participate in this study with my child and any questions I have about the study will be answered prior to participating. I may direct additional questions regarding study specifics to the evaluators at the follow-up visit. I agree to participate in the selective mutism study described above and may withdraw at any time."
___________________________ _________________
Signature of Parent Participant Today's Date
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Child's Full Name Child's Date of Birth
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Phone Number (best time to call) E-mail address
Please sign & return the entire document to: Dr. Evelyn Klein, La Salle University , 1900 West Olney Ave. , Wister Hall, Philadelphia , PA 19141
Please keep a copy for yourself!