Dear Participant,
You have successfully entered the survey questionnaire site. As the parent of a child with selective mutism, you are invited to participate in this survey designed to help practitioners understand the decision-making process of parents in selecting treatments for their children diagnosed with selective mutism.
This survey consists of seven (7) sections:
Section I: Information on the Person Completing the Survey
Section II: Information about the Child's Family
Section III: Information about the Child's Mother
Section IV: Information about the Child's Father
Section V: Information about the Child Diagnosed with Selective Mutism
Section VI: Participant Feedback
Section VII: Information from the Researcher
Your survey responses will be stricly confidential and data from this research will be reported only in the aggregate. If you have questions at any time about the survey or the procedures used in this study, please contact Debbie Constable at 512-799-0167 or by email at [email protected].
Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can skip questions or withdraw from the survey at any point.
Please note: To complete this questionnaire, you must respond to each question. If you choose to skip a question, you still must respond by clicking the "No response" option for that particular question.
Thank you very much for your time and support. Please click on the Continue button below to complete the survey.
Section I: Information about the Person Completing the Questionnaire
Directions: Please complete this section about you, the person completing this questionnaire. 1. How many children do you have with selective mutism? (Please note: To participate in this study, you must have at least one child diagnosed with selective mutism. If you have more than one, please fill out a separate survey for each.) 2. What is your relationship to the child diagnosed with selective mutism? 3. What language do you use most often (your primary language)? 4. Where or from whom have you received information about the CHARACTERISTICS of selective mutism? (Please check all that apply.) 5. Which of the following behaviors do you recognize as characteristics of children with selective mutism? (Please check all that apply.) 6. Where or from whom have you received information about TREATMENT for selective mutism? (Please check all that apply.) 7. Which of the following do you recognized as reasonable treatment options for children with selective mutism? (Please check all that apply.) Section II: Information about the Child's Immediate Family
Directions: Please answer questions in this section about the immediate family of the child with selective mutism. In this section, "parents" refers to the current legal guardians of the child. What is the marital status of the child's parents? 2. What is the annual income of the child's family? 3. What is the child's country of residence? 4. How would you describe the child's residence? 5. How long has the child lived in the current residence? 6. How many times has the child moved within the past 10 years? 7. What were the reasons for the changes in residence? (Please check all that apply.) Section III: Information about the Child's Mother
Directions: Please complete this section about the child's mother. In this section, "mother" refers to the child's current female legal guardian. 1. Is this child's current female legal guardian the child's biological mother? 2. How old is the child's mother? (Please remember: For the remainder of this section, you are answering questions about the child's current female legal guardian, regardless if whether or not this is the child's biological mother.) 3. What is the ethnicity of the child's mother? 4. What is the religious affiliation (Catholic, Protestant, Buddist, none, etc.) of the child's mother? (Please note: If you choose to not respond to this question, please type the words "no response" then continue to the next question.) 5. What is the highest level of education of the child's mother? 6. What was the educational focus of the child's mother after high school? 7. What is the occupation of the child's mother? 8. Which members of the mother's family, if any, have experienced anxiety-related disorders? (Please check all that apply.) 9. Has the child's mother taken medication as a treatment for anxiety? 10. Please select the correct option for the following questions regarding the behavior of the child's CURRENT legal guardian. 11. Please share any other information about the child's mother you believe is relevant to this study. Section IV: Information about the Child's Father
Directions: Please complete this section about the child's father. In this section, "father" refers to the child's current male legal guardian. 1. Is this child's current male legal guardian the child's biological father? 2. How old is the child's father? (Please remember: For the remainder of this section, you are answering questions about the child's current male legal guardian, regardless if whether or not this is the child's biological father.) 3. What is the ethnicity of the child's father? 4. What is the religious affiliation (Catholic, Protestant, Buddist, none, etc.) of the child's father? (Please note: If you choose to not respond to this question, please type the words "no response" then continue to the next question.) 5. What is the highest level of education of the child's father? 6. What was the educational focus of the child's father after high school? 7. What is the occupation of the child's father? 8. Which members of the father's family, if any, have experienced anxiety-related disorders? (Please check all that apply.) 9. Has the child's father taken medication as a treatment for anxiety? 10. Please select the correct option for the following questions regarding the behavior of the child's CURRENT male legal guardian. 11. Please share any other information about the child's father you believe is relevant to this study. Section V: Information about the Child Diagnosed with Selective Murtism
Directions: Please complete this section about the child diagnosed with selective mutism.
The five parts of this section include:Part A: Background Information
Part B: Characteristics of Selective Mutism
Part C: Diagnosis
Part D: Treatment and Outcomes
Part E: Academics Section V - Part A: Background Information 1. What is your child's gender? 5. Prior to displaying characteristics of selective mutism, which of the following events (if any) did your child experience? (Please check all that apply.) 6. Please share any other information about your child's background that may be of value in this study. (If none, please type "none." If skipping this question, please type "no response.") Section V - Part B: Characteristics of Selective Mutism 2. Who first recognized your child was displaying characteristics of selective mutims? (Please check all that apply.) 3. When first recognized, which of the following behaviors associated with selective mutism did your child display in the following environments? 4. Which of the following behaviors associated with selective mutism does your child CURRENTLY display in the following environments? Section V - Part C: Diagnosis 2. Who diagnosed your child with selective mutism? 3. Has your child been diagnosed with any medical and/or psychological condition other than selective mutism? (Please check all that apply.) 4. Please provide any additional information about your child's diagnosis that you believe could be of value to this study. (If nothing, please type "none." If you choose to skip this questions, please type "no response.") Section V - Part D: Treatment and Outcomes 1. Is your child currently receiving treatment for selective mutism? 1.2.a. Why is your child not receiving treatment for selective mutism at this time? 1.2.b. Do you plan to seek treatment for your child with selective mutism? 1.1.a. What treatment is your child currently receiving? If you do not know an specific name for the treatment, please describe it. 1.1.b. At what age did your child begin receiving this treatment? Please type your response in years and months. 1.1.c. Where or from whom did you hear about this treatment? 1.1.d. Who is providing this treatment? (Please list everyone involved and their specific roles.) 1.1.e. What effect has this treatment had on your child? 2. Did your child receive treatment for selective mutism in the past? 2.b. Why has your child not received treatment for selective mutism in the past? 2.1.a. What treatment did your child receive? If you do not know an specific name for the treatment, please describe it. 2.1.b. At what age did your child begin receiving this treatment? Please type your response in years and months. 2.1.c. At what age did your child stop receiving this treatment? Please type your response in years and months. 2.1.d. Where or from whom did you hear about this treatment? 2.1.e. Who provided this treatment? (Please list everyone involved and their specific roles.) 2.1.f. What effect did this treatment have on your child? 2.1.g. Why did your child stop receiving this treatment? 2.1.h. Is there another treatment your child previously received? 2.2.a. What treatment did your child receive? If you do not know an specific name for the treatment, please describe it. 2.2.b. At what age did your child begin receiving this treatment? Please type your response in years and months. 2.2.c. At what age did your child stop receiving this treatment? Please type your response in years and months. 2.2.d. Where or from whom did you hear about this treatment? 2.2.e. Who provided this treatment? (Please list everyone involved and their specific roles.) 2.2.f. What effect did this treatment have on your child? (The option "No Response" means you are choosing to skip that particular question.) 2.2.g. Why did your child stop receiving this treatment? 2.2.h. Is there another treatment your child previously received? 2.3.a. What treatment did your child receive? If you do not know an specific name for the treatment, please describe it. 2.3.b. At what age did your child begin receiving this treatment? Please type your response in years and months. 2.3.c. At what age did your child stop receiving this treatment? Please type your response in years and months. 2.3.d. Where or from whom did you hear about this treatment? 2.3.e. Who provided this treatment? (Please list everyone involved and their specific roles.) 2.3.f. What effect did this treatment have on your child? (Remember, the "No Response" option means you have no response and are skipping that particular question.) 2.3.g. Why did your child stop receiving this treatment? 2.3.h. Is there another treatment your child previously received? 2.3.i. What other treatments has your child received in the past? 3. Please share any other information about your child's treatment and outcomes that you believe could be valuable to this study. Section V - Part E: Academics 1. What type of education is your child receiving? 2. What is your child's current school setting? 3. In what grade (or year) is your child currently enrolled? 4. What is your child's current instructional setting? 4.a. What type(s) of related services does your child receive? 5. How does your child perform academically (based on grades received) in the following classes compared to his/her peers? 8. Please share any other information about your child's academics or school experiences that you believe may be valuable to this study. (If nothing, please type "none." If you choose to skip this question, please type "no response.") Section VI: Participant Feedback
Directions: Please complete this section regarding your experience as a participant in this study. 1. How did you hear about this study? 2. In how many other studies of selective mutism (not counting this one) have you or your child with selective mutism been a participant? 8. Please provide any additional information about your participation in this study that you believe might be of value to the researcher. (If you don't have any additional information to share, please type "none." If you choose to skip this question, please type "no response.") Section VII: Information from the Researcher The results of this study will be posted at http://www.constable.ws upon completion of the study. (Anticipated study completion date: June 1, 2005.)
For more information on Selective Mutism, check out the following organizations:
The Selective Mutism Foundation, Inc.
http://www.selectivemutismfoundation.org/
The Selective Mutism Group - Childhood Anxiety Network
http://www.selectivemutism.org/
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