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Selective Mutism Questionnaire

This document is a 23-item Selective Mutism Questionnaire (SMQ) that is used to assess how frequently a child speaks in different social situations. The questionnaire is divided into three sections - at school, home/family, and social situations outside of school. Parents are asked to rate how often statements about the child's speech are true, using a scale from Always to Never. The final five questions ask parents to rate how much the child's lack of speech interferes with different areas of life and how much it bothers the child and parents. Scores are calculated by assigning numerical values to the response options, with higher total scores indicating more frequent speech.

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Lidia Rivera
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605 views

Selective Mutism Questionnaire

This document is a 23-item Selective Mutism Questionnaire (SMQ) that is used to assess how frequently a child speaks in different social situations. The questionnaire is divided into three sections - at school, home/family, and social situations outside of school. Parents are asked to rate how often statements about the child's speech are true, using a scale from Always to Never. The final five questions ask parents to rate how much the child's lack of speech interferes with different areas of life and how much it bothers the child and parents. Scores are calculated by assigning numerical values to the response options, with higher total scores indicating more frequent speech.

Uploaded by

Lidia Rivera
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Selective Mutism Questionnaire (SMQ) ©

Please consider your child’s behavior in the last two weeks and rate how frequently each statement is true
for your child.

AT SCHOOL

1. When appropriate, my child talks to selected peers


(his/her friends) at school. Always Often Seldom Never

2. When appropriate, my child talks to most peers at


school. Always Often Seldom Never

3. When my child is asked a question by his/her teacher,


s/he answers. Always Often Seldom Never

4. When appropriate, my child asks his or her teacher


questions. Always Often Seldom Never

5. When appropriate, my child speaks to most teachers


or staff at school. Always Often Seldom Never

6. When appropriate, my child speaks in groups or in


front of the class. Always Often Seldom Never

HOME/ FAMILY

7. When appropriate, my child talks to family members


living at home when other people are present. Always Often Seldom Never

8. When appropriate, my child talks to family members


while in unfamiliar places. Always Often Seldom Never

9. When appropriate, my child talks to family members that


don’t live with him/her (e.g. grandparent, cousin). Always Often Seldom Never

10. When appropriate, my child talks on the phone


to his/her parents and siblings. Always Often Seldom Never

11. When appropriate, my child speaks with family


friends who are well-known to him/her. Always Often Seldom Never

12. My child speaks to at least one babysitter. Always Often Seldom Never N/A
IN SOCIAL SITUATIONS (OUTSIDE OF SCHOOL)

13. When appropriate, my child speaks with other


children who s/he doesn’t know. Always Often Seldom Never

14. When appropriate, my child speaks with family


friends who s/he doesn’t know. Always Often Seldom Never

15. When appropriate, my child speaks with his or her


doctor and/or dentist. Always Often Seldom Never

16. When appropriate, my child speaks to store clerks


and/or waiters. Always Often Seldom Never

17. When appropriate, my child talks when in clubs,


teams or organized activities outside of school. Always Often Seldom Never N/A

Interference/Distress*

18. How much does not talking interfere


with school for your child? Not at all Slightly Moderately Extremely

19. How much does not talking interfere


with family relationships? Not at all Slightly Moderately Extremely

20. How much does not talking interfere in


social situations for your child? Not at all Slightly Moderately Extremely

21. Overall, how much does not talking


interfere with life for your child? Not at all Slightly Moderately Extremely

22. Overall, how much does not talking


bother your child? Not at all Slightly Moderately Extremely

23. Overall, how much does your child’s


not talking bother you? Not at all Slightly Moderately Extremely

Scoring: Always = 3; Often = 2; Seldom = 1; Never = 0

*These items are not included in total score and are for clinical purposes only.

Developed by R. Lindsey Bergman, Phd. Reproduce only with permission

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