Family accommodation and selective mutism: Evaluating the Survey of Accommodation in Verbal Encounters (SAVE)

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Furr, Aileen Herrera, Leah Feinberg, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9295482/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Family accommodation is a key environmental factor that can maintain and reinforce child anxiety disorders, but research on accommodation specific to childhood selective mutism (SM) is limited and inconsistent. The absence of a supported measure of accommodation specifically in verbal contexts may explain, in part, why research on accommodation in the families of youth with SM has lagged. In a sample of 412 treatment-seeking anxious youth ages 2–18 years (52.7% with SM; 56.7% female; ~50% Hispanic and/or Latinx), the present study examined the psychometric properties of the Survey of Accommodation in Verbal Encounters (SAVE) – a newly developed caregiver-report scale assessing the frequency of parental accommodation specifically in situations in which child verbal communication is expected. Confirmatory factor analysis supported an 18-item, four-factor structure corresponding to four SAVE subscales: Surrogate Speaking, Permitting of Whispered Communication, Permitting of Nonverbal Communication, and Instrumental Accommodation. The SAVE also demonstrated strong reliability, convergent and divergent validity, incremental utility, and clinical relevance to SM. These findings offer support for the SAVE as the first measure of parental accommodation in contexts in which child speech is expected. Results also provide empirical insight into the frequency, patterns, and correlates of such accommodation among families of anxious children with and without SM. The SAVE appears to offer a useful tool for researchers and clinicians to assess SM-specific accommodation and key family dynamics associated with verbal reticence in youth. family accommodation accommodation selective mutism SM child anxiety assessment Introduction Selective mutism (SM) is a highly interfering anxiety disorder characterized by a child’s failure to speak in certain social and unfamiliar settings, despite their ability to produce fluent speech in other situations (American Psychiatric Association, 2022 ). Studies suggest SM affects at least 0.2-2% of the population, with documented prevalence estimates continue to steadily rising with improved awareness and assessment (Muris & Ollendick, 2015 ). The absence of verbal communication in specific social situations among individuals with SM is associated with considerable impairments in school achievement, social interactions, and general functioning in public places where speech is expected. SM is also associated with elevated psychiatric comorbidity (most commonly social anxiety disorder) (Carbone et al., 2010 ; Driessen et al., 2020 ), and over the long-term can predict ongoing social skills deficits, educational and occupational challenges, and low self-esteem into adolescence and adulthood (Remschmidt et al., 2001 ; Steinhausen et al., 2006 ; Tomohisa et al., 2023 ). Despite the serious impairments and interference associated with SM, research on the phenomenology and family dynamics of the disorder has lagged relative to other anxiety disorders. Supported cognitive-behavioral treatments (CBTs) for childhood SM target contextual factors of SM by working directly with the important individuals in affected children’s lives (e.g., parents, teachers, peers). Recent years have witnessed particularly promising treatment outcomes associated with family-based SM programs adapted from Parent-Child Interaction Therapy (PCIT), school-based programs that engage with teachers to adjust classroom practices, and intensive group programs that implement interventions in structured peer contexts (e.g., Bergman et al., 2013 ; Cornacchio et al., 2019 ; Hong et al., 2023 ; Lang et al., 2016 ; Oerbeck et al., 2018 ). Many of the most successful SM programs emphasize key environmental factors that can reinforce and maintain patterns of anxiety, avoidance, and restricted speech – e.g., overly protective parenting styles and avoidance-enabling teaching styles (see Kovac & Furr, 2018; Lorenzo et al., 2021 ). To reduce these behaviors, caregivers often play an active role in treatment, receiving psychoeducation on negative reinforcement cycles linked with inhibited child speech and receiving coaching in SM-specific strategies that promote child verbal communication (Lorenzo et al., 2021 ; Furr et al., 2020 ). Family accommodation is one of the key environmental factors increasingly targeted in CBTs for childhood SM. Originally studied in the context of obsessive-compulsive disorder (OCD; Calvocoressi et al., 1995 ), family accommodation refers to actions and behavioral changes by family members that are aimed to prevent, reduce, or alleviate their child’s immediate disorder-related distress (Lebowitz et al., 2012 ; Storch et al., 2007 ; Thompson-Hollands et al., 2014 ). For example, the caregiver of a child with OCD might turn the stove on and off repeatedly at the request of their child until the child is confident the stove is truly turned off. Although family accommodation may alleviate the child’s disorder-related distress in the short-term, this anxiety relief can be negatively reinforcing and can promote and maintain longer-term patterns of child avoidance (Thompson-Hollands et al., 2014 ). Moreover, family accommodation can interfere with the child’s ability to develop an independent sense of mastery and self-efficacy in the management of uncomfortable feelings, as the child learns to cope by relying on accommodating family members (Ginsburg et al., 2004 ; Norman et al., 2015 ). The study of family accommodation has expanded beyond its initial focus on children with OCD to encompass children across the full anxiety spectrum (Kagan et al., 2016 ; Kerns et al., 2017 ; La Buissonnière-Ariza et al., 2018 ; Lebowitz et al., 2013 ; Storch et al., 2015 a; Thompson-Hollands et al., 2014 ). Research has found that as many as 88–97% of caregivers of children with anxiety disorders engage in at least some form of accommodation, with higher levels of accommodation linked with greater symptom severity, functional and family impairment, caregiver burden, and negative treatment outcomes (Kagan et al., 2016 ; La Buissonnière-Ariza et al., 2018 ; Lebowitz et al., 2012 ; Merlo et al., 2009 ; Storch et al., 2007 ; Storch et al., 2015 a; Thompson-Hollands et al., 2014 ). Treatments for anxious youth that directly target family accommodation have shown great success (e.g., Comer et al., 2017 ; Comer et al., 2021 ; Lebowitz et al., 2020 ; Storch et al., 2024 ). The investigation and targeted treatment of accommodation in families of anxious youth has been greatly served by caregiver measures that demonstrate strong psychometric properties – e.g., the Family Accommodation Scale – Anxiety (FASA; Lebowitz et al., 2013 ; Lebowitz et al., 2020 ), the Pediatric Accommodation Scale (PAS; Benito et al., 2015 ), and the Family Accommodation Checklist and Interference Scale (FACLIS; Thompson-Hollands et al., 2014 ). That said, the psychometric properties of these measures have not been specifically evaluated within the SM population. The absence of support for a measure of accommodation specifically in SM populations may help explain, in part, why research on accommodation in the families of youth with SM has lagged relative to other anxiety disorders (Iniesta-Sepúlveda et al., 2021). To date, only three studies have examined family accommodation in relation to SM, and findings across these studies have been mixed. Specifically, using the FASA, Freitag and colleagues ( 2024 ) and Shorer and colleagues ( 2023 ) both found family accommodation to have significant associations with increased SM severity, whereas Fisher and colleagues ( 2025 ) did not. Limited research and mixed findings on the associations between family accommodation and SM symptoms underscore the need for a reliable and valid measure of SM-specific family accommodation. It is not clear that the FASA, PAS, or FACLIS offer a preferred approach to assessing accommodation patterns specific to verbal encounters. The FASA and PAS offer generic assessments of the overall accommodation frequency across broad domains of parental behavior (i.e., modifying routines, facilitating avoidance, providing reassurance) and does not specify anything directly about parental behaviors in verbal contexts. Parents of youth with SM may not perceive speaking on behalf of their child to be a form of accommodation, and thus their responses to generic family accommodation measures, such as the FASA or PAS, may suggest inaccurately low levels of accommodation (Fisher et al., 2025 ). Whereas the FACLIS provides a checklist of specific accommodation forms and does not require the parent to self-identify various behaviors as accommodating, only two of the 20 items pertain to verbal encounters, and thus total scores are not poised to specifically capture verbal accommodation behaviors. Importantly, family accommodation presentations vary across different anxiety disorders. In the case of SM, a caregiver might speak on behalf of their child, allow their child to communicate via whispers or nonverbal gestures, or work to excuse their child from speaking situations (e.g., presentations) (Fisher et al., 2025 ; Furr et al., 2020 ; Lorenzo et al., 2021 ). Accordingly, measures that evaluate family accommodation more generically or broadly, or that focus predominantly on accommodation forms that occur outside of situations in which speech is expected, may underestimate accommodation in families of youth with SM. The current study developed the Survey of Accommodation in Verbal Encounters (SAVE) to assess the frequency of parental accommodations as they occur specifically in situations in which child verbal communication is expected. In a sample of treatment-seeking anxious youth in which roughly half met criteria for SM, we examined the preliminary structure, reliability, and validity of the SAVE. We predicted the SAVE would exhibit good psychometric properties as evidenced by high internal consistency and strong concurrent, divergent, and incremental validity. Given that accommodations evaluated in the SAVE are specific to verbal contexts, we further hypothesized that the measure would show improved performance over generic family accommodation measures and that scores would be significantly higher for children whose anxiety disorder profiles include SM compared to children whose anxiety disorder profiles do not include SM. Methods Participants Participants were 412 children and adolescents between the ages of 2 and 18 years ( M = 8.20, SD = 3.86) seeking clinical services for anxiety-related concerns, and their caregivers. Families were recruited across two university-affiliated specialty clinics for child anxiety – the Mental health Interventions and Novel Therapeutics (MINT) Program in the Center for Children and Families ( n = 217) at Florida International University (FIU) and the Center for Anxiety and Related Disorders ( n = 195) at Boston University (BU). Families who were receiving services at one of these clinics and completed the SAVE were eligible for the present study. Both clinics offer specialty SM treatment programs, affording an enriched sample with a higher rate of SM than that found in most child anxiety samples [ n = 217 (52.7%) with SM]. Participating families completed study measures as part of their clinical intake via REDCap, a secure web application for managing online surveys and data. Caregivers had the option to complete the questionnaires in English or Spanish. Table 1 presents sociodemographic and clinical characteristics of the sample. Most participating caregivers were college-educated mothers reporting a range of household income levels. A slight majority of the child sample identified as female. Hispanic and/or Latinx participants made up approximately half the sample. Although most families spoke English in the home (88.5%), 115 reported speaking Spanish in the household, and 82 spoke another language. Youth met DSM criteria for an average of 1.50 diagnoses (SD = 1.01). Table 1 Sociodemographic characteristics and diagnostic makeup of the sample. Child Age (years) a 12 Child Gender b Female Male Non-Binary or Another Gender Identity N % 170 167 69 232 171 6 41.9 41.1 17.0 56.7 41.8 1.5 Child Race/Ethnicity c Non-Hispanic, White Hispanic/Latinx Asian Black Native Hawaiian Multiracial Another race not listed 146 121 41 19 1 49 14 49.5 40.1 10.0 4.6 0.2 11.9 6.3 Participating Caregiver b Mother Father 367 42 89.7 10.3 Annual Household Income b ≥ $ 200,000 $ 100,00 - $ 199,999 ≤ $ 99,999 153 120 136 37.4 29.3 33.3 Caregiver Education: (Highest Degree) d High school or equivalent Bachelor’s degree Graduate degree 60 123 222 14.8 30.4 54.8 Diagnoses c Selective mutism Social anxiety disorder Generalized anxiety disorder Specific phobia Separation anxiety disorder Obsessive compulsive disorder Attention-deficit/hyperactivity disorder Oppositional defiant disorder Depressive disorders 217 170 87 37 28 28 14 13 11 52.7 41.3 21.1 9.0 6.8 6.8 3.4 3.2 2.7 Note: a Based on n = 406 participants who provided these data. b Based on n = 409 participants who provided these data. c Participants could select more than one option. d Based on n = 405 participants who provided these data. Measures Survey of Accommodation in Verbal Encounters (SAVE) The SAVE is a caregiver-report measure developed for the current study to evaluate the frequency of parental accommodations specifically in situations in which verbalizations are expected of the child. An initial pool of 21 items conceptually divided into four sections was generated by two clinical psychologists with extensive expertise in SM and a doctoral student, in consultation with ten master’s- and doctoral-level therapists who carry a high volume of SM cases on their caseloads (see Supplemental Material 1 for a list of the 21 items in the initial SAVE item pool). All students involved in the development process were trainees in clinical or counseling psychology programs. Item-level questions were generated based on clinical experience and SM literature. The Spanish language version of the SAVE was subject to a thorough translation and back-translation process. Each item is assessed on a 0 (“never”) to 5 (“always”) scale and the measure is organized into four sections. Section 1 contained items assessing the frequency with which the caregiver speaks or answers for the child in various social situations (5 items initially), Section 2 contained items assessing the frequency with which the caregiver allows their child to whisper in their ear in various social situations (5 items initially), and Section 3 contained items assessing the frequency with which the caregiver allows their child to communicate nonverbally (e.g., by nodding or pointing) in various social situations (5 items initially). Consistent with existing functional assessment tools for SM (e.g., Social Communication Anxiety Inventory; Shipon-Blum, 2023 ), five different social situations assessed within each of these three sections were: (a) when child interacts with familiar adults, (b) when child interacts with strangers, (c) when child interacts with familiar peers, (d) when child interacts with unfamiliar peers, and (e) when child orders at a restaurant. Section 4 contained six items assessing the frequency with which caregivers actively work to modify various situations in which child speech may be required (e.g., speaking with the child’s teacher to get them out of speech-based assignments) or the frequency with which they make sure to accompany their child to places so they are available to assist if the child is required to speak (e.g., field trips). Internalizing and externalizing psychopathology The Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001 ) is a well-established, parent-report questionnaire assessing youth behavioral and emotional problems. For children < 6, caregivers completed the CBCL 1.5-5 (Achenbach and Rescorla, 2000 ) and for children ≥6 caregivers completed the CBCL 6–18 (Achenbach and Rescorla, 2001 ). Using a 3-point scale (0 = not true, 1 = somewhat or sometimes true, 2 = very true or often true), caregivers rate how well each item describes their child across the past 6 months. Raw scores are converted to standardized T-scores, normed by child age and sex. Higher scores reflect greater psychopathology. The CBCL has demonstrated excellent reliability and validity (Achenbach and Rescorla, 2001 , Ivanova et al., 2007 ). The higher-order, broadband Internalizing and Externalizing problem scales were used in the present analysis. Internal consistency in the current sample was good-to-excellent (i.e., CBCL 1.5-5: α Internalizing = 0.90, α Externalizing = 0.89; CBCL 6–18: α Internalizing = 0.84, α Externalizing = 0.87). Selective mutism symptoms The Selective Mutism Questionnaire (SMQ; Bergman et al., 2008 ) is a caregiver-report measure that captures the frequency of (and interference and distress associated with) a child’s failure to speak across social settings. Caregivers are provided with 17 statements describing typical situations in which child verbal communication is expected (e.g., “my child speaks to most teachers or staff at school”). Statements are categorized into three domains: at school, at home/with family, and in social/public situations (outside of school). A four-point scale ranging from 0 (“never”) to 3 (“always”) is used to rate how frequently the child speaks in each situation. Lower scores reflect lower frequencies of speaking behavior (i.e., more severe SM). Additional items assess interference and distress linked with SM symptoms. The SMQ has exhibited moderate-to-high internal consistency and strong convergent and discriminant validity (Bergman et al., 2008 ; α = 0.84 in present sample). Due to differences in assessment protocols across sites, the SMQ was only administered to a subset of n = 274 participants in the present sample. General family accommodation The Family Accommodation Checklist and Interference Scale (FACLIS; Thompson-Hollands et al., 2014 ) is a caregiver-report measure of the scope and interference of family accommodation in the families of anxious youth. The questionnaire provides a checklist of 20 specific forms of accommodation in which caregivers of youth with the common anxiety disorders often engage. Caregivers are asked which of the accommodations in the checklist they perform, and to then rate the extent to which each endorsed accommodation causes personal or family interference on a scale from 0 (“no interference”) to 8 (“extreme interference”). An accommodation scope score is generated by tallying the number of endorsed accommodation items (FACLIS Scope), and a total interference score is generated by summing the interference ratings (FACLIS Total Interference). The FACLIS has shown good reliability and validity (Thompson-Hollands et al., 2014 ; α Scope = 0.78 and α Interference = 0.77 in present sample). Due to differences in assessment protocols across sites, the FACLIS was only administered to a subset of n = 293 participants in the present sample. The Family Accommodation Scale – Anxiety (FASA; Lebowitz et al., 2013 ) is another caregiver-report of general accommodation in families of children with the common anxiety disorders. The FASA is a 13-item measure of the frequency with which caregivers participate in their child’s anxiety-related behaviors, modify their functioning, and experience distress and emotional consequences that result from accommodation. The measure includes five items asking about participation in anxiety symptoms, four items on modifications of routines, and additional items on distress and consequences. Participation and modification items are rated on 5-point frequency scales ranging from 0 (“never”) to 4 (“daily”) and summed for an overall accommodation score. The FASA has shown strong convergent and divergent validity (Lebowitz et al., 2013 ; Lebowitz et al., 2020 ), satisfactory retest reliability, and excellent internal consistency (α = 0.91 in the present sample). Due to differences in assessment protocols across sites, the FASA was only administered to a subset of n = 216 participants in the present sample. Procedures Study procedures were approved by FIU and BU Institutional Review Boards. Clinic procedures at both sites screen out for current psychotic symptoms, homicidal/suicidal risk, ≥ 2 psychiatric hospitalizations, and/or moderate-to-severe intellectual impairments. Parents provided informed consent prior to participation, and children ≥ 7 years provided informed assent. Diagnostic assessments were conducted by trained master’s or doctoral graduate students, postdoctoral fellows, and licensed mental health counselors. At both sites, clinical interviewers received similar training and were supervised by licensed mental health professionals specializing in youth anxiety treatment. Training at both sites included didactics, multiple observations of live ADIS-IV-C/P interviews conducted by senior assessors, followed by interviews co-administered with senior assessors who interjected as necessary, and then interviews led by trainees being observed by senior assessors. All interviews were reviewed in group supervision meetings, and diagnostic decisions were determined collaboratively by consensus. Reliability checks on ADIS assessments have yielded high diagnostic agreement/interrater reliability at both sites ( κ > 0.80; see Comer et al., 2021 ; Cornacchio et al., 2019 ; Hong et al., 2023 ). Analytical Strategy Analyses were conducted in R and SPSS. To examine the SAVE factor structure and finalize the items, the initial item pool was subjected to confirmatory factor analysis (CFA). Given the ordinal nature of the SAVE data, models were estimated based on polychoric correlations matrices, using the weighted least squares with mean and variance-adjusted (WLSMV) method (Park, 2023 ). For comparison, the CFA was also estimated using maximum likelihood (ML) to assess the robustness of the findings. Given we had hypothesized measurement models, and given the analytic goal was model structure testing rather than structure discovery, CFA (rather than exploratory factor analysis, or EFA) was used to identify potential item alignments. EFA can also capitalize on chance in more modest clinical samples, and thus a theory-driven approach was used. Four theoretically guided models were tested and compared, including one model with all 21 items loading onto a single factor (i.e., Model 1: Unifactorial Model) and three additional four-factor models that were differentially structured around the measure’s four distinct sections. Model 2 tested a four-factor model that included all 21 original items loading onto factors that correspond to the four different sections of the initial SAVE item pool (i.e., Four-Factor, 21 Item Model). As parental accommodation may be less relevant during verbal encounters involving familiar adults (e.g., aunts/uncles), Model 3 tested a similar four-factor structure as in Model 2, but excluded items assessing accommodation when the child interacts with familiar adults (i.e., Four-Factor, 18 Item Model, excluding familiar adult interactions). Finally, as parental accommodation may be less relevant during verbal encounters involving familiar peers (e.g., best friends), Model 4 tested a similar four-factor structure as in Model 2, but excluded items assessing accommodation when the child interacts with familiar peers (i.e., Four-Factor, 18 Item Model, excluding familiar peer interactions). We did not run a fifth model testing a similar four-factor structure that excluded items assessing accommodation during encounters with familiar adults and during encounters with familiar peers, as there would be multiple factors with only 3 items, rendering the overall structure unstable (Knekta et al., 2019 ). Due to the parallel question formatting of the first three SAVE sections, all models accounted for the residuals of high correlations among identically worded sets of items. Conventional fit indices and cutoff guidelines were used to asses model fit (Hu & Bentler, 1999 ; Yu, 2002 ): Comparative Fit Index (CFI; values ≥0.95 considered good), Root Mean Square Error of Approximation (RMSEA; values ranging 0.06–0.08 considered fair, values ≤0.06 considered good), Standardized Root Mean Square Residual (SRMR; values ≤0.08 considered good). Models were interpreted as showing (a) “poor” fit if none (or only one) of the fit indices fell in the good range, (b) “acceptable” fit if two of the three indices (CFI, RMSEA, SRMR) fell in the good range, and (c) “good” fit if all three indices fell in the good range (Brown, 2015 ). After comparing CFAs to select the best final set of SAVE items and factor structure, Cronbach’s alphas, average inter-item correlation, and Spearman-Brown split-half reliability were computed to assess internal consistency. To examine concurrent validity, we examined associations between SAVE scores and measures of general family accommodation (i.e., FACLIS Scope, FACLIS Interference, FASA), SM symptoms (i.e., SMQ Total), and overall internalizing symptoms (i.e., CBCL Internalizing Problems). To assess divergent validity, we examined associations between SAVE scores and externalizing symptoms (i.e., CBCL Externalizing Problems). Given youth with SM tend to be younger and carry more comorbid diagnoses than anxious youth without SM (Viana et al., 2009 ), and given that accommodation patterns tend to be greater for younger children and children with higher case complexity (e.g., Thompson-Hollands et al., 2014 ), all validity analyses controlled for both child age and number of anxiety diagnoses. To evaluate clinical relevance of the SAVE to SM in particular, one-way ANCOVAs (controlling for child age and number of anxiety diagnoses) compared SAVE totals, subscale scores, and item scores across two anxiety groups: children whose anxiety disorder profile included SM ( n = 214) and children whose anxiety disorder profile did not ( n = 192). Given the number of comparisons involved, Holm-Bonferroni corrections (Holm, 1979) were applied before interpreting significance for this family of tests to reduce Type I error likelihood. Lastly, hierarchical regressions evaluated the incremental validity of the SAVE over existing measures of general family accommodation for assessing SM-specific accommodation. Three models were run, each comparing the SAVE with one of the following: the FACLIS Scope score, the FACLIS Interference score, and the FASA Total score. Change in explained variance when adding the SAVE as a predictor (ΔR 2 ) was interpreted as evidence of the SAVE’s incremental validity in predicting SM symptom severity above and beyond the variance accounted for by general family accommodation. Results Preliminary Findings SAVE Total scores in the sample ranged from 0 to 104 ( M = 36.31, SD = 24.50), with 96.1% of caregivers reporting they engage in at least one of the assessed accommodating behaviors in situations in which child verbal communication is expected. The most frequently endorsed accommodation was speaking or answering for their child when interacting with strangers. Specifically, 75.0% of caregivers in the full sample reported they do so at least “sometimes” (i.e. ≤ 2) and 57.3% reported they do so “often,” “very often,” or “always.” Among the subset of caregivers of youth with SM, these numbers were even higher, with 87.6% reporting they speak or answer for their child at least “sometimes” (i.e. ≤ 2) when interacting with a stranger, and 73.3% reporting they engage in this form of accommodation “often,” “very often,” or “always.” The least frequently endorsed caregiver accommodation on the SAVE was accompanying the child on field trips in case they are required to speak on the outing. Roughly 80% of caregivers in the full sample reported they “never” do this, although 20.7% of caregivers of youth with SM did do this at least “sometimes”. As expected, SAVE scores varied by child age ( β =-0.43, p <.001) and number of anxiety diagnoses ( β = 0.25, p <.001), such that caregivers of younger children and caregivers of children with more anxiety diagnoses reported engaging in more frequent accommodation in verbal contexts. Additionally, age – but not gender – differed significantly between anxious youth with SM versus without SM. Specifically, children whose anxiety disorder profile included SM were significantly younger than children whose anxiety disorder profile did not, t (332.83) = 11.38, p<.001. Factor Structure Table 2 presents model fit indices for the four CFAs conducted on the SAVE items, estimated using the WLSMV method. Model fit statistics indicated a “poor” fit for the unifactorial model retaining all 21 original items (Model 1), and “acceptable” for the four-factor model that retained all 21 original SAVE items (Model 2), and the four-factor model that excluded three items pertaining to accommodation when the child is interacting with familiar adults (Model 3). In contrast, the four-factor model that excluded three items pertaining to accommodation when the child is interacting with familiar peers (Model 4) showed “good” fit, with all three fit indices (CFI, RMSEA, and SRMR) falling within the “good” range. Furthermore, factor loadings for each of the 18 items retained in this model were all acceptable and ranged from moderate to very strong (see Table 3 ). The CFAs conducted using ML estimation produced similar findings, with Model 4 continuing to demonstrate the best fit (see Supplemental Material 2 for results). Table 2 Confirmatory factor analysis fit indices across tested models using WLSMV. Model # of factors # of items CFI RMSEA SRMR Fit Category a 1 a 1 21 0.913 0.197 0.170 Poor 2 b 4 21 0.988 0.075 0.051 Acceptable 3 c 4 18 0.990 0.078 0.054 Acceptable 4 d 4 18 0.994 0.059 0.047 Good Note: A model was deemed “acceptable” if two of the three (CFI, RMSEA, SRMR) indices fell in good ranges. A model was deemed “poor” if only one or none of the fit indices fell in good ranges. a Model 1 = Unifactorial Model: All 21 items from the original SAVE item pool load onto a single factor. b Model 2 = Four-factor 21 Item Model: All 21 items from the original SAVE item pool are included and load onto four factors that correspond to the four different SAVE subsections. c Model 3 = Four-factor, 18 Item Model, excluding familiar adult interactions: The three items assessing accommodation when the child interacts with familiar adults are removed, and the remaining 18 items from the original SAVE item pool load onto four factors that correspond to the four different SAVE subsections. d Model 4 = Four-factor 18 Item Model, excluding familiar peer interactions: The three items assessing accommodation when the child interacts with familiar peers are removed, and the remaining 18 items from the original SAVE item pool load onto four factors that correspond to the four different SAVE subsections. Table 3 Final SAVE items, factor loadings, and mean scores by clinical profile. SAVE Factors and Items Factor loading a Anxiety Disorder Profile Significance Test Includes SM M(SD) Does Not Include SM M(SD) F p Factor 1: Surrogate Speaking – 11.73(0.44) 8.06(0.48) 23.10 < .001 † How often do you speak or answer for your child when they are : 1. Interacting with a familiar adult (e.g., relatives that don’t live in the home, family friends) 0.628 2.38(0.13) 1.50(0.14) 16.86 < .001 † 2. Interacting with a stranger (e.g., cashier at grocery store) 0.948 3.30(0.14) 2.48(0.15) 12.46 < .001 † 3. Interacting with an unfamiliar peer (e.g., on the playground) 0.809 2.83(0.14) 1.84(0.15) 18.05 < .001 † 4. Ordering at a restaurant 0.933 3.21(0.14) 2.24(0.16) 15.48 < .001 † Factor 2: Permitting of Whispered Communication – 10.38(0.51) 6.02(0.55) 24.25 < .001 † How often do you allow your child to whisper in your ear when they are : 5. Interacting with a familiar adult (e.g., relatives that don’t live in the home, family friends) 0.857 2.26(0.14) 1.27(0.15) 17.40 < .001 † 6. Interacting with a stranger (e.g., cashier at grocery store) 0.982 2.79(0.14) 1.68(0.16) 20.17 < .001 † 7. Interacting with an unfamiliar peer (e.g., on the playground) 0.907 2.47(0.14) 1.52(0.16) 14.60 < .001 † 8. Ordering at a restaurant 0.941 2.87(0.15) 1.56(0.16) 25.46 < .001 † Factor 3: Permitting of Nonverbal Communication – 10.74(0.51) 6.55(0.55) 22.63 < .001 † How often do you allow your child to communicate nonverbally when they are : 9. Interacting with a familiar adult (e.g., relatives that don’t live in the home, family friends) 0.858 2.32(0.14) 1.44(0.16) 12.81 < .001 † 10. Interacting with a stranger (e.g., cashier at grocery store) 0.970 2.97(0.14) 1.77(0.15) 25.33 < .001 † 11. Interacting with an unfamiliar peer (e.g., on the playground) 0.937 2.67(0.14) 1.62(0.15) 19.40 < .001 † 12. Ordering at a restaurant 0.955 2.77(0.15) 1.73(0.16) 16.99 < .001 † Factor 4: Instrumental Accommodation – 5.41(0.51) 2.76(0.55) 9.07 .003 † How often do you : 13. Speak with your child’s teacher or other school personnel in order to have your child skip an assignment or activity requiring them to speak 0.862 0.78(0.11) 0.43(0.12) 3.60 .058 14. Advocate for your child to have special accommodations in class that get them out of speaking 0.890 1.21(0.12) 0.38(0.13) 16.99 < .001 † 15. Allow your child to skip a performance requiring them to speak or sing 0.790 0.79(0.11) 0.42(0.12) 3.88 .050 16. Go on field trips with your child in case they are required to speak 0.878 0.62(0.11) 0.45(0.12) .87 .351 17. Go other places with your child in case they are required to speak 0.920 0.97(0.12) 0.44(0.13) 6.95 .009 † 18. Avoid putting your child in activities or situations where they might be required to speak 0.794 1.04(0.11) 0.65(0.12) 3.96 .047 TOTAL – 44.65(1.72) 26.89(1.85) 35.94 < .001 † Note: SAVE items range: 0 = Never to 5 = Always; a Loadings in table based on CFA Model 4. † Significant after Holm-Bonferroni correction. Based on these CFA results, the 18-item version of the SAVE tested in Model 4 was selected for further psychometric scrutiny. The first factor of the 18-item SAVE includes four items assessing the frequency with which caregivers speak or answer for their child, and was labeled “Surrogate Speaking.” The second factor includes four items assessing the frequency with which caregivers allow their child to whisper in their ear in various social situations, and was labeled “Permitting of Whispered Communication.” The third factor includes four items assessing the frequency with which caregivers allow their child to communicate strictly non-verbally in various situations (e.g., nodding, pointing), and was labeled “Permitting of Nonverbal Communication.” Finally, the fourth factor includes six items assessing the frequency with which caregivers actively work to modify situations in which children may be required to verbally communicate, and was labeled “Instrumental Accommodation.” Internal Consistency The mean correlation among all pairs of items from the retained 18-item SAVE was acceptable (average inter-item correlation = 0.42) and Spearman-Brown split-half reliability was good ( r = 0.84). Cronbach’s alpha values further indicated strong internal consistency with all in the good-to-excellent range (i.e., Total Score: α = 0.94, Surrogate Speaking: α = 0.87, Permitting of Whispered Communication: α = 0.93, Permitting of Nonverbal Communication: α = 0.94, Instrumental Accommodation: α = 0.86). Concurrent and Divergent Validity Table 4 presents partial correlations (controlling for child age and number of anxiety diagnoses) between each of the SAVE scales and the other study measures. Concurrent validity was evidenced by significant associations between SAVE scores and each of the three measures of general family accommodation for child anxiety. Each of the SAVE subscales were also significantly associated with both FACLIS scores, although only the Instrumental Accommodation subscale was associated with the FASA. Further evidence of concurrent validity was found in significant associations between SAVE scores and child SM symptoms (SMQ Total score) and between SAVE scores and overall internalizing scores (i.e., CBCL Internalizing Problems). Evidence of divergent validity was supported by relatively weaker (and often non-significant) associations between SAVE scores and CBCL Externalizing scores (see Table 4 ). To examine the extent to which the SAVE was uniquely associated with internalizing versus externalizing symptoms, a supplemental linear regression was conducted with CBCL Internalizing and Externalizing Problem scores entered as simultaneous predictors of SAVE Total (along with the covariates of child age and number of anxiety diagnoses). In this model, CBCL Externalizing Problems were no longer significantly associated with SAVE Total scores, whereas CBCL Internalizing Problems remained a significant predictor ( β = 0.17, t = 3.09, p =.002). Table 4 Partial pairwise correlations among study variables for full sample. Correlations M SD 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. SAVE Total 36.31 24.50 – 2. Surrogate Speaking (SAVE Subscale 1) 9.98 5.89 .74 *** – 3. Whispered Communication (SAVE Subscale 2) 8.38 6.91 .82 *** .52 *** – 4. Nonverbal Communication (SAVE Subscale 3) 8.75 7.04 .83 *** .56 *** .59 *** – 5. Instrumental Accommodation (SAVE Subscale 4) 4.17 6.23 .62 *** .25 *** .37 *** .32 *** – 6. FACLIS Scope 3.24 2.50 .26 *** .24 *** .26 *** .18 ** .23 *** – 7. FACLIS Interference 11.32 11.46 .24 *** .25 *** .20 ** .15 * .24 *** .67 *** – 8. FASA Total 9.64 8.17 .24 *** − .01 .12 .12 .38 *** .31 ** .46 *** – 9. SMQ Total 19.78 7.95 − .61 *** − .34 *** − .36 *** − .49 *** − .36 *** − .19 * − .24 ** − .15 * – 10. CBCL Internalizing 59.63 10.12 .18 *** .11 * .16 ** .12 * .16 * .29 *** .30 *** .53 *** − .19 ** – 11. CBCL Externalizing 46.80 10.33 .10 * .06 − .11 * .05 .10 .30 *** .33 *** .43 *** − .08 .60 *** Note: Each partial pairwise correlations in table controls for age and number of anxiety diagnoses. SAVE = Survey of Accommodation in Verbal Encounters; SAVE Factor 1 = Surrogate Speaking; SAVE Factor 2 = Permitting of Whispered Communication; SAVE Factor 3 = Permitting of Non-Verbal Communication; SAVE Factor 4 = Instrumental Accommodation; FACLIS = Family Accommodation Checklist and Interference Scales; FASA = Family Accommodation–Anxiety; SMQ = Selective Mutism Questionnaire; CBCL = Child Behavior Checklist. * p < 0.05 ** p < 0.01 *** p < 0.001 Table 3 includes the estimated marginal means (EMMs) and between-group significance tests from one-way ANCOVAs (controlling for child age and number of anxiety diagnoses) examining SAVE score differences between anxious youth with versus without SM. Caregivers of children with SM reported significantly higher SAVE Total scores than caregivers of anxious children without SM, F (1, 406) = 35.94, p <.001. Examination of SAVE subscale scores found further evidence of SAVE clinical relevance to SM, with caregivers of children with SM reporting significantly higher levels of Surrogate Speaking, Permitting of Whispered Communication, Permitting of Nonverbal Communication, and Instrumental Accommodation (see Table 3 ). These results all retained significance after applying Holm-Bonferroni corrections. Incremental Validity Table 5 presents the results of three hierarchical regressions evaluating the incremental validity of the SAVE (over existing general family accommodation measures) for assessing accommodation specific to SM symptoms. In each of these regressions, the measure of general family accommodation included in that model (i.e., FACLIS Scope in the first model, FACLIS Interference in the second, and FASA in the third) was found to be a significant step 1 predictor – i.e., general family accommodation significantly predicted SM symptoms in the absence of the SAVE. However, the SAVE consistently emerged as the most robust and significant accommodation predictor of SM symptoms across all three constrained, rationally determined models. Adding the SAVE as a predictor in Step 2 significantly increased the amount of variance in SM symptoms explained in each model. Across models including the SAVE, links between general family accommodation and SM were reduced to negligible magnitudes, whereas the incremental associations between the SAVE and SM constituted large effect sizes (Cohen, 1988). Table 5 Incremental validity of the SAVE over other existing measures of general family accommodation in predicting SM symptoms. Model Incremental Validity Tested Step Adjusted R 2 Δ R 2 Predictor B SE β t p 1 a Utility Over FACLIS Scope 1 0.03 * – FACLIS Scope -0.76 0.27 -0.23 -2.82 0.006 2 b 0.27 *** 0.23 *** FACLIS Scope -0.26 0.25 -0.08 -1.06 0.292 SAVE -0.18 0.03 -0.51 -6.94 < .001 2 c Utility Over FACLIS Interference 1 0.05 * – FACLIS Interference -0.16 0.05 -0.26 -3.25 0.001 2 d 0.28 *** 0.23 *** FACLIS Interference -0.08 0.05 -0.13 -1.80 0.073 SAVE -0.18 0.03 -0.50 -6.90 < .001 3 e Utility Over FASA 1 0.03 * – FASA -0.15 0.07 -0.16 -2.30 0.023 2 f 0.32 *** 0.29 *** FASA -0.03 0.06 -0.03 -0.58 0.561 SAVE -0.21 0.02 -0.56 -9.52 < .001 Note: SM = selective mutism; FASA = Family Accommodation Scale-Anxiety; FACLIS = Family Accommodation Checklist and Interference Scales; SAVE = Survey of Accommodation in Verbal Encounters. All models in table predict SM symptoms, as measured by the Selective Mutism Questionnaire (SMQ). a Predictors: Step 1 predictors are FACLIS Scope, age, # of anxiety diagnoses; Step 2 retains same predictors as Step 1, and adds SAVE Total Score. Based on a subset of participants ( n = 293) who completed the FACLIS. b F Change (1,148) = 48.10, p < .001 c Predictors: Step 1 predictors are FACLIS Interference, age, # of anxiety diagnoses; Step 2 retains same predictors as Step 1, and adds SAVE Total Score. Based on a subset of participants ( n = 293) who completed the FACLIS. d F Change (1,148) = 47.58, p < .001 e Predictors: Step 1 predictors are FASA, age, # of anxiety diagnoses; Step 2 retains same predictors as Step 1, and adds SAVE Total Score. Based on a subset of participants ( n = 216) who completed the FASA. b F Change (1,210) = 90.53, p < .001 Discussion Despite the prominence of family accommodation in modern conceptualizations of SM and its identification as a primary clinical target in supported treatments for SM (Cornacchio et al., 2019 ; Furr et al., 2020 ; Lorenzo et al., 2021 ; Shorer et al., 2023 ), the development of reliable and valid tools for assessing SM-specific accommodation behaviors has been lacking (Fisher et al., 2025 ). The SAVE offers the first measure of family accommodation specifically focused on parental behaviors when child verbalizations are expected, and the present study provides initial psychometric support for the SAVE as a useful caregiver-report measure of direct relevance to the unique clinical portrait of SM. CFA supported an 18-item version of the scale with a four-factor structure corresponding to four SAVE subscales: Surrogate Speaking, Permitting of Whispered Communication, Permitting of Nonverbal Communication, and Instrumental Accommodation. The SAVE also demonstrated excellent internal consistency and divergent validity, as well as strong concurrent validity via significant associations with measures of SM symptoms, internalizing problems, and general family accommodation not specific to speaking contexts. Whereas the absence of an SM-specific accommodation measure may have impeded and/or muddled research to date on the family dynamics of SM, the present findings highlight the promising utility of the SAVE for advancing SM conceptualizations, research, and practice. In the present sample of anxious youth, the SAVE was uniquely associated with SM. SAVE scores were significantly higher among caregivers of children with SM compared to caregivers of anxious youth without SM. This pattern held for the measure’s total score, all four subscales, and approximately 80% of the individual SAVE items. That said, it is also important to acknowledge that caregivers of anxious children without SM did report moderate levels of verbal accommodation on the SAVE. Many anxious individuals without SM may also exhibit inhibited speech and/or discomfort communicating with others (e.g., Lorant et al., 2000 ). For example, socially anxious and behaviorally inhibited children are more likely to stutter, stumble over words, or freeze when approached by a stranger or when having to give presentations (Buss, 2011 ; Iverach et al., 2016 ), which may similarly pull for parental accommodation. Taken together, the present findings suggest family accommodation in the context of verbal encounters has relevance, but not uniqueness, to SM, and thus remains transdiagnostically relevant across the anxiety disorders. Accordingly, the SAVE appears to capture prominent family dynamics that are hallmarks of SM, but that are also present in the families of many other anxious youth, underscoring the measure’s potential for enhancing research and practice for a range of anxious children and adolescents. Incremental validity analyses found the SAVE to be a more robust and significant predictor of SM than established measures of general family accommodation. Specifically, the SAVE provided unique incremental value in predicting SM symptoms beyond what is already captured by the FASA and FACLIS, and in fact, after accounting for SAVE scores, neither the FASA nor FACLIS provided any significant unique contribution in predicting SM. These established general family accommodation measures have shown great utility in mixed samples of anxiety-disordered youth, but the present findings suggest these measures may nonetheless be insufficient for capturing specific parental accommodation forms that manifest in verbal contexts and that characterize family dynamics in SM. Accommodations for SM often focus on subtle rescue behaviors in verbal contexts (e.g., answering on behalf of the child), rather than on modifications to daily routines or changes to family schedules, which are more prominently assessed in the FASA and FACLIS. This may help explain the incremental value of the SAVE over general family accommodation measures in the assessment of SM-specific accommodation. The CFAs found no support for any of the measurement models that included SAVE items assessing accommodation during child interactions with familiar peers. Among the constrained, rationally determined models examined, results suggest the most coherent and robust model of family accommodation in child verbal contexts applies to child interactions with familiar and unfamiliar adults, and with unfamiliar (but not familiar) peers. It is not uncommon for children with SM to have certain trusted peers with whom they verbally communicate, and who in turn speak for the child in school and other settings (Williams, et al., 2021 ). Familiar peers may actually serve more as agents of accommodation themselves for children with SM, than as people whose presence pulls for parental accommodation. Research on such possible peer accommodation is needed to elucidate interpersonal dynamics and patterns of accommodation during child interactions with familiar peers. Availability of the SAVE now affords an opportunity to study reinforcement processes (Beech et al., in press) that may underlie the development and/or maintenance of SM. Caregiver rescue behaviors assessed by the SAVE may reinforce a child’s speech hesitancy and promote longer-term reliance on nonverbal communication. Although excessive assistance and direct involvement from caregivers in verbal contexts may temporarily relieve an anxious child of their distress, this relief can inadvertently negatively reinforce mutism patterns over time, as the child learns to rely on caregivers to speak on their behalf, to communicate through nonverbal gestures or whispering, and to depend on other caregiver-provided rescue behaviors. Avoidance-enabling accommodations can also interfere with a child’s natural development of independent coping skills and can prevent important experiential learning that feared outcomes are unlikely (Ginsburg et al., 2004 ; Norman et al., 2015 ). Avoiding feared situations can also limit children’s self-efficacy and confidence for managing their own anxiety, further reducing the likelihood of future verbal responses in challenging contexts. Some research suggests that parental accommodation can be reinforcing not only for the child, but also for the caregiver (Aschenbrand & Kendall, 2012 ; Feinberg et al., 2018 ; Kerns et al., 2017 ; Shorer et al., 2023 ), and may serve a co-regulation function. Greater caregiver anxiety, experiential avoidance, and emotion dysregulation predict greater caregiver engagement in accommodation behaviors (e.g., Feinberg et al., 2018 ; Jones et al., 2013; Kerns et al., 2017 ; Thompson-Hollands et al., 2014 ), and, through negative reinforcement, caregivers may learn that accommodating their child’s SM-related distress also alleviates their own short-term distress (Shorer et al., 2023 ). To clarify interpersonal pathways and causal chains that may maintain SM, investigations would now do well to use the SAVE to examine links between parental anxiety, accommodation when child speech is expected, and long-term patterns of child verbal reticence. The SAVE may afford new opportunities to uncover mechanisms of effective SM treatment response, and can support improved clinical practices for SM. Research on the treatment of other anxiety disorders and OCD has found reductions in family accommodation can lead to downstream improvements in child symptoms (e.g., Etkin et al., 2022 ; Kagan et al., 2022; Merlo et al., 2009 ). The availability of the SAVE now creates an opportunity for researchers to study the extent to which SM treatment response is mediated by changes in parental accommodation in situations in which child speech is expected. Such findings would be integral for clarifying the “active ingredients” in family treatments for SM, and could help identify key mechanisms to target. The SAVE can also be utilized to improve clinical practice for SM, and to inform individual case conceptualization and treatment planning. By offering improved assessment of the interpersonal context of SM symptoms, clinicians are now better equipped to identify useful treatment targets for their SM cases, and they may find value in incorporating the SAVE into routine outcome monitoring practices to track treatment responses and outcomes beyond a restricted focus on child symptoms. Limitations of the current study warrant consideration. First, the SAVE only assessed family accommodation in a limited range of social contexts and relied exclusively on one caregiver’s (mostly mother’s) self-reports. Accommodating behaviors can vary across family members, and school staff can also play a role in avoidance-oriented accommodations (Benito et al., 2015 ; Conroy et al., 2022; Thompson-Hollands et al., 2014 ). Second, self-report can be biased, especially in the assessment of parenting and child internalizing symptoms (Comer & Kendall, 2004 ; De Los Reyes et al., 2023 ). Continued evaluation of SAVE validity should incorporate structured behavioral observations (e.g., the Selective Mutism Interaction Coding System, SMICS; Carpenter et al., 2014 ; Cotter et al., 2018 ). Third, unlike the FASA and FACLIS, the SAVE does not assess caregiver distress or interference associated with accommodation. An expanded SAVE may do well to add items assessing accommodation-related impairment. Fourth, study assessments were collected at the same timepoint, and thus our findings cannot speak to issues of temporal precedence or causality. Longitudinal research is needed to clarify matters of directionality and SAVE test-retest reliability. Research in the context of clinical trials is also needed to evaluate the SAVE’s sensitivity to treatment-related changes. Lastly, despite the ethnic diversity of the sample, participants were predominantly of middle-to-high socioeconomic status, White, and treatment-seeking. Replicating this study in more racially and economically diverse samples, and in non-treatment seeking families, is needed to more broadly consider the generalizability of the present findings. Despite limitations, the present study offers strong psychometric support for the first measure of parental accommodation specifically in contexts in which child speech is expected. In addition to demonstrating initial reliability, validity, and incremental utility of the SAVE, these findings provide rare empirical insight into the frequency, patterns, and correlates of parental accommodation in verbal situations among families of anxious children with and without SM. With continued support, the SAVE can offer a useful tool for research and practice to evaluate key family dynamics associated with verbal reticence in youth and SM-specific accommodation. Declarations Disclosures: Dr. Comer earns textbook royalties from Macmillan Learning, and an editorial stipend from the Association for Behavioral and Cognitive Therapies, for work unrelated to the present study. No other authors have financial disclosures to report. Funding /Support : This work was funded by a grant from the Andrew Kukes Foundation for Social Anxiety (PI: Comer) and by a grant from the Gordon & Marilyn Macklin Foundation (PI: Furr). 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9295482","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":619256458,"identity":"188781e0-683d-437d-877c-c638a3167d6f","order_by":0,"name":"Adelia Kamenetskiy","email":"","orcid":"","institution":"Florida International University","correspondingAuthor":false,"prefix":"","firstName":"Adelia","middleName":"","lastName":"Kamenetskiy","suffix":""},{"id":619256460,"identity":"d8e2e63d-3cd3-432c-af50-888478d7eb3c","order_by":1,"name":"Jami M. Furr","email":"","orcid":"","institution":"Florida International University","correspondingAuthor":false,"prefix":"","firstName":"Jami","middleName":"M.","lastName":"Furr","suffix":""},{"id":619256462,"identity":"a51280ce-fa14-44a0-b480-53e6a3ce9825","order_by":2,"name":"Aileen Herrera","email":"","orcid":"","institution":"Florida International University","correspondingAuthor":false,"prefix":"","firstName":"Aileen","middleName":"","lastName":"Herrera","suffix":""},{"id":619256464,"identity":"31b174c9-75a1-42e4-b62e-4495fc21be8b","order_by":3,"name":"Leah Feinberg","email":"","orcid":"","institution":"Systems Evolution, Inc","correspondingAuthor":false,"prefix":"","firstName":"Leah","middleName":"","lastName":"Feinberg","suffix":""},{"id":619256466,"identity":"1fd676bf-8145-44e1-aca3-f9719b8b87e5","order_by":4,"name":"Rachel A. Merson","email":"","orcid":"","institution":"Boston University","correspondingAuthor":false,"prefix":"","firstName":"Rachel","middleName":"A.","lastName":"Merson","suffix":""},{"id":619256469,"identity":"3de51de9-668a-44ad-bb63-942c8081525b","order_by":5,"name":"Donna B. Pincus","email":"","orcid":"","institution":"Boston University","correspondingAuthor":false,"prefix":"","firstName":"Donna","middleName":"B.","lastName":"Pincus","suffix":""},{"id":619256471,"identity":"4b62c811-2512-45c3-8dce-ab91f8db25bc","order_by":6,"name":"Jonathan S. Comer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAp0lEQVRIiWNgGAWjYBACxgYILcfeDKLYSNBizHOYWC0wkNhzgFgtzO3NDx/dqLiX3sPOY8DwoewwEQ7rOWZsnHOmOLeHmceAccY5YrTMyGGTzm1LyN0P1MLM20a0ln8J6TwgLX+J19KQkADWwkiUFrBfjiUY9jCzFRzsOZdOWIshMMQe59QkyPPwH9744EeZNRFaGpA4BwirBwJ5olSNglEwCkbByAYAa7k0NKDcBQUAAAAASUVORK5CYII=","orcid":"","institution":"Florida International University","correspondingAuthor":true,"prefix":"","firstName":"Jonathan","middleName":"S.","lastName":"Comer","suffix":""}],"badges":[],"createdAt":"2026-04-01 19:23:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9295482/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9295482/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106725022,"identity":"babc16fd-184c-4e55-96e9-0e37aac55051","added_by":"auto","created_at":"2026-04-12 18:31:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1304159,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9295482/v1/8a7bb061-8a95-4f89-9929-38678ee91940.pdf"},{"id":106553407,"identity":"bc33f393-e06b-4adf-a0b2-4afb3d1622e2","added_by":"auto","created_at":"2026-04-09 19:07:24","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":22708,"visible":true,"origin":"","legend":"","description":"","filename":"SAVESupplementaryMaterialsChildPsychiatryHumanDev.docx","url":"https://assets-eu.researchsquare.com/files/rs-9295482/v1/1794fa5253c2656db638ccf7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Family accommodation and selective mutism: Evaluating the Survey of Accommodation in Verbal Encounters (SAVE)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSelective mutism (SM) is a highly interfering anxiety disorder characterized by a child\u0026rsquo;s failure to speak in certain social and unfamiliar settings, despite their ability to produce fluent speech in other situations (American Psychiatric Association, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Studies suggest SM affects at least 0.2-2% of the population, with documented prevalence estimates continue to steadily rising with improved awareness and assessment (Muris \u0026amp; Ollendick, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The absence of verbal communication in specific social situations among individuals with SM is associated with considerable impairments in school achievement, social interactions, and general functioning in public places where speech is expected. SM is also associated with elevated psychiatric comorbidity (most commonly social anxiety disorder) (Carbone et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Driessen et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), and over the long-term can predict ongoing social skills deficits, educational and occupational challenges, and low self-esteem into adolescence and adulthood (Remschmidt et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Steinhausen et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Tomohisa et al., \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Despite the serious impairments and interference associated with SM, research on the phenomenology and family dynamics of the disorder has lagged relative to other anxiety disorders.\u003c/p\u003e \u003cp\u003eSupported cognitive-behavioral treatments (CBTs) for childhood SM target contextual factors of SM by working directly with the important individuals in affected children\u0026rsquo;s lives (e.g., parents, teachers, peers). Recent years have witnessed particularly promising treatment outcomes associated with family-based SM programs adapted from Parent-Child Interaction Therapy (PCIT), school-based programs that engage with teachers to adjust classroom practices, and intensive group programs that implement interventions in structured peer contexts (e.g., Bergman et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Cornacchio et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Hong et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Lang et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Oerbeck et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Many of the most successful SM programs emphasize key environmental factors that can reinforce and maintain patterns of anxiety, avoidance, and restricted speech \u0026ndash; e.g., overly protective parenting styles and avoidance-enabling teaching styles (see Kovac \u0026amp; Furr, 2018; Lorenzo et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). To reduce these behaviors, caregivers often play an active role in treatment, receiving psychoeducation on negative reinforcement cycles linked with inhibited child speech and receiving coaching in SM-specific strategies that promote child verbal communication (Lorenzo et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Furr et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFamily accommodation is one of the key environmental factors increasingly targeted in CBTs for childhood SM. Originally studied in the context of obsessive-compulsive disorder (OCD; Calvocoressi et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1995\u003c/span\u003e), family accommodation refers to actions and behavioral changes by family members that are aimed to prevent, reduce, or alleviate their child\u0026rsquo;s immediate disorder-related distress (Lebowitz et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Storch et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Thompson-Hollands et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). For example, the caregiver of a child with OCD might turn the stove on and off repeatedly at the request of their child until the child is confident the stove is truly turned off. Although family accommodation may alleviate the child\u0026rsquo;s disorder-related distress in the short-term, this anxiety relief can be negatively reinforcing and can promote and maintain longer-term patterns of child avoidance (Thompson-Hollands et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Moreover, family accommodation can interfere with the child\u0026rsquo;s ability to develop an independent sense of mastery and self-efficacy in the management of uncomfortable feelings, as the child learns to cope by relying on accommodating family members (Ginsburg et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Norman et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study of family accommodation has expanded beyond its initial focus on children with OCD to encompass children across the full anxiety spectrum (Kagan et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Kerns et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; La Buissonni\u0026egrave;re-Ariza et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lebowitz et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Storch et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2015\u003c/span\u003ea; Thompson-Hollands et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Research has found that as many as 88\u0026ndash;97% of caregivers of children with anxiety disorders engage in at least some form of accommodation, with higher levels of accommodation linked with greater symptom severity, functional and family impairment, caregiver burden, and negative treatment outcomes (Kagan et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; La Buissonni\u0026egrave;re-Ariza et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lebowitz et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Merlo et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Storch et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Storch et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2015\u003c/span\u003ea; Thompson-Hollands et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Treatments for anxious youth that directly target family accommodation have shown great success (e.g., Comer et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Comer et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Lebowitz et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Storch et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe investigation and targeted treatment of accommodation in families of anxious youth has been greatly served by caregiver measures that demonstrate strong psychometric properties \u0026ndash; e.g., the Family Accommodation Scale \u0026ndash; Anxiety (FASA; Lebowitz et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Lebowitz et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), the Pediatric Accommodation Scale (PAS; Benito et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), and the Family Accommodation Checklist and Interference Scale (FACLIS; Thompson-Hollands et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). That said, the psychometric properties of these measures have not been specifically evaluated within the SM population. The absence of support for a measure of accommodation specifically in SM populations may help explain, in part, why research on accommodation in the families of youth with SM has lagged relative to other anxiety disorders (Iniesta-Sep\u0026uacute;lveda et al., 2021). To date, only three studies have examined family accommodation in relation to SM, and findings across these studies have been mixed. Specifically, using the FASA, Freitag and colleagues (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and Shorer and colleagues (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) both found family accommodation to have significant associations with increased SM severity, whereas Fisher and colleagues (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) did not.\u003c/p\u003e \u003cp\u003eLimited research and mixed findings on the associations between family accommodation and SM symptoms underscore the need for a reliable and valid measure of SM-specific family accommodation. It is not clear that the FASA, PAS, or FACLIS offer a preferred approach to assessing accommodation patterns specific to verbal encounters. The FASA and PAS offer generic assessments of the overall accommodation frequency across broad domains of parental behavior (i.e., modifying routines, facilitating avoidance, providing reassurance) and does not specify anything directly about parental behaviors in verbal contexts. Parents of youth with SM may not perceive speaking on behalf of their child to be a form of accommodation, and thus their responses to generic family accommodation measures, such as the FASA or PAS, may suggest inaccurately low levels of accommodation (Fisher et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Whereas the FACLIS provides a checklist of specific accommodation forms and does not require the parent to self-identify various behaviors as accommodating, only two of the 20 items pertain to verbal encounters, and thus total scores are not poised to specifically capture verbal accommodation behaviors. Importantly, family accommodation presentations vary across different anxiety disorders. In the case of SM, a caregiver might speak on behalf of their child, allow their child to communicate via whispers or nonverbal gestures, or work to excuse their child from speaking situations (e.g., presentations) (Fisher et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Furr et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Lorenzo et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Accordingly, measures that evaluate family accommodation more generically or broadly, or that focus predominantly on accommodation forms that occur outside of situations in which speech is expected, may underestimate accommodation in families of youth with SM.\u003c/p\u003e \u003cp\u003e The current study developed the Survey of Accommodation in Verbal Encounters (SAVE) to assess the frequency of parental accommodations as they occur specifically in situations in which child verbal communication is expected. In a sample of treatment-seeking anxious youth in which roughly half met criteria for SM, we examined the preliminary structure, reliability, and validity of the SAVE. We predicted the SAVE would exhibit good psychometric properties as evidenced by high internal consistency and strong concurrent, divergent, and incremental validity. Given that accommodations evaluated in the SAVE are specific to verbal contexts, we further hypothesized that the measure would show improved performance over generic family accommodation measures and that scores would be significantly higher for children whose anxiety disorder profiles include SM compared to children whose anxiety disorder profiles do not include SM.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eParticipants were 412 children and adolescents between the ages of 2 and 18 years (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8.20, SD\u0026thinsp;=\u0026thinsp;3.86) seeking clinical services for anxiety-related concerns, and their caregivers. Families were recruited across two university-affiliated specialty clinics for child anxiety \u0026ndash; the Mental health Interventions and Novel Therapeutics (MINT) Program in the Center for Children and Families (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;217) at Florida International University (FIU) and the Center for Anxiety and Related Disorders (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;195) at Boston University (BU). Families who were receiving services at one of these clinics and completed the SAVE were eligible for the present study. Both clinics offer specialty SM treatment programs, affording an enriched sample with a higher rate of SM than that found in most child anxiety samples [\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;217 (52.7%) with SM]. Participating families completed study measures as part of their clinical intake via REDCap, a secure web application for managing online surveys and data. Caregivers had the option to complete the questionnaires in English or Spanish.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents sociodemographic and clinical characteristics of the sample. Most participating caregivers were college-educated mothers reporting a range of household income levels. A slight majority of the child sample identified as female. Hispanic and/or Latinx participants made up approximately half the sample. Although most families spoke English in the home (88.5%), 115 reported speaking Spanish in the household, and 82 spoke another language. Youth met DSM criteria for an average of 1.50 diagnoses (SD\u0026thinsp;=\u0026thinsp;1.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics and diagnostic makeup of the sample.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChild Age (years)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7\u003c/p\u003e \u003cp\u003e7\u0026ndash;12\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;12\u003c/p\u003e \u003cp\u003eChild Gender\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eNon-Binary or Another Gender Identity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e170\u003c/p\u003e \u003cp\u003e167\u003c/p\u003e \u003cp\u003e69\u003c/p\u003e \u003cp\u003e232\u003c/p\u003e \u003cp\u003e171\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.9\u003c/p\u003e \u003cp\u003e41.1\u003c/p\u003e \u003cp\u003e17.0\u003c/p\u003e \u003cp\u003e56.7\u003c/p\u003e \u003cp\u003e41.8\u003c/p\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild Race/Ethnicity\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNon-Hispanic, White\u003c/p\u003e \u003cp\u003eHispanic/Latinx\u003c/p\u003e \u003cp\u003eAsian\u003c/p\u003e \u003cp\u003eBlack\u003c/p\u003e \u003cp\u003eNative Hawaiian\u003c/p\u003e \u003cp\u003eMultiracial\u003c/p\u003e \u003cp\u003eAnother race not listed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146\u003c/p\u003e \u003cp\u003e121\u003c/p\u003e \u003cp\u003e41\u003c/p\u003e \u003cp\u003e19\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e49\u003c/p\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.5\u003c/p\u003e \u003cp\u003e40.1\u003c/p\u003e \u003cp\u003e10.0\u003c/p\u003e \u003cp\u003e4.6\u003c/p\u003e \u003cp\u003e0.2\u003c/p\u003e \u003cp\u003e11.9\u003c/p\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipating Caregiver\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMother\u003c/p\u003e \u003cp\u003eFather\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e367\u003c/p\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.7\u003c/p\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnnual Household Income\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u0026ge; \u003cspan\u003e$\u003c/span\u003e200,000\u003c/p\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e100,00 - \u003cspan\u003e$\u003c/span\u003e199,999\u003c/p\u003e \u003cp\u003e\u0026le;\u003cspan\u003e$\u003c/span\u003e99,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153\u003c/p\u003e \u003cp\u003e120\u003c/p\u003e \u003cp\u003e136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.4\u003c/p\u003e \u003cp\u003e29.3\u003c/p\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiver Education: (Highest Degree)\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHigh school or equivalent\u003c/p\u003e \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e \u003cp\u003eGraduate degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003cp\u003e123\u003c/p\u003e \u003cp\u003e222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.8\u003c/p\u003e \u003cp\u003e30.4\u003c/p\u003e \u003cp\u003e54.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnoses\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSelective mutism\u003c/p\u003e \u003cp\u003eSocial anxiety disorder\u003c/p\u003e \u003cp\u003eGeneralized anxiety disorder\u003c/p\u003e \u003cp\u003eSpecific phobia\u003c/p\u003e \u003cp\u003eSeparation anxiety disorder\u003c/p\u003e \u003cp\u003eObsessive compulsive disorder\u003c/p\u003e \u003cp\u003eAttention-deficit/hyperactivity disorder\u003c/p\u003e \u003cp\u003eOppositional defiant disorder\u003c/p\u003e \u003cp\u003eDepressive disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e217\u003c/p\u003e \u003cp\u003e170\u003c/p\u003e \u003cp\u003e87\u003c/p\u003e \u003cp\u003e37\u003c/p\u003e \u003cp\u003e28\u003c/p\u003e \u003cp\u003e28\u003c/p\u003e \u003cp\u003e14\u003c/p\u003e \u003cp\u003e13\u003c/p\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.7\u003c/p\u003e \u003cp\u003e41.3\u003c/p\u003e \u003cp\u003e21.1\u003c/p\u003e \u003cp\u003e9.0\u003c/p\u003e \u003cp\u003e6.8\u003c/p\u003e \u003cp\u003e6.8\u003c/p\u003e \u003cp\u003e3.4\u003c/p\u003e \u003cp\u003e3.2\u003c/p\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: \u003csup\u003ea\u003c/sup\u003eBased on n\u0026thinsp;=\u0026thinsp;406 participants who provided these data. \u003csup\u003eb\u003c/sup\u003eBased on n\u0026thinsp;=\u0026thinsp;409 participants who provided these data. \u003csup\u003ec\u003c/sup\u003eParticipants could select more than one option. \u003csup\u003ed\u003c/sup\u003eBased on n\u0026thinsp;=\u0026thinsp;405 participants who provided these data.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurvey of Accommodation in Verbal Encounters (SAVE)\u003c/h2\u003e \u003cp\u003e The SAVE is a caregiver-report measure developed for the current study to evaluate the frequency of parental accommodations specifically in situations in which verbalizations are expected of the child. An initial pool of 21 items conceptually divided into four sections was generated by two clinical psychologists with extensive expertise in SM and a doctoral student, in consultation with ten master\u0026rsquo;s- and doctoral-level therapists who carry a high volume of SM cases on their caseloads (see Supplemental Material 1 for a list of the 21 items in the initial SAVE item pool). All students involved in the development process were trainees in clinical or counseling psychology programs. Item-level questions were generated based on clinical experience and SM literature. The Spanish language version of the SAVE was subject to a thorough translation and back-translation process. Each item is assessed on a 0 (\u0026ldquo;never\u0026rdquo;) to 5 (\u0026ldquo;always\u0026rdquo;) scale and the measure is organized into four sections. Section 1 contained items assessing the frequency with which the caregiver speaks or answers for the child in various social situations (5 items initially), Section 2 contained items assessing the frequency with which the caregiver allows their child to whisper in their ear in various social situations (5 items initially), and Section 3 contained items assessing the frequency with which the caregiver allows their child to communicate nonverbally (e.g., by nodding or pointing) in various social situations (5 items initially). Consistent with existing functional assessment tools for SM (e.g., Social Communication Anxiety Inventory; Shipon-Blum, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), five different social situations assessed within each of these three sections were: (a) when child interacts with familiar adults, (b) when child interacts with strangers, (c) when child interacts with familiar peers, (d) when child interacts with unfamiliar peers, and (e) when child orders at a restaurant. Section 4 contained six items assessing the frequency with which caregivers actively work to modify various situations in which child speech may be required (e.g., speaking with the child\u0026rsquo;s teacher to get them out of speech-based assignments) or the frequency with which they make sure to accompany their child to places so they are available to assist if the child is required to speak (e.g., field trips).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInternalizing and externalizing psychopathology\u003c/h3\u003e\n\u003cp\u003eThe \u003cem\u003eChild Behavior Checklist\u003c/em\u003e (CBCL; Achenbach \u0026amp; Rescorla, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2001\u003c/span\u003e) is a well-established, parent-report questionnaire assessing youth behavioral and emotional problems. For children\u0026thinsp;\u0026lt;\u0026thinsp;6, caregivers completed the CBCL 1.5-5 (Achenbach and Rescorla, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2000\u003c/span\u003e) and for children \u0026ge;6 caregivers completed the CBCL 6\u0026ndash;18 (Achenbach and Rescorla, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Using a 3-point scale (0\u0026thinsp;=\u0026thinsp;not true, 1\u0026thinsp;=\u0026thinsp;somewhat or sometimes true, 2\u0026thinsp;=\u0026thinsp;very true or often true), caregivers rate how well each item describes their child across the past 6 months. Raw scores are converted to standardized T-scores, normed by child age and sex. Higher scores reflect greater psychopathology. The CBCL has demonstrated excellent reliability and validity (Achenbach and Rescorla, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2001\u003c/span\u003e, Ivanova et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). The higher-order, broadband Internalizing and Externalizing problem scales were used in the present analysis. Internal consistency in the current sample was good-to-excellent (i.e., CBCL 1.5-5: α\u003csub\u003eInternalizing\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.90, α\u003csub\u003eExternalizing\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.89; CBCL 6\u0026ndash;18: α\u003csub\u003eInternalizing\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.84, α\u003csub\u003eExternalizing\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.87).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSelective mutism symptoms\u003c/h2\u003e \u003cp\u003eThe \u003cem\u003eSelective Mutism Questionnaire\u003c/em\u003e (SMQ; Bergman et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) is a caregiver-report measure that captures the frequency of (and interference and distress associated with) a child\u0026rsquo;s failure to speak across social settings. Caregivers are provided with 17 statements describing typical situations in which child verbal communication is expected (e.g., \u0026ldquo;my child speaks to most teachers or staff at school\u0026rdquo;). Statements are categorized into three domains: at school, at home/with family, and in social/public situations (outside of school). A four-point scale ranging from 0 (\u0026ldquo;never\u0026rdquo;) to 3 (\u0026ldquo;always\u0026rdquo;) is used to rate how frequently the child speaks in each situation. Lower scores reflect lower frequencies of speaking behavior (i.e., more severe SM). Additional items assess interference and distress linked with SM symptoms. The SMQ has exhibited moderate-to-high internal consistency and strong convergent and discriminant validity (Bergman et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; α\u0026thinsp;=\u0026thinsp;0.84 in present sample). Due to differences in assessment protocols across sites, the SMQ was only administered to a subset of \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;274 participants in the present sample.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eGeneral family accommodation\u003c/h3\u003e\n\u003cp\u003eThe \u003cem\u003eFamily Accommodation Checklist and Interference Scale\u003c/em\u003e (FACLIS; Thompson-Hollands et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) is a caregiver-report measure of the scope and interference of family accommodation in the families of anxious youth. The questionnaire provides a checklist of 20 specific forms of accommodation in which caregivers of youth with the common anxiety disorders often engage. Caregivers are asked which of the accommodations in the checklist they perform, and to then rate the extent to which each endorsed accommodation causes personal or family interference on a scale from 0 (\u0026ldquo;no interference\u0026rdquo;) to 8 (\u0026ldquo;extreme interference\u0026rdquo;). An accommodation scope score is generated by tallying the number of endorsed accommodation items (FACLIS Scope), and a total interference score is generated by summing the interference ratings (FACLIS Total Interference). The FACLIS has shown good reliability and validity (Thompson-Hollands et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; α\u003csub\u003eScope\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.78 and α\u003csub\u003eInterference\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.77 in present sample). Due to differences in assessment protocols across sites, the FACLIS was only administered to a subset of \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;293 participants in the present sample.\u003c/p\u003e \u003cp\u003eThe \u003cem\u003eFamily Accommodation Scale \u0026ndash; Anxiety\u003c/em\u003e (FASA; Lebowitz et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) is another caregiver-report of general accommodation in families of children with the common anxiety disorders. The FASA is a 13-item measure of the frequency with which caregivers participate in their child\u0026rsquo;s anxiety-related behaviors, modify their functioning, and experience distress and emotional consequences that result from accommodation. The measure includes five items asking about participation in anxiety symptoms, four items on modifications of routines, and additional items on distress and consequences. Participation and modification items are rated on 5-point frequency scales ranging from 0 (\u0026ldquo;never\u0026rdquo;) to 4 (\u0026ldquo;daily\u0026rdquo;) and summed for an overall accommodation score. The FASA has shown strong convergent and divergent validity (Lebowitz et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Lebowitz et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), satisfactory retest reliability, and excellent internal consistency (α\u0026thinsp;=\u0026thinsp;0.91 in the present sample). Due to differences in assessment protocols across sites, the FASA was only administered to a subset of \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;216 participants in the present sample.\u003c/p\u003e\n\u003ch3\u003eProcedures\u003c/h3\u003e\n\u003cp\u003e Study procedures were approved by FIU and BU Institutional Review Boards. Clinic procedures at both sites screen out for current psychotic symptoms, homicidal/suicidal risk, \u0026ge; 2 psychiatric hospitalizations, and/or moderate-to-severe intellectual impairments. Parents provided informed consent prior to participation, and children\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;7 years provided informed assent. Diagnostic assessments were conducted by trained master\u0026rsquo;s or doctoral graduate students, postdoctoral fellows, and licensed mental health counselors. At both sites, clinical interviewers received similar training and were supervised by licensed mental health professionals specializing in youth anxiety treatment. Training at both sites included didactics, multiple observations of live ADIS-IV-C/P interviews conducted by senior assessors, followed by interviews co-administered with senior assessors who interjected as necessary, and then interviews led by trainees being observed by senior assessors. All interviews were reviewed in group supervision meetings, and diagnostic decisions were determined collaboratively by consensus. Reliability checks on ADIS assessments have yielded high diagnostic agreement/interrater reliability at both sites (\u003cem\u003eκ\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.80; see Comer et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Cornacchio et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Hong et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAnalytical Strategy\u003c/h2\u003e \u003cp\u003eAnalyses were conducted in R and SPSS. To examine the SAVE factor structure and finalize the items, the initial item pool was subjected to confirmatory factor analysis (CFA). Given the ordinal nature of the SAVE data, models were estimated based on polychoric correlations matrices, using the weighted least squares with mean and variance-adjusted (WLSMV) method (Park, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). For comparison, the CFA was also estimated using maximum likelihood (ML) to assess the robustness of the findings. Given we had hypothesized measurement models, and given the analytic goal was model structure testing rather than structure discovery, CFA (rather than exploratory factor analysis, or EFA) was used to identify potential item alignments. EFA can also capitalize on chance in more modest clinical samples, and thus a theory-driven approach was used. Four theoretically guided models were tested and compared, including one model with all 21 items loading onto a single factor (i.e., Model 1: Unifactorial Model) and three additional four-factor models that were differentially structured around the measure\u0026rsquo;s four distinct sections. Model 2 tested a four-factor model that included all 21 original items loading onto factors that correspond to the four different sections of the initial SAVE item pool (i.e., Four-Factor, 21 Item Model). As parental accommodation may be less relevant during verbal encounters involving familiar adults (e.g., aunts/uncles), Model 3 tested a similar four-factor structure as in Model 2, but excluded items assessing accommodation when the child interacts with familiar adults (i.e., Four-Factor, 18 Item Model, excluding familiar adult interactions). Finally, as parental accommodation may be less relevant during verbal encounters involving familiar peers (e.g., best friends), Model 4 tested a similar four-factor structure as in Model 2, but excluded items assessing accommodation when the child interacts with familiar peers (i.e., Four-Factor, 18 Item Model, excluding familiar peer interactions). We did not run a fifth model testing a similar four-factor structure that excluded items assessing accommodation during encounters with familiar adults \u003cem\u003eand\u003c/em\u003e during encounters with familiar peers, as there would be multiple factors with only 3 items, rendering the overall structure unstable (Knekta et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Due to the parallel question formatting of the first three SAVE sections, all models accounted for the residuals of high correlations among identically worded sets of items.\u003c/p\u003e \u003cp\u003eConventional fit indices and cutoff guidelines were used to asses model fit (Hu \u0026amp; Bentler, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Yu, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2002\u003c/span\u003e): Comparative Fit Index (CFI; values \u0026ge;0.95 considered good), Root Mean Square Error of Approximation (RMSEA; values ranging 0.06\u0026ndash;0.08 considered fair, values \u0026le;0.06 considered good), Standardized Root Mean Square Residual (SRMR; values \u0026le;0.08 considered good). Models were interpreted as showing (a) \u0026ldquo;poor\u0026rdquo; fit if none (or only one) of the fit indices fell in the good range, (b) \u0026ldquo;acceptable\u0026rdquo; fit if two of the three indices (CFI, RMSEA, SRMR) fell in the good range, and (c) \u0026ldquo;good\u0026rdquo; fit if all three indices fell in the good range (Brown, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter comparing CFAs to select the best final set of SAVE items and factor structure, Cronbach\u0026rsquo;s alphas, average inter-item correlation, and Spearman-Brown split-half reliability were computed to assess internal consistency. To examine concurrent validity, we examined associations between SAVE scores and measures of general family accommodation (i.e., FACLIS Scope, FACLIS Interference, FASA), SM symptoms (i.e., SMQ Total), and overall internalizing symptoms (i.e., CBCL Internalizing Problems). To assess divergent validity, we examined associations between SAVE scores and externalizing symptoms (i.e., CBCL Externalizing Problems). Given youth with SM tend to be younger and carry more comorbid diagnoses than anxious youth without SM (Viana et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), and given that accommodation patterns tend to be greater for younger children and children with higher case complexity (e.g., Thompson-Hollands et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), all validity analyses controlled for both child age and number of anxiety diagnoses.\u003c/p\u003e \u003cp\u003eTo evaluate clinical relevance of the SAVE to SM in particular, one-way ANCOVAs (controlling for child age and number of anxiety diagnoses) compared SAVE totals, subscale scores, and item scores across two anxiety groups: children whose anxiety disorder profile included SM (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;214) and children whose anxiety disorder profile did not (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;192). Given the number of comparisons involved, Holm-Bonferroni corrections (Holm, 1979) were applied before interpreting significance for this family of tests to reduce Type I error likelihood.\u003c/p\u003e \u003cp\u003eLastly, hierarchical regressions evaluated the incremental validity of the SAVE over existing measures of general family accommodation for assessing SM-specific accommodation. Three models were run, each comparing the SAVE with one of the following: the FACLIS Scope score, the FACLIS Interference score, and the FASA Total score. Change in explained variance when adding the SAVE as a predictor (ΔR\u003csup\u003e2\u003c/sup\u003e) was interpreted as evidence of the SAVE\u0026rsquo;s incremental validity in predicting SM symptom severity above and beyond the variance accounted for by general family accommodation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePreliminary Findings\u003c/h2\u003e \u003cp\u003eSAVE Total scores in the sample ranged from 0 to 104 (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;36.31, SD\u0026thinsp;=\u0026thinsp;24.50), with 96.1% of caregivers reporting they engage in at least one of the assessed accommodating behaviors in situations in which child verbal communication is expected. The most frequently endorsed accommodation was speaking or answering for their child when interacting with strangers. Specifically, 75.0% of caregivers in the full sample reported they do so at least \u0026ldquo;sometimes\u0026rdquo; (i.e. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e2) and 57.3% reported they do so \u0026ldquo;often,\u0026rdquo; \u0026ldquo;very often,\u0026rdquo; or \u0026ldquo;always.\u0026rdquo; Among the subset of caregivers of youth with SM, these numbers were even higher, with 87.6% reporting they speak or answer for their child at least \u0026ldquo;sometimes\u0026rdquo; (i.e. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e2) when interacting with a stranger, and 73.3% reporting they engage in this form of accommodation \u0026ldquo;often,\u0026rdquo; \u0026ldquo;very often,\u0026rdquo; or \u0026ldquo;always.\u0026rdquo; The least frequently endorsed caregiver accommodation on the SAVE was accompanying the child on field trips in case they are required to speak on the outing. Roughly 80% of caregivers in the full sample reported they \u0026ldquo;never\u0026rdquo; do this, although 20.7% of caregivers of youth with SM did do this at least \u0026ldquo;sometimes\u0026rdquo;.\u003c/p\u003e \u003cp\u003eAs expected, SAVE scores varied by child age (\u003cem\u003eβ\u003c/em\u003e=-0.43, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001) and number of anxiety diagnoses (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.25, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001), such that caregivers of younger children and caregivers of children with more anxiety diagnoses reported engaging in more frequent accommodation in verbal contexts. Additionally, age \u0026ndash; but not gender \u0026ndash; differed significantly between anxious youth with SM versus without SM. Specifically, children whose anxiety disorder profile included SM were significantly younger than children whose anxiety disorder profile did not, \u003cem\u003et\u003c/em\u003e(332.83)\u0026thinsp;=\u0026thinsp;11.38, p\u0026lt;.001.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFactor Structure\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents model fit indices for the four CFAs conducted on the SAVE items, estimated using the WLSMV method. Model fit statistics indicated a \u0026ldquo;poor\u0026rdquo; fit for the unifactorial model retaining all 21 original items (Model 1), and \u0026ldquo;acceptable\u0026rdquo; for the four-factor model that retained all 21 original SAVE items (Model 2), and the four-factor model that excluded three items pertaining to accommodation when the child is interacting with familiar adults (Model 3). In contrast, the four-factor model that excluded three items pertaining to accommodation when the child is interacting with familiar peers (Model 4) showed \u0026ldquo;good\u0026rdquo; fit, with all three fit indices (CFI, RMSEA, and SRMR) falling within the \u0026ldquo;good\u0026rdquo; range. Furthermore, factor loadings for each of the 18 items retained in this model were all acceptable and ranged from moderate to very strong (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The CFAs conducted using ML estimation produced similar findings, with Model 4 continuing to demonstrate the best fit (see Supplemental Material 2 for results).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConfirmatory factor analysis fit indices across tested models using WLSMV.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# of factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e# of items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSRMR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFit Category\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.913\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.988\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAcceptable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAcceptable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.994\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: A model was deemed \u0026ldquo;acceptable\u0026rdquo; if two of the three (CFI, RMSEA, SRMR) indices fell in good ranges. A model was deemed \u0026ldquo;poor\u0026rdquo; if only one or none of the fit indices fell in good ranges.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ea\u003c/sup\u003e Model 1\u0026thinsp;=\u0026thinsp;Unifactorial Model: All 21 items from the original SAVE item pool load onto a single factor.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003eb\u003c/sup\u003e Model 2\u0026thinsp;=\u0026thinsp;Four-factor 21 Item Model: All 21 items from the original SAVE item pool are included and load onto four factors that correspond to the four different SAVE subsections.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ec\u003c/sup\u003e Model 3\u0026thinsp;=\u0026thinsp;Four-factor, 18 Item Model, excluding familiar adult interactions: The three items assessing accommodation when the child interacts with familiar adults are removed, and the remaining 18 items from the original SAVE item pool load onto four factors that correspond to the four different SAVE subsections.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ed\u003c/sup\u003e Model 4\u0026thinsp;=\u0026thinsp;Four-factor 18 Item Model, excluding familiar peer interactions: The three items assessing accommodation when the child interacts with familiar peers are removed, and the remaining 18 items from the original SAVE item pool load onto four factors that correspond to the four different SAVE subsections.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinal SAVE items, factor loadings, and mean scores by clinical profile.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSAVE Factors and Items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFactor loading\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eAnxiety Disorder Profile\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eSignificance Test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIncludes SM\u003c/p\u003e \u003cp\u003e\u003cem\u003eM(SD)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDoes Not Include SM\u003c/p\u003e \u003cp\u003e\u003cem\u003eM(SD)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFactor 1: Surrogate Speaking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.73(0.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.06(0.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHow often do you speak or answer for your child when they are\u003c/em\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Interacting with a familiar adult (e.g., relatives that don\u0026rsquo;t live in the home, family friends)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.628\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.38(0.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.50(0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Interacting with a stranger (e.g., cashier at grocery store)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.948\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.30(0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.48(0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Interacting with an unfamiliar peer (e.g., on the playground)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.809\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.83(0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.84(0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Ordering at a restaurant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.933\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.21(0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.24(0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFactor 2: Permitting of Whispered Communication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.38(0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.02(0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHow often do you allow your child to whisper in your ear when they are\u003c/em\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Interacting with a familiar adult (e.g., relatives that don\u0026rsquo;t live in the home, family friends)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.857\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.26(0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.27(0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Interacting with a stranger (e.g., cashier at grocery store)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.982\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.79(0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.68(0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Interacting with an unfamiliar peer (e.g., on the playground)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.907\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.47(0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.52(0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Ordering at a restaurant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.87(0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.56(0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFactor 3: Permitting of Nonverbal Communication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.74(0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.55(0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHow often do you allow your child to communicate nonverbally when they are\u003c/em\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Interacting with a familiar adult (e.g., relatives that don\u0026rsquo;t live in the home, family friends)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.858\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.32(0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.44(0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. Interacting with a stranger (e.g., cashier at grocery store)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.970\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.97(0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.77(0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. Interacting with an unfamiliar peer (e.g., on the playground)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.937\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.67(0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.62(0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Ordering at a restaurant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.955\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.77(0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.73(0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFactor 4: Instrumental Accommodation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.41(0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.76(0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.003\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHow often do you\u003c/em\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. Speak with your child\u0026rsquo;s teacher or other school personnel in order to have your child skip an assignment or activity requiring them to speak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.862\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.78(0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.43(0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.058\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. Advocate for your child to have special accommodations in class that get them out of speaking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.890\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.21(0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.38(0.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. Allow your child to skip a performance requiring them to speak or sing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.790\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.79(0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.42(0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.050\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. Go on field trips with your child in case they are required to speak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.878\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.62(0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.45(0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.351\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17. Go other places with your child in case they are required to speak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.920\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.97(0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.44(0.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.009\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18. Avoid putting your child in activities or situations where they might be required to speak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.794\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.04(0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.65(0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.047\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOTAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.65(1.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.89(1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: SAVE items range: 0\u0026thinsp;=\u0026thinsp;Never to 5\u0026thinsp;=\u0026thinsp;Always; \u003csup\u003ea\u003c/sup\u003eLoadings in table based on CFA Model 4. \u003csup\u003e\u0026dagger;\u003c/sup\u003eSignificant after Holm-Bonferroni correction.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBased on these CFA results, the 18-item version of the SAVE tested in Model 4 was selected for further psychometric scrutiny. The first factor of the 18-item SAVE includes four items assessing the frequency with which caregivers speak or answer for their child, and was labeled \u0026ldquo;Surrogate Speaking.\u0026rdquo; The second factor includes four items assessing the frequency with which caregivers allow their child to whisper in their ear in various social situations, and was labeled \u0026ldquo;Permitting of Whispered Communication.\u0026rdquo; The third factor includes four items assessing the frequency with which caregivers allow their child to communicate strictly non-verbally in various situations (e.g., nodding, pointing), and was labeled \u0026ldquo;Permitting of Nonverbal Communication.\u0026rdquo; Finally, the fourth factor includes six items assessing the frequency with which caregivers actively work to modify situations in which children may be required to verbally communicate, and was labeled \u0026ldquo;Instrumental Accommodation.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eInternal Consistency\u003c/h2\u003e \u003cp\u003eThe mean correlation among all pairs of items from the retained 18-item SAVE was acceptable (average inter-item correlation\u0026thinsp;=\u0026thinsp;0.42) and Spearman-Brown split-half reliability was good (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.84). Cronbach\u0026rsquo;s alpha values further indicated strong internal consistency with all in the good-to-excellent range (i.e., Total Score: α\u0026thinsp;=\u0026thinsp;0.94, Surrogate Speaking: α\u0026thinsp;=\u0026thinsp;0.87, Permitting of Whispered Communication: α\u0026thinsp;=\u0026thinsp;0.93, Permitting of Nonverbal Communication: α\u0026thinsp;=\u0026thinsp;0.94, Instrumental Accommodation: α\u0026thinsp;=\u0026thinsp;0.86).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eConcurrent and Divergent Validity\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents partial correlations (controlling for child age and number of anxiety diagnoses) between each of the SAVE scales and the other study measures. Concurrent validity was evidenced by significant associations between SAVE scores and each of the three measures of general family accommodation for child anxiety. Each of the SAVE subscales were also significantly associated with both FACLIS scores, although only the Instrumental Accommodation subscale was associated with the FASA. Further evidence of concurrent validity was found in significant associations between SAVE scores and child SM symptoms (SMQ Total score) and between SAVE scores and overall internalizing scores (i.e., CBCL Internalizing Problems). Evidence of divergent validity was supported by relatively weaker (and often non-significant) associations between SAVE scores and CBCL Externalizing scores (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). To examine the extent to which the SAVE was uniquely associated with internalizing versus externalizing symptoms, a supplemental linear regression was conducted with CBCL Internalizing and Externalizing Problem scores entered as simultaneous predictors of SAVE Total (along with the covariates of child age and number of anxiety diagnoses). In this model, CBCL Externalizing Problems were no longer significantly associated with SAVE Total scores, whereas CBCL Internalizing Problems remained a significant predictor (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.17, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.09, \u003cem\u003ep\u003c/em\u003e=.002).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePartial pairwise correlations among study variables for full sample.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"10\" nameend=\"c13\" namest=\"c4\"\u003e \u003cp\u003eCorrelations\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003e9.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003e10.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. SAVE Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Surrogate Speaking (SAVE Subscale 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.74\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Whispered Communication (SAVE Subscale 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.82\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.52\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Nonverbal Communication (SAVE Subscale 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.83\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.56\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.59\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Instrumental Accommodation (SAVE Subscale 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.62\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.37\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.32\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. FACLIS Scope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.26\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.24\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.26\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.18\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.23\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. FACLIS Interference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.24\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.20\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.15\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.24\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.67\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. FASA Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.24\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.38\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.31\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.46\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. SMQ Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.61\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.34\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.36\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.49\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.36\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.19\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.24\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.15\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. CBCL Internalizing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.18\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.11\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.16\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.12\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.16\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.29\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.30\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.53\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.19\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. CBCL Externalizing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.10\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.11\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.30\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.33\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.43\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e.60\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003eNote: Each partial pairwise correlations in table controls for age and number of anxiety diagnoses. SAVE\u0026thinsp;=\u0026thinsp;Survey of Accommodation in Verbal Encounters; SAVE Factor 1\u0026thinsp;=\u0026thinsp;Surrogate Speaking; SAVE Factor 2\u0026thinsp;=\u0026thinsp;Permitting of Whispered Communication; SAVE Factor 3\u0026thinsp;=\u0026thinsp;Permitting of Non-Verbal Communication; SAVE Factor 4\u0026thinsp;=\u0026thinsp;Instrumental Accommodation; FACLIS\u0026thinsp;=\u0026thinsp;Family Accommodation Checklist and Interference Scales; FASA\u0026thinsp;=\u0026thinsp;Family Accommodation\u0026ndash;Anxiety; SMQ\u0026thinsp;=\u0026thinsp;Selective Mutism Questionnaire; CBCL\u0026thinsp;=\u0026thinsp;Child Behavior Checklist.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003e**\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003e***\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e includes the estimated marginal means (EMMs) and between-group significance tests from one-way ANCOVAs (controlling for child age and number of anxiety diagnoses) examining SAVE score differences between anxious youth with versus without SM. Caregivers of children with SM reported significantly higher SAVE Total scores than caregivers of anxious children without SM, \u003cem\u003eF\u003c/em\u003e(1, 406)\u0026thinsp;=\u0026thinsp;35.94, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001. Examination of SAVE subscale scores found further evidence of SAVE clinical relevance to SM, with caregivers of children with SM reporting significantly higher levels of Surrogate Speaking, Permitting of Whispered Communication, Permitting of Nonverbal Communication, and Instrumental Accommodation (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). These results all retained significance after applying Holm-Bonferroni corrections.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eIncremental Validity\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents the results of three hierarchical regressions evaluating the incremental validity of the SAVE (over existing general family accommodation measures) for assessing accommodation specific to SM symptoms. In each of these regressions, the measure of general family accommodation included in that model (i.e., FACLIS Scope in the first model, FACLIS Interference in the second, and FASA in the third) was found to be a significant step 1 predictor \u0026ndash; i.e., general family accommodation significantly predicted SM symptoms in the absence of the SAVE. However, the SAVE consistently emerged as the most robust and significant accommodation predictor of SM symptoms across all three constrained, rationally determined models. Adding the SAVE as a predictor in Step 2 significantly increased the amount of variance in SM symptoms explained in each model. Across models including the SAVE, links between general family accommodation and SM were reduced to negligible magnitudes, whereas the incremental associations between the SAVE and SM constituted large effect sizes (Cohen, 1988).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIncremental validity of the SAVE over other existing measures of general family accommodation in predicting SM symptoms.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncremental Validity Tested\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted \u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eΔ\u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eB\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eUtility Over FACLIS Scope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFACLIS Scope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e-0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-2.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.27\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.23\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFACLIS Scope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.292\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSAVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e-0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-6.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eUtility Over FACLIS Interference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFACLIS Interference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e-0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-3.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.28\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.23\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFACLIS Interference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e-0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSAVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e-0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-6.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUtility Over FASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e-0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-2.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.32\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.29\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.561\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSAVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e-0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-9.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eNote: SM\u0026thinsp;=\u0026thinsp;selective mutism; FASA\u0026thinsp;=\u0026thinsp;Family Accommodation Scale-Anxiety; FACLIS\u0026thinsp;=\u0026thinsp;Family Accommodation Checklist and Interference Scales; SAVE\u0026thinsp;=\u0026thinsp;Survey of Accommodation in Verbal Encounters. All models in table predict SM symptoms, as measured by the Selective Mutism Questionnaire (SMQ).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e\u003csup\u003ea\u003c/sup\u003e Predictors: Step 1 predictors are FACLIS Scope, age, # of anxiety diagnoses; Step 2 retains same predictors as Step 1, and adds SAVE Total Score. Based on a subset of participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;293) who completed the FACLIS.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e\u003csup\u003eb\u003c/sup\u003e \u003cem\u003eF\u003c/em\u003e\u003csub\u003eChange\u003c/sub\u003e (1,148)\u0026thinsp;=\u0026thinsp;48.10, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e\u003csup\u003ec\u003c/sup\u003e Predictors: Step 1 predictors are FACLIS Interference, age, # of anxiety diagnoses; Step 2 retains same predictors as Step 1, and adds SAVE Total Score. Based on a subset of participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;293) who completed the FACLIS.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e\u003csup\u003ed\u003c/sup\u003e \u003cem\u003eF\u003c/em\u003e\u003csub\u003eChange\u003c/sub\u003e (1,148)\u0026thinsp;=\u0026thinsp;47.58, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e\u003csup\u003ee\u003c/sup\u003e Predictors: Step 1 predictors are FASA, age, # of anxiety diagnoses; Step 2 retains same predictors as Step 1, and adds SAVE Total Score. Based on a subset of participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;216) who completed the FASA.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e\u003csup\u003eb\u003c/sup\u003e \u003cem\u003eF\u003c/em\u003e\u003csub\u003eChange\u003c/sub\u003e (1,210)\u0026thinsp;=\u0026thinsp;90.53, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDespite the prominence of family accommodation in modern conceptualizations of SM and its identification as a primary clinical target in supported treatments for SM (Cornacchio et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Furr et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Lorenzo et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Shorer et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), the development of reliable and valid tools for assessing SM-specific accommodation behaviors has been lacking (Fisher et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). The SAVE offers the first measure of family accommodation specifically focused on parental behaviors when child verbalizations are expected, and the present study provides initial psychometric support for the SAVE as a useful caregiver-report measure of direct relevance to the unique clinical portrait of SM. CFA supported an 18-item version of the scale with a four-factor structure corresponding to four SAVE subscales: Surrogate Speaking, Permitting of Whispered Communication, Permitting of Nonverbal Communication, and Instrumental Accommodation. The SAVE also demonstrated excellent internal consistency and divergent validity, as well as strong concurrent validity via significant associations with measures of SM symptoms, internalizing problems, and general family accommodation not specific to speaking contexts. Whereas the absence of an SM-specific accommodation measure may have impeded and/or muddled research to date on the family dynamics of SM, the present findings highlight the promising utility of the SAVE for advancing SM conceptualizations, research, and practice.\u003c/p\u003e \u003cp\u003eIn the present sample of anxious youth, the SAVE was uniquely associated with SM. SAVE scores were significantly higher among caregivers of children with SM compared to caregivers of anxious youth without SM. This pattern held for the measure\u0026rsquo;s total score, all four subscales, and approximately 80% of the individual SAVE items. That said, it is also important to acknowledge that caregivers of anxious children without SM did report moderate levels of verbal accommodation on the SAVE. Many anxious individuals without SM may also exhibit inhibited speech and/or discomfort communicating with others (e.g., Lorant et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). For example, socially anxious and behaviorally inhibited children are more likely to stutter, stumble over words, or freeze when approached by a stranger or when having to give presentations (Buss, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Iverach et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), which may similarly pull for parental accommodation. Taken together, the present findings suggest family accommodation in the context of verbal encounters has relevance, but not uniqueness, to SM, and thus remains transdiagnostically relevant across the anxiety disorders. Accordingly, the SAVE appears to capture prominent family dynamics that are hallmarks of SM, but that are also present in the families of many other anxious youth, underscoring the measure\u0026rsquo;s potential for enhancing research and practice for a range of anxious children and adolescents.\u003c/p\u003e \u003cp\u003eIncremental validity analyses found the SAVE to be a more robust and significant predictor of SM than established measures of general family accommodation. Specifically, the SAVE provided unique incremental value in predicting SM symptoms beyond what is already captured by the FASA and FACLIS, and in fact, after accounting for SAVE scores, neither the FASA nor FACLIS provided any significant unique contribution in predicting SM. These established general family accommodation measures have shown great utility in mixed samples of anxiety-disordered youth, but the present findings suggest these measures may nonetheless be insufficient for capturing specific parental accommodation forms that manifest in verbal contexts and that characterize family dynamics in SM. Accommodations for SM often focus on subtle rescue behaviors in verbal contexts (e.g., answering on behalf of the child), rather than on modifications to daily routines or changes to family schedules, which are more prominently assessed in the FASA and FACLIS. This may help explain the incremental value of the SAVE over general family accommodation measures in the assessment of SM-specific accommodation.\u003c/p\u003e \u003cp\u003eThe CFAs found no support for any of the measurement models that included SAVE items assessing accommodation during child interactions with familiar peers. Among the constrained, rationally determined models examined, results suggest the most coherent and robust model of family accommodation in child verbal contexts applies to child interactions with familiar and unfamiliar adults, and with unfamiliar (but not familiar) peers. It is not uncommon for children with SM to have certain trusted peers with whom they verbally communicate, and who in turn speak for the child in school and other settings (Williams, et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Familiar peers may actually serve more as agents of accommodation themselves for children with SM, than as people whose presence pulls for parental accommodation. Research on such possible peer accommodation is needed to elucidate interpersonal dynamics and patterns of accommodation during child interactions with familiar peers.\u003c/p\u003e \u003cp\u003eAvailability of the SAVE now affords an opportunity to study reinforcement processes (Beech et al., in press) that may underlie the development and/or maintenance of SM. Caregiver rescue behaviors assessed by the SAVE may reinforce a child\u0026rsquo;s speech hesitancy and promote longer-term reliance on nonverbal communication. Although excessive assistance and direct involvement from caregivers in verbal contexts may temporarily relieve an anxious child of their distress, this relief can inadvertently negatively reinforce mutism patterns over time, as the child learns to rely on caregivers to speak on their behalf, to communicate through nonverbal gestures or whispering, and to depend on other caregiver-provided rescue behaviors. Avoidance-enabling accommodations can also interfere with a child\u0026rsquo;s natural development of independent coping skills and can prevent important experiential learning that feared outcomes are unlikely (Ginsburg et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Norman et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Avoiding feared situations can also limit children\u0026rsquo;s self-efficacy and confidence for managing their own anxiety, further reducing the likelihood of future verbal responses in challenging contexts.\u003c/p\u003e \u003cp\u003eSome research suggests that parental accommodation can be reinforcing not only for the child, but also for the caregiver (Aschenbrand \u0026amp; Kendall, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Feinberg et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Kerns et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Shorer et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and may serve a co-regulation function. Greater caregiver anxiety, experiential avoidance, and emotion dysregulation predict greater caregiver engagement in accommodation behaviors (e.g., Feinberg et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Jones et al., 2013; Kerns et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Thompson-Hollands et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), and, through negative reinforcement, caregivers may learn that accommodating their child\u0026rsquo;s SM-related distress also alleviates their own short-term distress (Shorer et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). To clarify interpersonal pathways and causal chains that may maintain SM, investigations would now do well to use the SAVE to examine links between parental anxiety, accommodation when child speech is expected, and long-term patterns of child verbal reticence.\u003c/p\u003e \u003cp\u003eThe SAVE may afford new opportunities to uncover mechanisms of effective SM treatment response, and can support improved clinical practices for SM. Research on the treatment of other anxiety disorders and OCD has found reductions in family accommodation can lead to downstream improvements in child symptoms (e.g., Etkin et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Kagan et al., 2022; Merlo et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). The availability of the SAVE now creates an opportunity for researchers to study the extent to which SM treatment response is mediated by changes in parental accommodation in situations in which child speech is expected. Such findings would be integral for clarifying the \u0026ldquo;active ingredients\u0026rdquo; in family treatments for SM, and could help identify key mechanisms to target. The SAVE can also be utilized to improve clinical practice for SM, and to inform individual case conceptualization and treatment planning. By offering improved assessment of the interpersonal context of SM symptoms, clinicians are now better equipped to identify useful treatment targets for their SM cases, and they may find value in incorporating the SAVE into routine outcome monitoring practices to track treatment responses and outcomes beyond a restricted focus on child symptoms.\u003c/p\u003e \u003cp\u003eLimitations of the current study warrant consideration. First, the SAVE only assessed family accommodation in a limited range of social contexts and relied exclusively on one caregiver\u0026rsquo;s (mostly mother\u0026rsquo;s) self-reports. Accommodating behaviors can vary across family members, and school staff can also play a role in avoidance-oriented accommodations (Benito et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Conroy et al., 2022; Thompson-Hollands et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Second, self-report can be biased, especially in the assessment of parenting and child internalizing symptoms (Comer \u0026amp; Kendall, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; De Los Reyes et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Continued evaluation of SAVE validity should incorporate structured behavioral observations (e.g., the Selective Mutism Interaction Coding System, SMICS; Carpenter et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Cotter et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Third, unlike the FASA and FACLIS, the SAVE does not assess caregiver distress or interference associated with accommodation. An expanded SAVE may do well to add items assessing accommodation-related impairment. Fourth, study assessments were collected at the same timepoint, and thus our findings cannot speak to issues of temporal precedence or causality. Longitudinal research is needed to clarify matters of directionality and SAVE test-retest reliability. Research in the context of clinical trials is also needed to evaluate the SAVE\u0026rsquo;s sensitivity to treatment-related changes. Lastly, despite the ethnic diversity of the sample, participants were predominantly of middle-to-high socioeconomic status, White, and treatment-seeking. Replicating this study in more racially and economically diverse samples, and in non-treatment seeking families, is needed to more broadly consider the generalizability of the present findings.\u003c/p\u003e \u003cp\u003eDespite limitations, the present study offers strong psychometric support for the first measure of parental accommodation specifically in contexts in which child speech is expected. In addition to demonstrating initial reliability, validity, and incremental utility of the SAVE, these findings provide rare empirical insight into the frequency, patterns, and correlates of parental accommodation in verbal situations among families of anxious children with and without SM. With continued support, the SAVE can offer a useful tool for research and practice to evaluate key family dynamics associated with verbal reticence in youth and SM-specific accommodation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDisclosures:\u003c/h2\u003e \u003cp\u003eDr. Comer earns textbook royalties from Macmillan Learning, and an editorial stipend from the Association for Behavioral and Cognitive Therapies, for work unrelated to the present study. No other authors have financial disclosures to report.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e \u003cb\u003e/Support\u003c/b\u003e: This work was funded by a grant from the Andrew Kukes Foundation for Social Anxiety (PI: Comer) and by a grant from the Gordon \u0026amp; Marilyn Macklin Foundation (PI: Furr).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.K. and J.C. wrote the main manuscript text and prepared tables. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData can be made available upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbdi H (2010) Holm\u0026rsquo;s sequential Bonferroni procedure. Encyclopedia Res Des 1:1\u0026ndash;8\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAchenbach TM, Rescorla LA (2000) Manual for ASEBA Preschool Forms \u0026amp; Profiles. ASEBA, Burlington, VT\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAchenbach TM, Rescorla LA (2001) Child Behavior Checklist for Ages 6\u0026ndash;18. ASEBA, Burlington, VT\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association (2022) \u003cem\u003eDiagnostic and statistical manual of mental disorders\u003c/em\u003e (5th ed., text rev.). 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Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://smcenter.wpenginepowered.com/wp-content/uploads/2022/08/SCAI_Child.pdf\u003c/span\u003e\u003cspan address=\"https://smcenter.wpenginepowered.com/wp-content/uploads/2022/08/SCAI_Child.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShorer M, Ben-Haim Z, Krispin O, Ben-Ami N, Fennig S (2023) Parents\u0026rsquo; social anxiety, authority style and accommodation are associated with symptom severity in children with selective mutism. J Child Fam stud 32(9):2748\u0026ndash;2760\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilverman WK, Albano AM (1996) Anxiety Disorders Interview Schedule for DSM-IV.: Parent Interview Schedule, vol 1. Oxford University Press\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilverman WK, Albano AM (2024) Anxiety and related disorders interview schedule for DSM-5, child and parent version: Clinician manual. Oxford University Press\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilverman WK, Ollendick TH (2005) Evidence-based assessment of anxiety and its disorders in children and adolescents. J Clin Child Adolesc Psychol 34:380\u0026ndash;411\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilverman WK, Saavedra LM, Pina AA (2001) Test\u0026ndash;retest reliability of anxiety symptoms and diagnoses with the anxiety disorders interview schedule for DSM-IV: child and parent versions. J Am Acad Child Adolesc Psychiatry 40(8):937\u0026ndash;944\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteinhausen HC, Wachter M, Laimb\u0026ouml;ck K, Metzke CW (2006) A long-term outcome study of selective mutism in childhood. 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J Anxiety Disord 35:75\u0026ndash;81\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson-Hollands J, Kerns CE, Pincus DB, Comer JS (2014) Parental accommodation of child anxiety and related symptoms: Range, impact, and correlates. J Anxiety Disord 28(8):765\u0026ndash;773\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTomohisa Y, Yumi I, Inoue M (2023) Long-term outcome of selective mutism: factors influencing the feeling of being cured. Eur Child Adolesc Psychiatry 32:2209\u0026ndash;2221\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViana AG, Beidel DC, Rabian B (2009) Selective mutism: A review and integration of the last 15 years. Clin Psychol Rev 29(1):57\u0026ndash;67\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams CE, Hadwin JA, Bishop FL (2021) Primary teachers\u0026rsquo; experiences of teaching pupils with selective mutism: A grounded theory study. 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University of California, Los Angeles\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"child-psychiatry-and-human-development","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chud","sideBox":"Learn more about [Child Psychiatry \u0026 Human Development](http://link.springer.com/journal/10578)","snPcode":"10578","submissionUrl":"https://submission.nature.com/new-submission/10578/3","title":"Child Psychiatry \u0026 Human Development","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"family accommodation, accommodation, selective mutism, SM, child anxiety, assessment","lastPublishedDoi":"10.21203/rs.3.rs-9295482/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9295482/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eFamily accommodation is a key environmental factor that can maintain and reinforce child anxiety disorders, but research on accommodation specific to childhood selective mutism (SM) is limited and inconsistent. The absence of a supported measure of accommodation specifically in verbal contexts may explain, in part, why research on accommodation in the families of youth with SM has lagged. In a sample of 412 treatment-seeking anxious youth ages 2\u0026ndash;18 years (52.7% with SM; 56.7% female; ~50% Hispanic and/or Latinx), the present study examined the psychometric properties of the Survey of Accommodation in Verbal Encounters (SAVE) \u0026ndash; a newly developed caregiver-report scale assessing the frequency of parental accommodation specifically in situations in which child verbal communication is expected. Confirmatory factor analysis supported an 18-item, four-factor structure corresponding to four SAVE subscales: Surrogate Speaking, Permitting of Whispered Communication, Permitting of Nonverbal Communication, and Instrumental Accommodation. The SAVE also demonstrated strong reliability, convergent and divergent validity, incremental utility, and clinical relevance to SM. These findings offer support for the SAVE as the first measure of parental accommodation in contexts in which child speech is expected. Results also provide empirical insight into the frequency, patterns, and correlates of such accommodation among families of anxious children with and without SM. The SAVE appears to offer a useful tool for researchers and clinicians to assess SM-specific accommodation and key family dynamics associated with verbal reticence in youth.\u003c/p\u003e","manuscriptTitle":"Family accommodation and selective mutism: Evaluating the Survey of Accommodation in Verbal Encounters (SAVE)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 19:07:21","doi":"10.21203/rs.3.rs-9295482/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"143532433784577091486384036555373187108","date":"2026-05-06T19:06:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"240398754571927510865481970289496352457","date":"2026-04-27T12:40:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-03T01:00:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-03T00:59:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-02T10:49:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child Psychiatry \u0026 Human Development","date":"2026-04-01T19:11:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"child-psychiatry-and-human-development","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chud","sideBox":"Learn more about [Child Psychiatry \u0026 Human Development](http://link.springer.com/journal/10578)","snPcode":"10578","submissionUrl":"https://submission.nature.com/new-submission/10578/3","title":"Child Psychiatry \u0026 Human Development","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"817890fa-bc6f-4466-865a-e7bc508faae0","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"143532433784577091486384036555373187108","date":"2026-05-06T19:06:09+00:00","index":82,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T19:07:21+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 19:07:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9295482","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9295482","identity":"rs-9295482","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}