Behavioral Techniques in the Treatment of Selective Mutism Aimee Kotrba, Ph.D.

Can you identify the child with selective mutism?

DSM-IV Criteria Consistent, ongoing failure to speak in specific social situations Interferes with education or social communication Not due to lack of language skills Other disorders (e.g., stuttering, PDD) have been ruled out A relatively rare childhood disorder, affecting approximately 1% of children in elementary school settings

Assessment of Selective Mutism History Behavioral observations Cognitive functioning Language functioning Shy, anxious temperment from birth. Approximately 50% of children with selective mutism have a speech or language delay; this likely creates a bidirectional relationship.

Psychological Treatment of Selective Mutism Education Medication Desensitization Hierarchical exposure Relaxation techniques Shaping speech Generalization

Psycho-education of Child Bibliotherapy Cat’s Got Your Tongue: A Story for Children Afraid to Speak Written by Charles Schaefer Published by Magination Press in 1992 Treatment is explained in age-appropriate language to child Child is assured that the therapist will practice with them in becoming braver and stronger.

Psycho-education of Parents Selective mutism is conceptualized as a social anxiety disorder Behavioral techniques are explained Describe ways parents could prevent inadvertently reinforcing mutism Pediatrician discusses role of medication Anti-depressants have been found to produce beneficial effects for children with selective mutism. However, research demonstrates that the most effective treatment is cognitive-behavioral therapy.

Treatment Package Implementation Flowchart Individual work with child Work with parent present Training parents Collaboration with other professionals

Fear Hierarchies Expanding stimulus & response classes Example Fear Hierarchy Expanding stimulus & response classes Expand hierarchy to include other adults and children Increase volume requirements for speech Decrease latencies to responding Utilizing shaping and fading principles Maintain eye contact for 5 second count Imitate simple body movements Imitate sounds made with instruments Imitate sounds made with the mouth Imitate words, then phrases Answering questions with head nod Answering yes/no questions (audible) Answer novel “Wh” questions Ask spontaneous questions

Self Modeling

Case Example 1 Alone with Mother 6 year old (Annie) diagnosed with selective mutism 2nd session of treatment Early treatment on her fear hierarchy

Escape Contingency Required to nod head Yes or No as a response to the question posed by the therapist Posture, facial expression, and demeanor changes when therapist enters the room

Relaxation Techniques Deep breathing exercises Positive self-statements Visualization

Shaping Techniques One word spoken simultaneously with therapist One word spoken alone Repeated a short sentence Answered questions Gradually increased voice volume

Generalizing Behavior to School Teachers are given information concerning the present step on the heirarchy. Importance of practicing heirarchy in the school setting Steps are only added when they were “cleanly” demonstrated in the therapy session

Generalizing Behavior to Public Gradually increasing proximity to peers Working with peer dyad in the clinical setting Parents asked child questions in public Parents arranged play dates

Post treatment with Therapist Hierarchical steps have been accomplished with the therapist Future goals will include expanding the response class to include additional adults and children in a variety of settings

Termination Achieving spontaneous speech across multiple settings Booster sessions will likely be necessary