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

2. Can you identify the child with selective mutism?

3. 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

4. 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.

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

6. 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.

7. 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.

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

9. 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

10. Self Modeling

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

12. 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

13. Relaxation Techniques
Deep breathing exercises
Positive self-statements
Visualization

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

15. 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

16. 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

17. 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

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