assessment and behavioral treatment of selective mutism

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  • Case Studies online version of this article can be found at:

    DOI: 10.1177/1534650104269029 2006 5: 382Clinical Case Studies

    Brian J. Fisak, Jr, Arazais Oliveros and Jill T. EhrenreichAssessment and Behavioral Treatment of Selective Mutism

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  • 10.1177/1534650104269029CLINICALCASE STUDIES / October 2006Fisak et al. / TREATMENTOF SELECTIVEMUTISM

    Assessment and Behavioral Treatmentof Selective Mutism

    BRIAN J. FISAK, JR.University of North Florida

    ARAZAIS OLIVEROSUniversity of Central Florida

    JILL T. EHRENREICHBoston University

    Abstract: Children with selective mutism present with a complicated set of symptoms, asthey not only refuse to speak in particular social situations but are often shy, sociallyisolative, anxious, and may present as oppositional and negativistic in their behavior. Lim-ited research on treatments for selective mutism suggests a need for additional researchexamining intervention possibilities. The following case description presents a 10-year-oldmalewith selectivemutismand concurrent anxiety symptoms.Treatment included theuseof a significantlymodified version of Social Effectiveness Therapy for Children (SET-C), amanualized behavioral treatment for social anxiety. In addition to SET-C, treatment alsoincluded concurrent parent training in themanagement of child anxiety. The rationale forthe treatment selection and a description of treatment course are provided. Further, a dis-cussion is presented concerning challenges to treatment progress, including cultural differ-ences between the primary clinician and the client.

    Keywords: selective mutism; assessment; behavioral treatment; therapy


    Children with selective mutism (SM) demonstrate a challenging constellation ofsymptoms, as they not only refuse to speak in particular social situations but are also fre-quently shy, behaviorally avoidant, and fearful, in addition to often appearing oppositionalin their behavior (Kehle, Madaus, Baratta, & Bray, 1998). The anxiety-related aspects ofSM, and its high comorbidity with social phobia (SP), have informed the suggestion thatSM may be a particularly severe variant of SP rather than a fully distinct diagnosis(Lehman, 2002). For example, Black and Uhde (1995) found that 97% of a clinical sam-pleof childrenwithSMalsomet thecriteria forSP.Specifically, a childwithSMmaycopewith intense fear of social situations through avoidance of speech. This coping strategyresults in a pattern of behavior that is extremely resistant to change, given that children


    CLINICAL CASE STUDIES, Vol. 5 No. 5, October 2006 382-402DOI: 10.1177/1534650104269029 2006 Sage Publications

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  • with SMare often negatively reinforced by the subsequent decrease in requests for speechover time (Kehle et al., 1998). For example, a teacher may ask for a response in class, andthe SM child may repeatedly fail to answer. As a result, the teacher may withdraw therequests for responses, thereby negatively reinforcing the childs lack of responding.

    Although conceptualization of SM as an extreme form of SP has received empiri-cal support, a number of studies have foundother differences between childrenwithSMand children with SP. Dummit et al. (1997) found that social anxiety ratings of childrenwith SM were in the moderate range, suggesting that behavioral factors beyond socialanxiety may also be associated with the presentation of SM.When comparing parentalreports of children with SP versus those with comorbid SM and SP, via responses on theChild Behavior Checklist (CBCL; Achenbach & Rescorla, 2001), parents of SM chil-dren indicate significantly higher scores on the Delinquency subscale and marginallyhigher scores on the Aggression subscale when compared to those with comorbid pre-sentation (Yeganeh, Beidel, Turner, Pina, & Silverman, 2003). Although Delinquencyand Aggression subscale scores observed in both groups were largely in the nonclinicalrange andgenerally lower than scores on Internalizing subscales, the difference in scoresfound in this investigation corroborates clinical observations of significant parental diffi-culties in managing oppositional behaviors in children with SM, particularly amongthose without concurrent SP symptoms.

    In summary, SMhas been conceptualized as an extreme formof SP; however, thisdistinction may not fully characterize SM, as those with SM may also exhibitoppositional behaviors (Yeganeh et al., 2003). As a result, Yeganeh et al. suggest that,when compared to treatment of SP, a broader range of interventions may be needed forsuccessful treatment of children with SM (e.g., parent training, behavior modification,and interventions to decrease social distress). Further, despite the potential complexitiesassociatedwith treating childrenwithSM, structured interventions designed specificallyto treat children with SM are lacking. For example, in a review of empirically supportedtreatments conducted byChambless andOllendick (2001), there were no specific treat-ments listed for SM. As a result of these challenges, further research into potentiallyeffective interventions for children with SM is needed.


    This case description presents the conceptualization and treatment of a 10-year-old Hispanic male diagnosed with SM whose speech was limited to the home environ-ment. Given the potential overlap between SM and SP, and the lack of empirically sup-ported treatment protocols specifically targeting SM symptoms, the clinicians in thiscase attempted to use amodified version of a popular social skills treatment protocol forsocial anxiety symptomatology (Beidel, Turner,&Morris, 1994), in conjunctionwith an


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  • alternative treatment generalization component in the childs school andcomprehensive parent training.


    At the time of initial evaluation, which took place as LM was entering the fifthgrade, he would not speak in class unless the teacher insisted, at which point LM spokein a barely audible volume and appeared fearful during speech. In thehome setting, LMspoke freely to his mother, a professional housekeeper; his father, an electrical workerseeking employment; as well as his 13-year-old brother. According to his father, LMwould show visible distress when faced with social situations (e.g., parties, dances) andrefused to interact with neighboring children. LM did not respond when greeted, evenby familiar acquaintances, and would avoid ordering at restaurants, often having hisbrother or his parents order for him. LMdenied any difficulties at school (by shaking hishead to indicate no) and responded accordingly on questionnaires presented (seeAssessment section).

    Mrs. M had few complaints with regard to LMs behavior, a fact that appeared toresult in disagreementwith her spouse during an assessment interview. She relayedmildconcern that LMoftenused a baby voice at homebut indicated that this only occurredwith her and that she often enjoyed this type of interaction with him. She agreed thatLMs activities were mostly limited to those in the home, but in contrast with LMsfather,Mrs.Mwas reportedly not bothered byLMs social constriction, as she felt hewasgenerally safer inside the home, although the family did not live in a neighborhood thatwas considered particularly dangerous or unsafe. Both parents did agree with regard toLMs need to speak in the classroom and in other appropriate situations (e.g., orderingfood for himself, greeting others, etc.).


    LMwasborn in thenortheasternportionof theUnitedStates,wherehe completedkindergarten through third grade, and he consistently limited his speech to only familyand extremely familiar friends. From all indications, LMs developmental history waslargely unremarkable. He was the result of a normal and uncomplicated pregnancy anddelivery. All developmental milestones, with the exception of generalization of speechto certain settings, weremetwithin normal limits.Hehadnohistory of surgery or seriousillness and was presently in good health. According to his father, LM was a quiet andcalm baby. LMs shyness and refusal to speak were first noticed when he entered kinder-garten. LMs hearing and speech were tested by his school at that time, but no organicetiology was found. He also received a psychological assessment when he was in third

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  • grade (age 8), resulting in a diagnosis of selective mutism, but there was no subsequenttreatment provided at that time.

    LMs shyness becamemore apparent after hemoved to his current residence in thesoutheastern United States, at age 9, where he initially had no familiar peers except hisolder brother. LMapparently chose not to initiate contact or interact with any peers in hisnew neighborhood and seemingly rejected his fathers instructions to try to go ou


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