assessment and behavioral treatment of selective mutism

22
http://ccs.sagepub.com/ Clinical Case Studies http://ccs.sagepub.com/content/5/5/382 The online version of this article can be found at: DOI: 10.1177/1534650104269029 2006 5: 382 Clinical Case Studies Brian J. Fisak, Jr, Arazais Oliveros and Jill T. Ehrenreich Assessment and Behavioral Treatment of Selective Mutism Published by: http://www.sagepublications.com can be found at: Clinical Case Studies Additional services and information for http://ccs.sagepub.com/cgi/alerts Email Alerts: http://ccs.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: http://ccs.sagepub.com/content/5/5/382.refs.html Citations: What is This? - Sep 6, 2006 Version of Record >> by Andreea Nicoleta Nicolae on October 12, 2011 ccs.sagepub.com Downloaded from

Upload: andreea-nicolae

Post on 06-Nov-2015

16 views

Category:

Documents


2 download

DESCRIPTION

Behavioral therapy

TRANSCRIPT

  • http://ccs.sagepub.com/Clinical Case Studies

    http://ccs.sagepub.com/content/5/5/382The 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

    Published by:

    http://www.sagepublications.com

    can be found at:Clinical Case StudiesAdditional services and information for

    http://ccs.sagepub.com/cgi/alertsEmail Alerts:

    http://ccs.sagepub.com/subscriptionsSubscriptions:

    http://www.sagepub.com/journalsReprints.navReprints:

    http://www.sagepub.com/journalsPermissions.navPermissions:

    http://ccs.sagepub.com/content/5/5/382.refs.htmlCitations:

    What is This?

    - Sep 6, 2006Version of Record >>

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • 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

    1 THEORETICAL AND RESEARCH BASIS

    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

    382

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

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • 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.

    2 CASE PRESENTATION

    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

    Fisak et al. / TREATMENT OF SELECTIVEMUTISM 383

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

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

    3 PRESENTING COMPLAINTS

    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.).

    4 HISTORY

    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

    384 CLINICAL CASE STUDIES / October 2006

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • 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 out andmake friends. During the early part of the fourth grade at his new school, LM had afemale classmate who would voluntarily speak for him in class. However, LM and thispeer were then assigned to different fourth-grade teachers, after which LM reportedly didnot talk to any peers in his classroom. LMalso stopped talking to the female ex-classmate,who had made attempts to visit with him at his home.

    5 ASSESSMENT

    INITIAL INTERVIEW ANDMEASUREMENT ADMINISTRATION

    During the initial evaluation, LMdisplayed a variety of behaviors potentially indic-ative of anxiety, such as facial tension, rigid posture with crossed arms, andhypervigilance. These behaviors slowly decreased as the initial interview progressed.LMremained quiet throughout this interview, typically answering questions by noddingyes or no. As the interview progressed, however, LM began to provide brief (i.e., one- totwo-word) responses to questions. In addition, when LMand his father were in the sameroom, LM appeared to become more anxious and withdrawn whenever his fatherdirected him to speak. LMsmotherwas not available during initial interviews due to herwork schedule, whereas LMs father was unemployed during this period, allowing himto attendmost appointments. As treatment progressed, LMsmother was available for anoccasional one to two sessions at a time, but his father attended the majority of sessionswith LM alone.

    TheParent-Report Formof theAnxietyDisorders InterviewSchedule forDSM-IV(Child Version; ADIS-IV-C/P; Silverman & Albano, 1997), a semistructured diagnosticinterview for parents of children and adolescents, was administered to LMs father toassess the extent to which current psychopathology was clinically significant and inter-feringwithLMs functioning.Results of this interview supporteddiagnoses of both socialphobia and selectivemutism. LMevidenced social phobia via significant fear and avoid-ance in situations that require social interaction (e.g., parties, class participation),although this was admittedly difficult to distinguish from his selective mutism symp-toms.Mr.Mendorsed an average severity rating of 6 (on aLikert-type scale from0 [not atall] to 8 [very, verymuch]) inhis discussionofLMs social fears,with themost disturbanceevident in the school setting. Mr. M. rated LMs specific fears as 6 and above for situa-tions such as speaking in class and speaking to unfamiliar people.

    Fisak et al. / TREATMENT OF SELECTIVEMUTISM 385

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • LM also met diagnostic criteria for selective mutism, owing to his refusal to speakor answer questions in a variety of settings such as school and parties, despite speakingfrequently in the home environment and with family members or very familiar people.Mr. M rated the interference of LMs selective mutism as a 6. No other diagnoses wereapparent at that time.

    On the ADIS-IV-C/P (Silverman & Albano, 1997), LM endorsed symptoms con-sistent with social phobia, including fear and avoidance/distress with regard to giving areport or reading aloud in front of the class and during musical performances. LMsresponses throughout this diagnostic interview were mostly head nods or one-wordresponses.

    LMs father also completed theCBCL, a questionnaire that provides both generalandmore specific indices of a childs emotional andbehavioral functioning (Achenbach&Rescorla, 2001). LMs score on the Internalizing Behavior Problems scale fell withinthe clinical range.More specifically, LMs score on theWithdrawn/Depressed scale fellwithin the clinical range, indicating that LM often refused to speak and may be secre-tive, shy, withdrawn, sometimes preferring to be alone, lacking energy, and finding fewthings enjoyable. All other scale scores on the CBCL, including the Externalizing andBehavior Problems scale, fell within the nonclinical range, indicating that LM was notexperiencing difficulty in domains such as inattentiveness or aggressive behavior. LMsTotal Competence, Activities Competence, and Social Competence scores fell withinthe clinical range, whereas his score on the School Competence scale fell within thenonclinical range. Specifically, LM showed a low level of social interaction (i.e., friends,

    386 CLINICAL CASE STUDIES / October 2006

    TABLE 1Summary of Parent and Teacher Ratings of Clients Behavior

    Parent Rating (CBCL) Teacher Rating (TRF)

    Scale T-Score Percentile T-Score Percentile

    Anxious/depressed 53 62 52 58Withdrawn/depressed 85a > 97 73a > 97Somatic complaints 50 50 60 50Total internalizing behavior problems 66a 95 54a 92Rule-breaking behavior 53 63 50 50Aggressive behavior 57 76 50 50Total externalizing behavior problems 56 73 41 18Social problems 60 84 50 50Thought problems 50 50 50 50Attention problems 50 50 50 50Total behavior problems 56 73 47 38Activities competence 28a < 3 n/a n/aSocial competence 25a < 3 n/a n/aSchool competence 43 24 n/a n/aTotal competence functioning 24a < 2 50 50

    NOTE: CBCL = Child Behavior Checklist; TRF = Teacher Rating Form.a. Scores in the clinical range.

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • groupmembership) and involvement in activities (i.e., sports, hobbies). SeeTable 1 for asummary of the fathers CBCL ratings of LM, including T-scores and percentiles.

    LMs fourth-grade teacher completed the Teacher Report Form of the CBCL(TRF; Edelbrock & Achenbach, 1985). This profile corroborated parental reports ofLMs tendency to experience internalizing rather than externalizing emotional andbehavioral difficulties. Specifically, LMs score on the Internalizing Behavior Problemsscale fell within the clinical range, whereas his score on the Externalizing BehaviorProblems scale fell within the nonclinical range. LMs score on the Withdrawn/Depressed scale fell within the clinical range, also corroborating similar parental report.All other scale scores fell within the nonclinical range, indicating that withdrawn/depressed symptoms seemed to be themajor source of difficulty forLM, according to theteacher. See Table 1 for a summary of the teachers TRF ratings of LM, including T-scores and percentiles.

    To establish a more direct comparison with regard to reports of LMs competenceacross multiple domains, his father and fourth-grade teacher also completed the revisedversion of the Perceived Competence Scale for Children (Harter, 1982). This measureallows for ratings in ScholasticCompetence, Social Acceptance, AthleticCompetence,Physical Appearance, Behavioral Conduct, and Global Self-Worth. According to LMsfather, Social Acceptance and Athletic Competence scores were more than two stan-dard deviations above the mean, indicating that LMwas perceived by his father to havedifficulty making friends and playing sports as well as his peers. LMs teacher endorsedsimilar elevations, but to a slightly lesser extent. Parental and teacher ratings of PhysicalAppearance and Behavioral Conduct were disparate (i.e., by more than two standarddeviations), with LMs father perceiving him as much lower in these domains than histeacher in terms of competencies related to appearance and conduct. In querying thesediscrepancies, it was established that LMs behavior in the classroom was perceived byhis teacher to be very appropriate, despite his lack of speech in that environment,whereas LMwasmore likely to benoncompliantwith requests at home, leading to loweroverall parental ratings of LMs competencies. See Table 2 for z-scores associated withratings on this measure by LMs father and teacher.

    Fisak et al. / TREATMENT OF SELECTIVEMUTISM 387

    TABLE 2Summary of Parent and Teacher Ratings of Clients Competence

    Z-Score

    Scale Mean Standard Deviation Father Teacher

    Scholastic competence 2.81 .69 1.25 .28Social acceptance 2.87 .77 2.01 1.56Athletic competence 2.89 .73 2.59 1.67Physical appearance 2.91 .76 .80 1.43Behavioral conduct 3.04 .56 1.32 1.71Global competence 3.04 .69 1.32 .25

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • LM also completed the Revised Childrens Manifest Anxiety Scale (RCMAS;Reynolds &Richmond, 1985), ameasure that includes subscales to assess physiologicalanxiety, social anxiety, worry, and total anxiety, along with a Lie scale. His Total Anxiety(1st percentile), Physiological Anxiety (3rd percentile), Worry (14th percentile), andSocial Anxiety (21st percentile) scores all fell within the nonclinical range. His score onthe Lie scale (90th percentile), however, indicated that LMs denial of symptoms associ-ated with anxiety could be attributed to responding in a defensive manner.

    Given these circumstances, the RCMASwas readministered to the client 2 weekslater, following additional rapport building and the therapists encouragement that therewere no wrong or right answers for the questionnaire. LM answered all of the anxiety-related questions in the same fashion he had answered them the first time, receivingTotal Anxiety (1st percentile), Physiological Anxiety (3rd percentile), Worry (14th per-centile), and Social Anxiety (21st percentile) scores that matched his previous scores,again falling within the nonclinical range. His score on the Lie scale (10th percentile),however, showed a notable decrease from the previous session.

    ASSESSMENT OF FAMILY VARIABLES

    During a clinical interview, LMs parents reported some difficulties with regard tochild discipline. Specifically, they often disagreed concerning what rules to enforce andhow to enforce them, resulting in inconsistency. Contributing to the parental disciplinedifficulties was his parents basic lack of correspondence with regard to expectations forLMs behavior. LMs father frequently instructed him to go outside and play with neigh-bors, whereas his mother reported that she felt uneasy with her son being outside of thehome. However, both parents also reported few interactions with neighbors or friendsoutside of the home. LMs use of baby-talk instead of more comprehensible speech insome circumstances was undesirable to the father, whereas his mother spoke of it withendearment, indicating that such talk reminded her that LMwas her baby. Disagree-ments like these often led to arguing during subsequent sessions, presenting an overallpicture inwhichhis fathers attempts at behavioral controlwere impededbyhismothersefforts to protect and rescueLM frombeing bossed around, as themother reported shehad been as a child.

    The patterns observed in LMs family are consistent with literature pertaining toparenting strategies associated with anxious children. Becoming impatient with an anx-ious childs avoidant behaviors and being overly directive in response to a childs fearedbehavior are common parental responses to such symptoms.On the other hand, remov-ing a child froma feared situation and facilitating avoidance behaviors are also commonbehaviors for parents dealing with their childs anxiety (Rapee, Spence, Cogham, &Wignall, 2000). This aspect of LMs daily life was an integral part of his eventual caseconceptualization and treatment.

    388 CLINICAL CASE STUDIES / October 2006

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • 6 CASE CONCEPTUALIZATION

    On the basis of this multimodal assessment, LMs refusal to speak was conceptual-ized as a strategy for avoiding feelings of anxiety in speech-related situations and also con-ceptualized as the result of limited exposure to opportunities that would lead to thedevelopment of adequate social skills. LMs avoidance strategies hadbecome so effectivethat his motivation for change was understandably low. The family trend of sedentaryand nonsocial daily life was serving tomaintain LMs social isolation, despite his fathersperiodic efforts to encourage outside activities. Secondary gains, including decreasedrequirements at school and the baby role with his mother at home, also seemed to bereinforcing a lack of speech outside of the home. These secondary gains and parentingissues would eventually represent significant challenges to treatment.

    To improve LMs social skills, the initial treatment strategy focused on the usage ofa manualized behavioral treatment for social anxiety in children, Social EffectivenessTherapy for Children (SET-C; Beidel et al., 1994). The treatment manual had to bemodified froma group treatment format to an individual treatment format; however, theorder in which the educational modules were presented remained consistent with theoriginal SET-C manual. Sessions always began with a shaping/warm-up exercise withLM, his parent, and two therapists. This exercise requires repeated vocalization of asound, a word, and then a sentence by eachmember of the treatment team. Followingthis exercise, one therapist wouldmeet with LM individually to review the previous ses-sions social skill and then present a new social skill (e.g., eye contact, greetings, askingopen-ended questions, topic transitions). After presentation of this educational compo-nent, the new skill would be role-played during the session. LM also frequently com-pleted an exposure exercise during the session, wherein he carried out an anxiety-pro-voking task of increasing self-rated difficulty (e.g., giving a short speech to an audience ina classroom setting). LMs speech frequency and volume was also reinforced in the ses-sion via his preferred reward, trading cards. His speech increased in volume throughouttreatment, and by the end of treatment, LM independently generated sounds, words,and sentences during the session.

    LMs treatment was complemented with systematic interventions at his school.However, initial difficulties in establishing cooperation from the school may haverestricted treatment progress in this arena.During a behavioral observation of LM in theclassroom setting, his speechwas limited to barely audible answers to questions posed bythe teacher, and he failed to speak to peers, even when his classmates approached him.Treatment goals in the school setting included increasing opportunities for LM to speakin the classroom and consistent reinforcement of his speech by his teacher.

    To intervene in the family system, parent anxiety management training sessionswere concurrently conductedwithLMs father (andhismother, when available). A step-by-step guide to aid parents in dealing with their childs anxiety (Rapee et al., 2000) wasprimarily used to introduceboth factors contributing to child anxiety andparent trainingskills for managing/intervening with the childs difficulties. An important goal in this

    Fisak et al. / TREATMENT OF SELECTIVEMUTISM 389

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • form of parent training involves increasing opportunities for social interaction outside ofthe home for LM and applying reinforcement for the clients speech outside of thehome. Other strategies that were encouraged include parental modeling of self-expo-sure to social-evaluative situations, parental modeling of positive self-talk before andafter engaging in a novel social situation, practicing social skills at home, and reinforce-ment of social skills practice outside of the home.

    7 COURSE OF TREATMENT AND ASSESSMENT OF PROGRESS

    ADAPTATION OF THE SET-C

    As noted, the SET-Cwasmodified from a group treatment format to an individualtherapy format for use in this case. The implementation of the SET-C as an individualtreatment instead of a group treatment presented a notable disadvantage in that a groupsetting would have provided a built-in opportunity for LM to practice skills learned intreatmentwith peers. Practicingwith peers facilitates generalization of skills discussed insession and serves as a source of exposure for children who are fearful when interactingwith peers. Nonetheless, owing to the relatively small number of children being treatedfor similar difficulties in this treatment setting, a group format for treatment could not beachieved.

    To compensate for the absence of group peers, the therapists used a number ofalternative exposure and skill practice strategies. One strategy included attempts toengageLMs older brother (whowas of a similar age) in treatment by encouraginghim tohelpLMwithhis practice of social skills. A second strategywas to use the clinic staff. Theclinic staff members participated in role-plays with LM and were used as an audiencewhen LM gave practice speeches. The therapists treating LM also actively attempted toengage the family and the school in exposure and skills generalization exercises. Detailsof how generalization and exposure were conducted will be discussed below.

    SESSIONS 1-3

    Treatment began after two initial assessment sessions, the latter of which includedpsychoeducation concerning the nature and interaction of SM and SP, the rationale forthe SET-C, and the typical course of treatment. Starting in the first treatment session, allsessions began with the aforementioned speech game during which each individualinvolved in the treatment session (LM, the family member(s), and both of thecotherapists) took turns making a sound, followed by a word, and then a complete sen-tence. The soundwas first whispered by each groupmember, one at a time. The processwas then repeated several timeswith the volumeof the sound gradually increasing to thepointwhere eachmember of the group yelled the sound.This processwas then repeated

    390 CLINICAL CASE STUDIES / October 2006

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • with the word and the sentence. In the typical session structure, after the speech gamewas completed, LMwouldmeet individually with his therapist, while a second therapistwould meet with LMs parent.

    The primary agenda for the first session was to inquire about a reinforcementschedule for LM that was to be used when he successfully performed target behaviors(e.g., speaking with others, completing exposure tasks, and completing related therapyhomework tasks). Based on inquiries about LMs interests, it became apparent that hisinterests revolved almost completely around aparticular type of animatedTV show (e.g.,trading cards, video games, andother activities related to this show).He appeared tohavefew other interests, including little interest in physical activity. It is interesting that it isnot uncommon for children with anxiety-related difficulties to have a narrow range ofinterests, whichmay limit the number of common activities and opportunities for inter-action with other children (Albano, DiBartolo, Heimberg, &Barlow, 1995). In additionto inquiring about a reinforcement schedule, another goal of the first session was tobegin reinforcement of speech through verbal praise. This process superseded otherpsychoeducational goals, as an increase in baseline in-session speechwas viewed as vitalto therapeutic rapport and overall progress in treatment.

    Beginning with the first session, several approaches were used to assess progress.Although a comprehensive assessment was conducted before the beginning of treat-ment, continueduse of the initial assessmentmeasureswasnot sufficient to track specificbehavioral progress. For example, although the ADIS-IV-C/P provides diagnostic infor-mation, symptom severity ratings obtained from the ADIS were not perceived to be sen-sitive enough to track subtle behavioral progress from session to session. The RCMAScould potentially have been used to track progress; however, there was an apparent flooreffect in LMs reporting of symptoms on thismeasure. Another issue is that the RCMASdoes not evaluate symptoms specific to selective mutism.

    In response to these limitations, the therapists decided to track the number of ver-balizations that LMmade during each session. A verbalizationwas defined as any verbalexpression inwhich LM spoke at least one discernible word. All speech conducted priorto a therapist response was counted as one verbalization, meaning that each verbaliza-tion could range fromoneword to, on rare occasions, several sentences. All sessionswereaudiotaped and the total number of verbalizations was tabulated for each session (seeFigure 1). Although the average number of words in each verbalization was not quanti-fied, verbalizations appeared to average approximately three to five words in length. Asecond way in which progress was assessed was through monitoring LMs successfulmastery of designated behavioral exposure tasks. The nature and intensity of the expo-sure tasks changed as treatment progressed, with a gradual increase in the intensity oftasks presented (exposure tasks are summarized in Table 3). An early measure of LMscomfort with speaking was assessed by asking LM to conduct a 1-minute speech abouthimself and about the clinic prior to the second session. During this initial assessment,he refused to engage in this task.

    Fisak et al. / TREATMENT OF SELECTIVEMUTISM 391

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • The therapeutic agenda for the second and third sessions was to further developrapport with LM and to begin to reinforce speech consistently throughout the session.Contingencies for speaking included verbal praise and small rewards (i.e., trading cardsand stickers). His speech increased significantly during the second session and third ses-sions (see Figure 1). Based on examination of Figure 1, it is noteworthy that the numberof verbalizations during sessions peaked early in treatment and waxed and wanedthroughout treatment. An explanation for this early peak in speech and the fluctuationsis that, as treatment progressed, sessions became increasingly challenging and the lack ofspeech may have been, in part, a coping response or oppositional response to newly

    392 CLINICAL CASE STUDIES / October 2006

    Figure 1. Number of Client Verbalizations by Session

    TABLE 3Exposure Tasks

    Session Number Task Was the Task Accomplished?

    In session exposure tasks:Session 2 speech in front of video camera noSession 4 speech in front of video camera yesSession 8 speech in front of an audience of 2 yesSession 9 speech in front of an audience of 4 yesSession 10 speech in front of an audience of 5 yesSession 16 speech in front of an audience of 5 (no note card) yes

    Assigned exposure tasks for school setting:Session 18 passing a note that says hi to another student yesSession 19 saying hi to another student yesSession 20 saying a complete sentence to another student yes

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • imposed therapeutic challenges. Further, it is feasible that he reached a ceiling effect inthe therapeutic context, with his speech reaching more of a typical frequency for chil-dren his age as the sessions progressed. Despite this, LMmaintained a substantial num-ber of verbalizations throughout treatment, suggesting that he successfully adapted tothe verbal demands of the therapeutic setting.

    SESSIONS 4-7

    Sessions 4 through 7 included social skills training based on modules outlined inthe SET-C. LM appeared to comprehend the material presented in each of these mod-ules. In addition to presentation of the social skills trainingmodule in Session 4, LMwasalso asked to provide a speech in front of a video camera. After development of anoutlinefor the speech, modeling of the speech by the therapist, and practice, LM was able tosuccessfully complete the task (see Table 3).

    SESSIONS 8-10

    Beginning with Session 8, the sessions were moved to an empty university class-room thatwas in close proximity to the clinic.The classroomsettingwasused to simulateLMs classroom at his elementary school. During Session 8, LM practiced social skillspresented in previous sessions with his brother. One goal of including his brother in thissession was for LM to begin to practice learned social skills with his brother on a regularbasis. Because in previous sessions LM appeared to have difficulty discussing interestsother than his favorite animated series, a second goal of meeting with LM and hisbrother together was to ascertain whether LMhad any interests beyond those previouslydiscussedwith his therapists.Other interests could be used to formadditional reinforcersfor LM, owing to concerns that the frequency with which the therapist relied on tradingcards and other paraphernalia related to LMs preferred animated TV show mightdecrease their potency as reinforcers over time. This reinforcer assessment was con-ducted by having both LM and his brother fill out a worksheet that included their owninterests and the interests of their sibling. In addition to the above interventions, a speechexposure task was again conducted. LM successfully conducted a brief speech in themock classroom setting, in front of both his brother and the therapist.

    Sessions 9 and 10 included preparing and conducting a variety of increasinglycomplex or anxiety-provoking speeches in the university classroom setting. In Session 9,LM successfully completed a brief speech with an audience of four (therapist, father,and two clinic staff members), and in Session 10, LM successfully completed a briefspeech with an audience of five (therapist, father, and three clinic staff members; seeTable 3).

    Fisak et al. / TREATMENT OF SELECTIVEMUTISM 393

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • SESSIONS 11-17

    Sessions 11 and 12 included a continuation of social skills training based on theSET-Cmodules. After Session 12, a reviewof his progress with social skills trainingmod-ules suggested a number of conclusions. First, when the social skills training moduleswere presented, LMappeared to comprehend thematerial; however, a weekly review ofprevious modules indicated that LM appeared to have difficulty retaining the informa-tion from previously presentedmodules. Second, his basic social skills appeared to haveimproved. Specifically, his eye contact improved, hebegan todevelop skills for introduc-ing himself, and he was able to discuss his favorite topic (animation). However, despitethese improvements, he appeared to have continued difficulty in his ability to fluentlyaccess and integrate social skills from previous sessions. For example, his voice stillsoundedmechanistic and his speechwas generally brief. Further, he had continued dif-ficulties with other skills discussed in previous sessions, such as changing topics duringrole-plays, engaging in verbal conversations not related to his favorite topic, and respond-ing verbally when a comment was made to him. Further, despite encouragement fromthe therapists, LMandhis parents didnot appear to bepracticing and reviewing the skillsbetween sessions.

    In response to the above-mentioned difficulties, modules presented in subsequentsessionswere audiotaped andLMwas given the tape to listen to at home.Sessions 13, 14,15, and 17 proceeded in this manner. In addition to social skills training, Session 16included an exposure task in which LM completed a speech for an audience of five,without the assistance of a note card (see Table 3).

    SESSIONS 18-21

    Between Sessions 17 and 18, LMs therapist observed LM in his regular classroomandmet with LMs teacher. Based on thismeeting, the teacher agreed to include a dailymonitoring log in a folder at LMs desk. The purpose of the logwas to have both LMandhis teacher monitor LMs speech and monitor his success with school-related exposuretasks that were assigned during the therapy sessions. The logwas to be sent to the teacherafter each of LMs subsequent sessions via e-mail.

    Following the visit to the school, the cotherapists, LM, and his fathermet togetherfor the first part of Session 18 to discuss the school visit and plans to focus on extendingthe existing treatment plan to LMs classroom.During the second portion of the session,LMworked on further developing his fear-avoidance hierarchy, with regard to commu-nications and interactionswith peers at school. The final step of the developedhierarchywas to give a speech in front of his class. As a first step in thehierarchy,LMagreed towritethe word hi on a piece of paper and hand it to the student who sits next to him, and heagreed to do this task prior to his next therapy session. This informationwas forwarded toLMs teacher via e-mail.

    394 CLINICAL CASE STUDIES / October 2006

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • Although LMs teacher reported that he did not observe LMpassing the note, LMreported that he successfully passed the note to a peer in school. The therapist and LMcontinued towork on the hierarchy in Session 19, and the next step on the hierarchywasto verbally say hi to another student. This homework assignment was forwarded to theteacher along with a self-monitoring log designed to help the teachermonitor LMs self-recorded frequency of speech and completion of therapy homework assignments. Thelog was to be completed by the teacher on a daily basis. During the next session, LMdidnot bring this log; however, he did report successful completion of the homework task.Despite the fact that the teacher apparently did not give LM the monitoring log, theteacher reported that LMwasmaking progress in school, primarily in terms of his inter-actions with the teacher. The teacher reported progress in that LM began to ask ques-tions verbally instead of making gestures and that LM would say bye to the teacherwhen prompted. During Session 20, work on the hierarchy was continued and LMagreed to say a full sentence to another student on one occasion and say hi to a studenton another occasion. An updated log was sent to the teacher.

    During Session 21, LM reported that he was successful at this homework butreported that he again had not received the log from his teacher. Although the log wasnot presented to LM, the teacher reported that LMs verbalizations had increased withregard to brief responding to direct questions in the classroom. AWechsler IntelligenceScale for ChildrenThird Edition (WISC-III) was also administered during Session 21(Wechsler, 1991). TheWISC-III was administered at this time in treatment because thetherapist was not certain that LMwould be responsive to items on the verbal scale of theWISC-III in the earlier stages of treatment. Moreover, although LM appeared to haveobtained basic conversational skills, he still appeared to have difficulty during role-playsmaintaining a conversation, integrating, and usingmaterial presented in the social skillsmodules. The goalwas to rule out significant cognitive difficulties thatmay behinderinghis progress. Overall, his scores on the WISC-III were in the average range.

    SESSIONS 22-23

    The school year was completed after Session 21. A final teacher report indicatedthat LM continued to make limited progress. By Session 21, LM interacted with theteacher verbally 4 to 6 times a day; however, responses remained brief and sparse and lit-tle interaction was observed with classmates. Sessions 22 to 24 were conducted duringthe summer holiday away from school. Session 23 included completion of the socialskills training modules, and both Sessions 23 and 24 focused on termination of treat-ment for the summer. Treatment with the SET-C was completed at this time, with LMdemonstrating progress with a variety of in-session exposure activities. At this time, it alsoappeared that LM likely reached maximum benefit from treatment conducted at theclinic.Theclinicians concluded that the focus of further interventions shouldbe school-based interventions.

    Fisak et al. / TREATMENT OF SELECTIVEMUTISM 395

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • PARENT SESSIONS

    Parent sessions were held concurrently and in Spanish for optimumbenefit toMr.and Mrs. M. Following the assessment phase and the session including LM and hisfather to determine possible reinforcers, the objective for the first parent training session(Session 2) involved orienting LMs parents to the goals of his treatment, mainly rein-forcing speech in session and generalizing his speech behavior to other settings. Parenttraining henceforth included instruction and role-play of behavioral strategies as well aspsychoeducation informed by a published guide for parents of anxious children, writtenby Rapee et al. (2000).

    Given Mrs. Ms report of LMs frequent baby-talk, the concept of reinforcingappropriate speechwhile ignoring baby-talk was discussed in Session 2.Mr. andMrs.Mappeared to disagree with regard to how to handle LMs avoidant behaviors (i.e.,demanding speech versus allowing speech avoidance). In contrast to pressuring the cli-ent to speak, emphasis was placed on providing opportunities for LM to speak outside ofthehomeandencouraging andpraising the client for any attempts at communication.

    In Session 3,Mrs.M reported that despite ignoring LMs baby-talk, he was contin-uing to use thismethod of communication. This was normalized and the importance ofconsistency in achieving behavioral change was emphasized. During Sessions 4 and 5,specific parenting strategies were presented, including role-playing with both parentsconcerning modeling nonanxious behavior in social situations (i.e., thinking out loudwith coping statements and then performing the interaction in LMs presence). Thisstrategy played a dual purpose of encouraging the parents to engage in routine socialbehavior, which was reportedly at a low level, and providing a positive technique forshowing LM how one can cope with social situations despite anxiety. In discussingpraise,Mr.M cited an example of praising LMs class participation one day of the pre-vious year by telling him that he needs to domore of that. After this, LM subsequentlyceased his participation in class. The possibility that praise linked with heightenedexpectations may have increased LMs anxiety (as described by Rapee et al., 2000) wasexplored. Alternative ways of praising were role-played.

    Mrs.M reported during Session 6 that LMcontinued his use of baby-talk. The dis-cussion revealed that she was ultimately answering his baby-talk, which was addressedthrough further training and in-session practice. Despite reporting that LM had spokento a peer and the peers parents,Mrs.Mdenied providing any verbal reinforcement. Theimportance of consistency and reinforcement continued to be integral topics in parentsessions.

    The next several sessions included psychoeducation about social skills that LMwas learning and practicing in his individual sessions.Mr. andMrs.Mwere encouragedto role-model and reinforce LMs use of social skills (e.g., eye-contact, greeting, askingopen-ended questions). In promoting exposure exercises for LM, frequent brainstorm-ing and trouble-shooting sessions were required. LMs parents experienced difficulty ininitiating social contacts that would provide such exposure. During Session 8, Mrs. M

    396 CLINICAL CASE STUDIES / October 2006

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • reported praising (without pressuring) in response to the client when he stated that hespoke to a classmate. This new parental practice was reinforced in session.

    During Session 11, Mr. M expressed anxiety about future consequences of LMstreatment. Having filled out job applications inquiring about psychological treatment,Mr.Mwasworried that records of LMs treatmentwould prevent him fromgetting a job.Confidentiality of treatment was reiterated and concern with regard to a treatment-related stigma was addressed in the context of LMs relatively benign diagnosis and thecommon use of psychological services.

    Mr. M continued to attend the final sessions, which included mostly trouble-shooting difficulties in providing exposure activities and encouragingparental reinforce-ment of LMs practice of social skills. Modeling use of various social skills was role-played, and Mr. M cited examples of his sons increasing social behavior. During the15thweek,LMrespondedon twooccasionswhengreetedbynewadults.Thenextweek,LM interacted for an hour with a peer in his neighborhood, which Mr. M admittedlyfailed to reinforce. During the 18th week, LM ordered for himself at a restaurant andcontinued to do so from that point on. LMs social behavior wasmet with reinforcementon an increasing basis, andMr.M stated at one point that all parents should attend simi-lar sessions to learn how to influence child behavior in a positive way.

    8 COMPLICATING FACTORS

    One of the complicating factors concerning LMs treatment, and also a factor typi-cal formany children with selectivemutism, is the long history of secondary gain associ-ated with LMs selective mutism behaviors. Regardless of the etiology of LMs selectivemutism, it became apparent that LMs refusal to speak enabled him to avoid a number ofsituations and behaviors, resulting in reinforcement of his reticence. For example, hewas able to avoid answering questions in class, and this avoidance led to reduction in thelikelihood that teachers would call on him in the future. Based on the abundance of sec-ondary gain for this client, it was challenging to motivate him to engage in increasedsocial interactions.

    A number of family issues also provided complications for treatment. The initialcomplication had to do with overall communication with LMs parents. Although LMwas fluent in English, both of his parents spoke little English. Therefore, LMs individ-ual therapist, who was not bilingual, had difficulty directly conversing with LMs par-ents. This difficulty was addressed by recruiting a bilingual cotherapist to conduct con-current sessions with LMs parents. The bilingual therapist was also able to translate forLMs primary therapist, so that LMs primary therapist could communicate informationabout LMs progress and homework assignments. In addition, the bilingual cotherapistconducted sessions with the parents that included parent training and education tomaximize the effectiveness of treatment.

    Fisak et al. / TREATMENT OF SELECTIVEMUTISM 397

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • Another complication had to do with poor parental compliance with parent anxi-ety management training and minimal parental facilitation of exposure tasks for LM.LMs father reported that economic and time constraints played a role in their inconsis-tencies with regard to carrying out the prescribed strategies. In addition, cultural differ-ences associated withHispanic familiesmay have complicated treatment (McGoldrick,Giordano, & Pearce, 1996). Specifically, the fathers expectation that children shouldobey directives without the use of rewards contributed to resistance related to applyingpositive behavior modification strategies. This expectation is consistent with the beliefcommonly held in Hispanic cultures that a child should be respectful, compliant, andwell-behaved, or what is referred to as bien educado (e.g., Fontes, 2002).

    Another possible factor that may have been associated with limited parental facili-tation of exposure tasks and limited compliance with prescribed parent training strate-gies was theminimal amount of social contact outside of the immediate family environ-ment evidenced by all familymembers. This isolationmeant that, with the exception ofschool, LM had few opportunities to practice skills with individuals outside of the corefamily unit, and limited modeling of social interactions occurred. Further, the parentsnot only were limited in their social interactions but also appeared somewhat resistant toengaging in social interactions with individuals outside of the family. As a result, the par-entsmay have beenmodeling avoidance of social interactions. It is interesting that socialisolationmay be common for families with a socially anxious child (Burch&Heimberg,1994).

    The limited social interactionmay be explained by the aforementioned economicand time constraints; however, a number of other factorsmay be associatedwith the fam-ilys limited social interaction. First, although there is a significant Spanish-speakingpopulation in the area in which LMs family resides, a limited ability to speak Englishmay have limited the possible number of opportunities to engage in more commonforms of social interaction, especially for families who are relatively new to a particularcommunity. Second, both parents appeared to exhibit a relatively high degree of socialdiscomfort. Such social discomfort may be associated with their reluctance to take partin the facilitation of exposure tasks for LM. The fathers social inhibition may also be apossible explanation for his reluctance to provide positive reinforcement to LM in pub-lic settings. An additional complicationwas that LMand his father appeared to have fewpositive social interactions. As a result, attempts on the part of the father to reinforceLMs speaking behavior may not have been very reinforcing for LM.

    The contrasting perceptions of LMs behavior on the parts of hismother and fatheralso posed a challenge in gaining some consistency concerning parental engagement intreatment. Fortunately, LMs father increasingly applied prescribed techniques andnoted improvement in terms of the frequency with which LM engaged in speech out-side of the home (e.g., responding to strangers greetings, ordering food).

    398 CLINICAL CASE STUDIES / October 2006

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • Application of reinforcement on the part of the parents was quite inconsistentthroughout treatment, however. To illustrate, during the 22nd week of treatment, LMagreed to participate in an impromptu yard sale. To his fathers reported surprise, LMstated the price of items to inquiring neighbors and strangers, described items, and evennegotiated a sale price with a peer. LMs father noted that although LM tried to speak aslittle as possible, he seemed to enjoy this particular activity. Nonetheless, his fathercritiqued LMs reluctance to sell more of his old toys, instead of verbally praising LMsspeech. Although this is just one example of the apparent intractability of ineffective butfamiliar parental behaviors, the practice of social skills with parents did increasethroughout treatment, and LMs father became increasingly invested in applying thestrategies discussed in session, especially to curtail LMs noncompliance.

    In addition to challenges related to LMs family dynamics, a number of challengesemerged when the therapist attempted to enter the school setting. One barrier was that,due to administrative constraints, it took the therapist approximately 2 months to gainpermission to go to the school for observation and consultation with the school staff.Once the therapist was able to enter the school, the school was generally receptive toconsultation; however, the teacher did not completely follow through with a number ofdesigned interventions. For example, the teacher agreed to designate an extroverted stu-dent as a peer who could actively attempt to engage LM in social interaction and assistLM in attempts to interact with other students. Second, the teacher agreed to give LM afolder with a daily monitoring log that could be completed by LM and reviewed by histeacher. Although the teacher willingly provided updates via e-mail on LMs behavior,the two above-mentioned interventions were not implemented.

    A final complication had to do with assessment of additional factors that may beassociated with the development and/or maintenance of LMs selective mutism. It wasapparent that LMexhibited a degree of social anxiety; however, throughout treatment, itseemed increasingly possible that cognitive and/or speech-related difficulties may havebeen impeding his progress, based on his continued difficulty maintaining conversa-tions during role-plays and integrating social skills presented in themodules. A compre-hensive screening for cognitive difficulties at the outset of treatmentwas not feasible dur-ing the initial assessment phase due to the presenting selective mutism symptoms.Similarly, before the current psychological intervention, he was referred to a speechpathologist at his school. The speech pathologist was also unable to conduct a compre-hensive speech assessment because of LMs refusal to speak. Nonetheless, when amea-sure of cognitive ability was successfully completed with LM, he performed in the aver-age range, relative to same-age peers. Further testing may help explicate more subtlelearning or developmental issues thatmay have contributed to LMs noted difficulties insession.

    Fisak et al. / TREATMENT OF SELECTIVEMUTISM 399

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • 9 MANAGED CARE CONSIDERATIONS

    Although research-based treatments have been shown to be efficacious inresearch-oriented settings, a number of considerations and adaptationsmaybenecessaryto maximize the effectiveness of such treatments in other clinical settings (e.g., Jensen,Hibbs, & Pilkonis, 1996). Specifically, the therapists who administered this treatment ina university clinic did not have to work within the constraints of the managed care sys-tem, and amanaged care settingmayhave necessitated a number ofmodifications to theabove-mentioned treatment process. For example, limitations may be placed on thenumber of authorized sessions. Further, therapists in managed care settings may nothave the liberty to use two cotherapists, concurrently working on the same case. In addi-tion, therapistsmay not always have the flexibility of being able to visit the school to con-sult with school staff and to observe the client in the school setting.

    One suggestion is that, regardless of treatment limitations, therapists make everyattempt to engage parents in SM treatment, as engaging the parents in treatment mayincrease the success rate of anxiety-related interventions (Barrett, Dadds, & Rapee,1996). Engaging the parents may be of particular importance in time-limited managedcare settings. Parents are able to implement treatment strategies on a daily basis (e.g.,reinforcement of speech behavior and exposure tasks) andmay be able to serve as a liai-son with the school. Further, parents are vital in creating an environment that wouldmaintain gains accomplished during therapy. As a result, despite session limitationsplaced by managed care, therapists should still spend a significant portion of therapyeducating the parents and engaging them in the treatment process with childrenexhibiting SM.

    In a managed care setting, facilitating client therapeutic interventions in schoolcan be accomplished in a number of possible ways. Interventions can include therapist-teacher phone consultations or assisting the parent in working with teachers to effec-tively initiate a school-based intervention.Another possibility,when feasible, is theuse ofbehavior modification specialists assigned to the schools. These specialists may be ableto most effectively implement school-based interventions prescribed by the therapist.

    10 FOLLOW-UP

    Treatment was completed in mid-summer. At this point in treatment, all SET-Cskills were completed, significant progress was documented (both inside and outside ofthe clinic), and LM appeared to reach a plateau in terms of his treatment progress. Theclinicians agreed to contact the family at the beginning of the new school year to assessthe necessity of reinitiating treatment.

    400 CLINICAL CASE STUDIES / October 2006

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • A follow-up with LMs mother at the beginning of the new school year indicatedthat LM was reportedly doing well in school and that he liked school. His mother alsoreported that the teacher had not reported significant concerns and that LMwas partici-pating in after-school activities on Fridays. In addition, LMs mother reported that LMdoes not seem to shy away from strangers as much as he used to and that he will respondto strangers with a verbal greeting. His mother reported that they are satisfied with hisbehavior and are no longer seeking services at this time; however, she agreed to contactthe clinic if future concerns were to arise.

    11 TREATMENT IMPLICATIONS OF THE CASE ANDRECOMMENDATIONS TO CLINICIANS AND STUDENTS

    Treatment of SM was accomplished through a number of relevant interventionsthat included social skills training for anxious children, exposure to feared situations,parent training, and a number of additional, specific interventions. This case study sug-gests that such a combination of interventions in conjunction with parent training andschool-based interventionsmay be an effective treatment for some childrenwith SM. Inaddition, this case adds to the literature suggesting that manual-based interventionsdeveloped for the treatment of anxiety disorders may be effective interventions for chil-dren with selectivemutism (Hudson, Krain, &Kendall, 2001). As a result, more system-atic research on the effectiveness of the application of manual-based anxiety interven-tions for the treatment of selective mutism is recommended. Further, it is noteworthythat other interventions in conjunction with manual-based interventions may increasethe effectiveness of treatment for SM. In addition, this case study highlights both theimportance of parent involvement in treatment and the challenges inherent in workingwith parents of anxious and selectively mute children (Barrett et al., 1996; Siqueland &Diamond, 1998).

    REFERENCES

    Achenbach,T.M.,&Rescorla, L. A. (2001).Manual for the ASEBA school-age forms&profiles. Burlington:University of Vermont, Research Center for Children, Youth, & Families.

    Albano, A. M., DiBartolo, P. M., Heimberg, R. G., & Barlow, D. H. (1995). Children and adolescents:Assessment and treatment. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.),Social phobia: Diagnosis, assessment and treatment (pp. 387-425). New York: Guilford.

    Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). Family treatment of childhood anxiety: A controlledtrial. Journal of Consulting & Clinical Psychology, 64, 333-342.

    Beidel, D. C., Turner, S. M., & Morris, T. L. (1994). Social effectiveness training for children: A treatmentmanual. Unpublished manuscript.

    Black, B., &Uhde, T.W. (1995). Psychiatric characteristics of childrenwith selectivemutism: A pilot study.Journal of the American Academy of Child and Adolescent Psychiatry, 34, 47-56.

    Fisak et al. / TREATMENT OF SELECTIVEMUTISM 401

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

  • Burch,M.A.,&Heimberg,R.G. (1994).Differences in perceptions of parental andpersonal characteristicsbetween generalized and nongeneralized social phobics. Journal of Anxiety Disorders, 8, 155-168.

    Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Contro-versies and evidence. Annual Review of Psychology, 52, 685-716.

    Dummit, S. E., Klein, R. G., Tancer, N. K., Asche, B.,Martin, J., & Fairbanks, J. A. (1997). Systemic assess-ment of 50 childrenwith selectivemutism. Journal of theAmericanAcademyofChild andAdolescentPsy-chiatry, 36, 653-660.

    Edelbrock, C. S., & Achenbach, T. M. (1985). The teacher version of the Child Behavior Profile: I. Boysaged 6-11. Journal of Consulting and Clinical Psychology, 52, 207-217.

    Fontes, L. (2002).Child discipline and physical abuse in immigrant Latino families: Reducing violence andmisunderstandings. Journal of Counseling and Development, 80, 31-41.

    Harter, S. (1982). The Perceived Competence Scale for Children. Child Development, 53, 87-97.Hudson, J. L., Krain, A. L., & Kendall, P. C. (2001). Expanding horizons: Adapting manual-based treat-

    ments for anxious children with comorbid diagnoses. Cognitive and Behavioral Practice, 8, 338-345.Jensen, P. S., Hibbs, E. D., & Pilkonis, P. A. (1996). From ivory tower to clinical practice: Future directions

    for child and adolescent psychotherapy research. InE.D.Hibbs&P. S. Jensen (Eds.),Psychosocial treat-ments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 701-711).Washington, DC: American Psychological Association.

    Kehle,T. J.,Madaus,M.R.,Baratta,V. S.,&Bray,M.A. (1998).Augmented self-modeling as a treatment forchildren with selective mutism. Journal of School Psychology, 36, 247-260.

    Lehman, R. B. (2002). Rapid resolution of social anxiety disorder, selective mutism, and separation anxietywith paroxetine in an 8-year-old girl. Journal of Psychiatry & Neuroscience, 27, 124-125.

    McGoldrick,M., Giordano, J., & Pearce, J. K. (1996).Ethnicity and family therapy. Piscataway, NJ: RobertWood Johnson Medical School.

    Rapee, R.M., Spence, S. H., Cobham, V., &Wignall, A. (2000).Helping your anxious child: A step-by-stepguide for parents. Oakland, CA: New Harbinger.

    Reynolds, C. R., & Richmond, B. O. (1985). Revised Childrens Manifest Anxiety Scale: Manual. LosAngeles: Western Psychological Services.

    Silverman,W.K.,&Albano, A.M. (1997).TheAnxietyDisorders InterviewSchedule forChildren. SanAnto-nio, TX: Psychological Corporation.

    Siqueland, L., & Diamond, G. S. (1998). Engaging parents in cognitive behavioral treatment for childrenwith anxiety disorders. Cognitive and Behavioral Practice, 5, 81-102.

    Wechsler, D. (1991).Wechsler Intelligence Scale for ChildrenThird Edition. San Antonio, TX: Psychologi-cal Corporation.

    Yeganeh, R., Beidel, D. C., Turner, S. M., Pina, A. A., & Silverman, W. K. (2003). Clinical distinctionsbetween selective mutism and social phobia: An investigation of childhood psychopathology. Journal ofthe American Academy of Child and Adolescent Psychiatry, 42, 1069-1076.

    Brian J. Fisak, Jr., is an assistant professor in the Department of Psychology at the University of NorthFlorida. His primary research and clinical interests are in the areas of prevention and treatment of child-hood anxiety disorders, developmental psychopathology, and evidence-based treatments.

    Arazais Oliveros received her bachelors degree in psychology from Florida International University wheresheworked in theChild Anxiety andPhobia Program. She is pursuing a doctoral degree in clinical psychol-ogy at the University of Central Florida and conducting research in the Family P.A.I.R.S. (Perception andInteraction Research Studies) Lab.

    Jill T. Ehrenreich, Ph.D., is a research assistant professor of psychology and associate director of the Childand Adolescent Fear and Anxiety Treatment Program at the Center for Anxiety and Related Disorders atBoston University. Her primary interests are in the etiology, assessment, and treatment of child and adoles-cent anxiety disorders.

    402 CLINICAL CASE STUDIES / October 2006

    by Andreea Nicoleta Nicolae on October 12, 2011ccs.sagepub.comDownloaded from

    /ColorImageDict > /JPEG2000ColorACSImageDict > /JPEG2000ColorImageDict > /AntiAliasGrayImages false /DownsampleGrayImages true /GrayImageDownsampleType /Bicubic /GrayImageResolution 300 /GrayImageDepth -1 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict > /GrayImageDict > /JPEG2000GrayACSImageDict > /JPEG2000GrayImageDict > /AntiAliasMonoImages false /DownsampleMonoImages true /MonoImageDownsampleType /Bicubic /MonoImageResolution 1200 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict > /AllowPSXObjects false /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox false /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile (U.S. Web Coated \050SWOP\051 v2) /PDFXOutputCondition () /PDFXRegistryName (http://www.color.org) /PDFXTrapped /Unknown

    /SyntheticBoldness 1.000000 /Description >>> setdistillerparams> setpagedevice