Clinical Case Studies-mutism Selectiv

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DOI: 10.1177/1534650113492997 2013 12: 335 originally published online 26 June 2013Clinical Case Studies

Marni L. Jacob, Cynthia Suveg and Anne ShafferSelective Mutism

Developmentally Sensitive Behavioral Treatment of a 4-Year-Old, Korean Girl With

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Article

Developmentally Sensitive Behavioral Treatment of a 4-Year-Old, Korean Girl With Selective Mutism

Marni L. Jacob1, Cynthia Suveg2, and Anne Shaffer2

AbstractThis case study reports on the use of a developmentally sensitive behavioral treatment program for a 4-year-old Korean girl diagnosed with selective mutism. Multi-method assessment, consisting of parent and teacher reports, as well as school and home-video observation, confirmed the diagnosis. Behavioral therapy was administered with an emphasis on behavioral reinforcement strategies that were adapted for the childs developmental level. After 17 sessions, the child evidenced a notable reduction in selective mutism symptoms, evidenced by clinician and school observation. Furthermore, she indicated a decrease in symptoms of withdrawal based on teacher report. This case study demonstrates how behavioral treatment strategies emphasizing behavioral reinforcement techniques can be applied in developmentally appropriate ways to treat young, bilingual children with selective mutism.

Keywordsselective mutism, behavioral therapy, child, culture, treatment

1 Theoretical and Research Basis for Treatment

According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000), selective mutism is characterized by the failure to speak in certain social situations where speaking is expected. The disorder must be present for at least 1 month and interfere with the childs functioning (e.g., academic functioning, social functioning) to meet diagnostic criteria. Selective mutism should not be diagnosed if fail-ure to speak is due solely to discomfort or lack of knowledge with the spoken language required in the environment; the disorder should only be diagnosed if the child possesses the required developmental capacities to speak and he or she speaks in some contexts (APA, 2000). Oftentimes, a child with selective mutism will not speak to teachers or peers at school, yet will speak nor-mally with family members at home.

1University of South Florida, St. Petersburg, USA2University of Georgia, Athens, USA

Corresponding Author:Marni L. Jacob, Rothman Center for Neuropsychiatry, University of South Florida, Box 7523, 880 6th Street South, St. Petersburg, FL 33701, USA. Email: [email protected]

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336 Clinical Case Studies 12(5)

To date, there is no comprehensive theory about the etiology, assessment, or treatment of selective mutism (see Viana, Biedel, & Rabian, 2009), as most of the current literature consists of case studies rather than empirical studies with large sample sizes. The etiology of selective mutism is thought to be multi-determined, though many models consider it to have a significant anxiety-based component. More specifically, several researchers have suggested similarities between selective mutism and other anxiety disorders (e.g., social phobia). Kristensen (2000) found that 74.1% of children with selective mutism had a comorbid anxiety disorder, primarily social phobia (67.9%) and separation anxiety disorder (31.5%). Other studies also demonstrated the high comorbidity between selective mutism and social phobia (Manassis et al., 2007; Vecchio & Kearney, 2005). When considering genetic contributions, Black and Uhde (1995) investigated a sample of 30 children with selective mutism and found that a family history of social phobia or selective mutism was present in 70% and 37% of first-degree relatives, respec-tively. However, some theories suggest that selective mutism could be due to child oppositional-ity, where he or she purposely refuses to speak. However, the evidence that supports this view is limited. In Manassis et al. (2007), 6.8% of children met criteria for oppositional defiant dis-order, which is much lower than the comorbidity found between selective mutism and anxiety disorders. Vecchio and Kearney (2005) also found low parent and teacher ratings of external-izing behaviors in children with selective mutism. Other studies have replicated these findings by finding no significant differences between children with selective mutism and control groups on measures of behavioral problems (Bergman, Piacentini, & McCracken, 2002; Cunningham, McHolm, Boyle, & Patel, 2004).

Some researchers hypothesize that cultural and environmental factors (e.g., immigration, bilingualism) may be implicated in selective mutism. Elizur and Perednik (2003) found the prevalence rate of selective mutism among immigrant children in Israel to be 2.2%, compared with 0.5% among native children. The study by Elizur and Perednik emphasizes that different languages may be spoken at home versus in public, thus making acquisition of a second lan-guage even more difficult, which might contribute to the development of selective mutism. Furthermore, different languages spoken at home versus in public may also create confusion for the child in regard to which language to speak. Toppelberg, Tabors, Coggins, Lum, and Burger (2005) discussed that while a normal period of nonspeaking may occur during acquisition of a second language, most children between 3 and 8 years old pass through this nonverbal period after approximately 6 months. Cohan, Chavira, and Stein (2006) suggested that a potential path-way to selective mutism for bilingual children may be associated with a behaviorally inhibited temperament in combination with immigration and pressure of learning a second language. Other studies have found the prevalence rates of selective mutism to be higher among immi-grants when compared with the general population (Vecchio & Kearney, 2007). This research suggests the importance of considering cultural factors when assessing a child with selective mutism.

Randomized clinical trials (RCTs) examining the efficacy of treatments for selective mutism have not yet been conducted. However, the research that does exist generally suggests that behav-ioral interventions are efficacious for the treatment of selective mutism (Beare, Torgerson, & Creviston, 2008; Cohan et al., 2006; Pionek Stone, Kratochwill, Sladezcek, & Serlin, 2002). Behavioral strategies generally include therapist modeling, shaping, exposure-based techniques, and stimulus fading with an emphasis on contingency reinforcement to reward desired speaking behavior (Kearney, Haight, & Day, 2011). Therapist modeling involves having the therapist exhibit desired behaviors first with the goal of having the child imitate the behaviors subse-quently. Shaping refers to positively reinforcing successive approximations of a desired behav-ior. In the case of selective mutism, shaping may first involve positive reinforcement of whispering or brief noises (e.g., humming), with successive reinforcements contingent on the childs approx-imations toward the ultimate goal of speaking with full volume. Exposure-based techniques



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involve having a child practice speaking in increasingly anxiety-provoking situations. Use of exposures generally involves the development of a hierarchy of anxiety-provoking scenarios which range in difficulty (e.g., they may range from speaking to the therapist in the presence of the childs parents to speaking to peers at school). Incorporation of metaphors that a young child may understand (e.g., getting used to cold water in a swimming pool) may also be helpful when explaining how exposure tasks work. One exposure method for selective mutism, self-modeling, involves audiotaping or videotaping a child when he or she speaks normally, such as in the home environment, and then playing the tape for the therapist so that the child recognizes that the new person has heard him or her speak. This is often followed by praise from the therapist for the childs use of verbal communication. Stimulus fading involves steadily increasing the difficulty of exposures by fading in new people. For instance, once the child gets comfortable speaking to the therapist, a confederate may be brought into the therapy session as well and the child will practice speaking in the presence of the therapist and the confederate.

Several RCTs support the efficacy of cognitive-behavioral therapy (CBT) for the treatment of anxiety disorders in children (Hirshfeld-Becker et al., 2010; Jansen et al., 2012; Kendall, 1994), which is relevant given anxiety-based etiological models of selective mutism. Accordingly, some studies specifically examine the efficacy of CBT for selective mutism and have found promising results (e.g., Fung, Manassis, Kenny, & Fiksenbaum, 2002). CBT for children with anxiety disorders generally involves recognition of anxiety, identification of anxious-thought patterns, replacement of anxious thoughts with more adaptive coping thoughts, relaxation, and use of exposure techniques. CBT is often more difficult to implement in preschool-aged children, due to their limited cognitive and developmental abilities, than with older children. For example, preschool-aged children may not possess the meta-cognitive abili-ties to evaluate their own thinking patterns, and they may not understand the rationale for expo-sure completion. These already present obstacles of working with a young child with anxiety are likely to become even more difficult when that child also does not speak. However, CBT can be effective for younger children with anxiety disorders when implemented in developmentally appropriate ways (Hirshfeld-Becker et al., 2010; Kingery et al., 2006). For example, use of cartoons with thought bubbles may be particularly helpful in young children given limitations in meta-cognitive awareness (Kingery et al., 2006). Although the process of challenging mal-adaptive thoughts may be difficult, young children can be encouraged to think of clues that support or refute a thought (Kingery et al., 2006). Friedberg and McClure (2002) suggest incor-porating enjoyable activities to facilitate child engagement in treatment. For instance, use of a storybook format may help illustrate the relationships between situations, thoughts, feelings, and behaviors.

2 Case Introduction

Hannah Lee (pseudonym) was a 4-year-old, Korean girl who was referred by her parents to a university-based psychology clinic due to failure to speak to people outside of her immediate family. Although Hannah was born to native Korean parents, her parents were fluent in English and Hannah herself was born in the United States and had been attending the same English-speaking day care center for the previous 3 years. Mr. and Mrs. Lee discussed that Hannah spoke normally at home, yet she had never spoken to teachers, classmates, some relatives, or friends. In settings where she did not speak, Hannah generally communicated in a nonverbal manner, using head-nodding and pointing. Hannah had never previously received any form of treatment for her selective mutism. Initially, teachers and parents encouraged Hannah to speak, yet over time, it seemed that the efforts to encourage her speaking decreased, and she began to receive accommodations and protection from speaking. Hannahs parents and teachers were worried that Hannahs limited speaking would impede her development, academically and socially.




3 Presenting Complaints

Mr. and Mrs. Lee reported that Hannah did not speak to individuals outside of her immediate family. She occasionally talked to close relatives when she saw them, such as grandparents, but most of these relatives lived long distances away and Hannah refused to talk to them over the telephone. Hannah primarily spoke only with her parents and her sister. Mr. and Mrs. Lee reported that they tried to encourage talking by offering Hannah participation in enjoyable activities in exchange for speaking to others, to no avail. For instance, Hannah expressed interest in partici-pating in an afterschool play group. Accordingly, Mr. and Mrs. Lee told Hannah that she could participate if she spoke to others; Hannah refused to do so and consequently, she did not partici-pate in the play group. Hannahs teachers reported that Hannah only spoke in the school setting when it was necessary to communicate her needs (e.g., saying the word potty).

4 History

Hannahs developmental and medical history was unremarkable. Mrs. Lee also denied a signifi-cant family medical or psychiatric history. Mrs. Lee indicated that Hannah was a quick learner and met all developmental milestones either early or on time. Hannah was in her 2nd year of preschool when she presented to the clinic. Mrs. Lee indicated that Hannah engaged in social interactions; Hannah had friends, played nicely with other children, and also participated in play dates. At other times though, Hannah reportedly kept to herself. Behavioral observations of Hannah interacting with her mother suggested they had a warm and secure relationship, and this notion was further supported by a letter from Hannahs speech pathologist written at the outset of treatment, that indicated, Hannah appears to have a good, loving relationship with her mother and family.

Of note, Mrs. Lee also expressed significant guilt regarding her parenting, indicating that she experienced depressive symptoms during her pregnancy and throughout Hannahs infancy. She also reported difficulty breastfeeding Hannah. Given these experiences, Mrs. Lee reported self-blame due to thoughts that her difficulties may have contributed to Hannahs selective mutism, and it seemed as though she harbored these feelings throughout Hannahs childhood. Mrs. Lees experience may be understood within a cultural framework. Asian cultures often emphasize col-lectivistic values, which place a strong emphasis on interdependence and family rather than focusing on individual concerns. Emotional expression, particularly when negative, is often dis-couraged, as it may disrupt group harmony. Research indicates that when compared with Caucasian individuals, individuals from Asian cultures make more attempts at masking their feelings (Gross & John, 1998), and they express their emotions less frequently (Gross & John, 2003). Furthermore, studies show that individuals from Asian cultures often have stigmatized views of mental illness and are less likely to obtain psychological treatment compared with European Americans (Eisenberg, Downs, Golberstein, & Zicin, 2009; Rao, Feinglass, & Corrigan, 2007). Consequently, Mrs. Lee may have been hesitant to disclose her difficulties due to con-cerns that she would disrupt group harmony or be perceived negatively by others due to mental illness. Importantly, Mrs. Lees feelings of guilt may have exacerbated her tendency to accom-modate Hannahs selective mutism.

5 Assessment

Multi-method, multi-informant assessment was conducted to provide a comprehensive assess-ment of Hannahs symptoms at the beginning of treatment. Assessment consisted of a clinical interview with parents and with teachers, parent and teachercompleted questionnaires, assess-ment of receptive language abilities, and observation (i.e., observing Hannahs behavior in



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presence of the therapist, observing Hannah and her family through a two-way mirror, home-video review, and school observation). Parents and teachers completed the Behavior Assessment System for Childrensecond edition (BASC-2; Reynolds & Kamphaus, 2004), which is a questionnaire that gathers information about a childs emotional and behavioral functioning. Results from the parent and teachercompleted BASC-2 forms indicated at-risk difficulties on the Internalizing Problems, Anxiety, Depression, Somatization, Atypicality, Adaptability and Functioning, and Functional Communication subscales. Clinically significant scores were evidenced on the with-drawal subscale, with T-scores ranging from 70 (teacher report) to 81 (mother report). Parents also completed the Selective Mutism Questionnaire (SMQ; Bergman, Keller, Piacentini, & Bergman, 2008) to evaluate Hannahs speaking at school, at home/with family, and in public/social settings. The SMQ consists of 17 items that describe the degree of selective mutism in various social con-texts. Respondents indicate how frequently the child speaks in different situations ranging from 0 (never) to 3 (always), with the total score ranging from 0 to 51. Lower scores reflect lower fre-quencies of speaking behaviors. Mrs. Lees responses on the SMQ, based on a total score of 13/51, indicated that Hannah was not speaking outside of the home/family environment. To determine whether Hannahs refusal to speak was related to language difficulties, the Peabody Picture Vocabulary Testthird edition (PPVT-III; Dunn & Dunn, 1997), a nonverbal measure of receptive language abilities, was administered. Consistent with Mrs. Lees report that Hannah was advanced for her age, Hannahs performance on the PPVT-III indicated above-average receptive language abilities (age equivalent = 5 years, 5 months). Two-way mirror and home-video observation showed that Hannah spoke normally with her family, despite her remaining silent when first inter-acting with the therapist.

Across reporters and consistent with behavioral observations conducted by the therapist, Hannah exhibited appropriate social behaviors such as interest in social interactions, ability to share enjoyment with peers, and made appropriate eye contact and emotional expressions. Thus, it was clear from the assessment that Hannahs refusal to speak was her only impediment to fully engaging in age-appropriate social interactions. Information obtained from parents, teachers, and through observation was supplemented with assessment information obtained during the therapy sessions. During the assessment, the therapist used yes or no questions that were accompanied by visual stimuli (e.g., choose red block for yes, blue block for no) to obtain an answer from Hannah. The therapist also described the use of a Feelings Thermometer (i.e., a 9-point scale where 0 indicates that the child is not at all experiencing anxiety and 8 indicates a great deal of anxiety) to assess whether anxiety played a role in Hannahs refusal to speak. The therapist used a list of predetermined anxiety-provoking scenarios (developed based on clinical interview with parents), and Hannah was asked to point to the number that represented how anxiety-provoking each situ-ation would be for her. Hannahs responses facilitated development of an exposure hierarchy that was subsequently used in treatment.

A functional assessment of Hannahs refusal to speak was also completed, which consisted of identification of whether speaking behavior varied in any specific situations, as well as identifi-cation of the antecedents and consequences of the behaviors. It seemed that Hannahs family accommodated her refusal to speak in many situations. Hannah generally communicated in a nonverbal manner, using pointing, head-nodding, and occasional gesturing, and this behavior was allowed by her family as a means to facilitate communication. Hannahs sister also whis-pered with Hannah and then spoke for her in some situations. In addition, when Hannahs mother brought her to school, she sometimes physically carried her into the classroom. During observa-tions in the classroom and through teacher reports, it appeared that several aspects of Hannahs nonspeaking behavior were also accommodated and reinforced by peers and school personnel. She generally communicated in a nonverbal manner at school, and others responded to these nonverbal behaviors. Accordingly, others accommodated Hannah by asking her yes or no ques-tions to facilitate her ability to answer them using head-nodding. At other times, peers assisted




her with tasks and also provided her with choices to help her convey which activity she wanted to do. Classmates and peers also seemed to protect her in social interactions when they perceived she needed assistance. For instance, when individuals who were new to the classroom tried to interact with Hannah, the peers surrounded Hannah and told the individual that Hannah was quiet and slow to warm up. When the therapist followed alongside Hannah in the classroom, fellow classmates politely told the therapist that Hannah was shy and does not speak. Thus, there seemed to be little expectation in the classroom for Hannah to speak. Nevertheless, Hannahs teachers reported that Hannah had friends in the classroom who she spent time with, though they emphasized that Hannahs friends tended to be the more talkative classmates who carried the conversation. Overall, Hannahs nonspeaking behavior was negatively reinforced in the home and school environment, as she received accommodations by having others reduce their expecta-tions for her speaking, which likely contributed to the maintenance of her selective mutism by allowing her to avoid speaking in situations where she felt uncomfortable or anxious.

Given the possibility that cultural factors (e.g., bilingualism) may be implicated in selective mutism, this issue was also addressed during the assessment process. It was clear based on our assessment, using the PPVT-III and through observations, that Hannah had neither receptive nor expressive English language difficulties. Although Hannah was bilingual, we also clarified through direct questioning that Hannahs refusal to speak in public was not due to confusion regarding which language to speak. Furthermore, Hannah was born in the United States and had been in the same English-speaking school for the past 3 years, suggesting that she was well accul-turated into the English language and American culture.

6 Case Conceptualization

Overall, Hannah presented as a polite, yet shy and reserved girl. It is likely that multiple factors, temperamental and environmental, contributed to the development of selective mutism for Hannah. In particular, Hannah appeared rather temperamentally inhibited. While Hannah enjoyed social interactions, her mother also reported that she sometimes preferred solitary activities. Anxiety also seemed to play a notable role in her refusal to speak. Parents and teachers reported clinically significant withdrawal, as well as at-risk difficulties with a variety of internalizing symptoms (e.g., anxiety, depression, somatization). Hannah herself also endorsed anxiety sur-rounding a variety of social scenarios that required her to speak. It is likely that Hannahs inhib-ited temperament and anxiety interacted with contextual factors to maintain her selective mutism. In particular, others accommodated Hannahs refusal to speak in the home and school settings. School observation and teachers emphasized that classmates were used to her not speaking. Hannahs school environment was also fairly unstructured. Classmates spoke for her at school, and her sister spoke for her in other situations. Collectively, the accommodations likely main-tained Hannahs refusal to speak.

7 Course of Treatment and Assessment of Progress

Treatment began with a variety of assessment methods to obtain a better understanding of Hannahs nonspeaking behavior. The initial session was spent gathering information and build-ing rapport through use of enjoyable activities with no pressure placed on Hannah to talk (e.g., coloring). After a diagnosis of selective mutism was determined via assessment, treatment pro-ceeded. The therapist began with psychoeducation regarding selective mutism with an emphasis on the role of anxiety. The therapist also normalized the experience of anxiety using relevant examples. A treatment plan using primarily behavioral strategies (e.g., use of positive reinforce-ment, use of exposures) was described to the family. Cognitive strategies were also used to the degree that Hannah could understand and benefit from their implementation. The primary goals



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of treatment were to increase the number of people, settings, and situations in which Hannah spoke and to decrease interference related to her selective mutism.

Most cognitive-behavioral treatment programs focus on modifying the cognitive (e.g., mal-adaptive thinking patterns) and behavioral (e.g., avoidance) components of anxiety. Parent and teacher interviews, along with yes or no questions answered by Hannah, suggested that Hannah possessed several maladaptive anxiety-provoking thoughts that seemed related to her failure to speak. For instance, it was discovered that Hannah possessed high levels of anxiety as well as a fear of losing her voice. Accordingly, developmentally appropriate cognitive restructuring was used to target her maladaptive thought patterns. Cognitive restructuring seeks to identify mal-adaptive thoughts and modify them into more adaptive thoughts so that the child possesses greater self-efficacy and willingness to engage in anxiety-provoking scenarios. Using yes or no questions so that Hannah could participate appropriately, the therapist facilitated Hannahs rec-ognition of evidence for and against her thoughts. For example, the therapist sought to emphasize Hannahs irrational thought patterns by asking relevant questions (e.g., You know other people who talk; Do they lose their voices?). This strategy was used to help Hannah recognize her negative thought patterns (e.g., catastrophic thinking).

Given Hannahs developmental level, her treatment plan sought to build her self-confidence and motivation for speaking. Self-confidence and motivation for speaking are particularly impor-tant at this young age given that Hannah was soon to begin formal schooling, where class partici-pation and the ability to ask questions are integral parts of achieving mastery. Accordingly, a positive reinforcement system was established early in treatment to facilitate Hannahs motiva-tion to participate in therapy and to meet treatment goals. Specifically, a sticker poster was cre-ated for use in session, in which Hannah earned stickers for exposure activities. Hannah was also given a success chart each week, which tracked her daily progress at home and at school. Hannah received points at school each time she spoke, and at the conclusion of the school day, Hannahs teacher told her mother how many points Hannah had earned. Accumulation of points was then associated with rewards (e.g., ice cream, small toy) or enjoyable activities. Apart from the use of rewards, other efforts to increase motivation for speaking were utilized. For instance, while meet-ing with Hannah, the therapist discussed positive benefits of speaking behavior, such as learning to read and having more opportunities to play games. Through head-nodding, Hannah conveyed that she wanted the therapist to help her speak. Accordingly, therapy was described to Hannah as a place where she was to practice speaking.

Thereafter, in conjunction with the use of positive reinforcement strategies, treatment gener-ally consisted of the use of modeling, exposures (including use of self-modeling), and stimulus fading techniques. Initially, self-modeling strategies consisted of the therapist having Mrs. Lee videotape Hannah speaking and singing in English at home with her family. This videotape was then watched by the therapist in session with Hannah so that Hannah recognized that the therapist heard her speak. The therapist also watched Hannah talk with her family through a two-way mir-ror, and then Hannah was shown the cool, magic mirror and told that the therapist had heard her speaking. After each instance, Hannah was praised enthusiastically for speaking (e.g., I saw you through the mirror and it was great to hear you speak! and What a nice voice you have!). The two-way mirror was then incorporated playfully into treatment.

As previously indicated, the therapist developed an exposure hierarchy based on information obtained during assessment. The hierarchy ranged from situations that provoked mild anxiety to situations that provoked significant anxiety. See Table 1 for examples of items on Hannahs hier-archy. Given that Hannah was minimally expressive in general, initial exposures sought to increase her expressivity. For instance, the first exposures consisted of playing a game which emphasized gesturing and nonverbal behavior. Hannah chose a card from a stack of cards that had animal pictures on them. Hannah acted out the animal and the therapist guessed which ani-mal Hannah was pretending to be (e.g., a fish swimming, a monkey climbing). Hannah




demonstrated some hesitancy at first, but she became much more engaged in the exposure once her older sister joined the session. This exposure eventually incorporated the use of animal noises (e.g., a dog barking). Hannahs older sister often participated in exposures to increase Hannahs sense of comfort, and to serve as a positive role model of speaking behavior. Next, exposures generally consisted of whispering, with the therapist first modeling whispering to Hannah. As a homework assignment, Hannah was encouraged to prepare a phrase to whisper to the therapist at the next session, and she was asked to practice whispering this phrase to her mother. Other expo-sures involved the therapist, Hannah, Hannahs sister, and her mother playing a game of whisper down the lane. Around the same time, Hannah began whispering in the school setting, and she also began consistently using brief phrases with the therapist (e.g., Thank you). Hannah was consistently and enthusiastically praised for her efforts.

Exposures continued in which Hannah and the therapist played games that incorporated developmentally appropriate knowledge. For instance, UNO cards were used in the context of a game where the therapist and Hannah practiced saying the name of the colors and numbers on each card. Hannah was able to demonstrate how intelligent she was while the therapist pretended to have difficulty recognizing the colors and numbers. The therapist also emphasized how cool Hannahs bilingualism was, and Hannah then taught the therapist a few words in Korean. Thus, focusing on Hannahs strengths was helpful in facilitating her treatment participation. Other games were played which required loud vocalizations (e.g., Marco-Polo), and Hannah success-fully participated in these games. Exposures then incorporated singing songs that Hannah knew (e.g., Twinkle Twinkle Little Star). Initially the therapist sang with Hannah, and then Hannah sang the songs independently with increasing volume. The therapist also began asking open-ended questions in an effort to decrease Hannahs use of head-nodding, and Hannah began to give verbal responses.

Once Hannah achieved some mastery in speaking with the therapist, stimulus fading was used to incorporate other people (e.g., familiar adults, familiar children including peers, novel adults) into exposures. Exposures included saying hello to different people, singing songs for several people at once, answering questions from several people, asking questions to several people, and

Table 1. Example of Items on Hannahs Exposure Hierarchy.

Exposure hierarchy SUDS

The therapist watches Hannah talk with family through two-way mirror 1In Hannahs presence, the therapist watches video of her talking/singing 2Gesturing in animal game 2Whispering a word to mom in the therapists presence 4Whispering a word in the therapists ear 5Whispering short phrases (e.g., Whisper Down the Lane) 5Making Animal Noises in Game 6Speaking out loud in soft voice 6Playing games that involve brief utterances(e.g., Marco-Polo) 6Singing for the therapist 6Answering the therapists questions and asking questions to the therapist 7Asking/answering questions with other people 8Singing in front of other people 8Brief phrases to teachers (e.g., good morning, go potty) 8Talking to a friend at school in the therapists presence 10Talking to a friend at school by herself 10

Note. SUDS = subjective units of distress.



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speaking to other people without the therapist present in the room. As indicated, Hannahs efforts to speak were positively reinforced. Not only did she earn rewards at home, she also earned rewards for her successful efforts and exposure completion in session. Rewards were often earned in creative ways that incorporated the use of developmentally appropriate, enjoyable activities. For instance, during one session, Hannah earned a bead each time she spoke, and at the end of the session Hannah made a bracelet using the beads earned during the session. As treat-ment proceeded, Hannah began speaking to her teachers more frequently. She also completed exposures where she spoke to peers at school. The 15th therapy session was conducted at school. With facilitation by the therapist, several social interactions were initiated with Hannahs friends at school, and games were played which required vocalizations. Hannah was received positively by peers for her success, and they reportedly requested that she speak even more to them.

Of note, not only did Hannah receive positive reinforcement for speaking, but she was also praised for demonstration of other adaptive behaviors (e.g., behaving compliantly) so that the sole focus was not always on speaking. Furthermore, Hannah was initially praised for any efforts she made toward trying to speak (e.g., preparatory actions such as making movements with her mouth), even if she was not successful in every attempt. Modeling by the therapist was often used so that Hannah had clear expectations of what to do in each exposure. Hannah appeared very proud and excited when praised by the therapist for her successes. Sessions 16 and 17 were spent reviewing Hannahs progress and emphasizing her success. By session 17, it appeared that Hannah had reached her peak of progress. Based on her successes, the parents and therapist col-laboratively decided that it would be beneficial to focus on Hannahs gains and work to maintain them. Although Hannah was not speaking to the same degree as her similar-aged peers, signifi-cant improvements were noted and Hannah had seemed to plateau. Given that skills were learned and Hannahs mother and teachers were coached on how to facilitate speaking, it seemed that the best course of action would be to allow Hannah the time to practice skills in real-life settings, rather than continuing to participate in therapy. Relapse prevention strategies were discussed, such as how the family could look for red flags that Hannahs selective mutism was worsening, so that they could quickly address setbacks. For example, the family was encouraged to be vigi-lant of any attempts by Hannah to answer questions with head-nodding rather than words. Hannahs parents and teachers were also encouraged to continue to positively reinforce her speaking behaviors. Hannahs parents and teachers were also coached on how to identify the subtle ways in which Hannahs nonspeaking behavior may be inadvertently reinforced and accommodated. Finally, given Hannahs inhibited temperament, the therapist discussed with the parents that increasing the absolute amount of social speaking in which Hannah engaged was a more appropriate treatment goal than aiming for her to speak as much as less-inhibited peers. Thus, the parents were encouraged to set appropriate goals and expectations for Hannah. Although improvements were evident based on observation, quantitative data (e.g., BASC-2, SMQ) were not obtained at Session 17, which is a limitation of this case study.

8 Complicating Factors

As indicated, Mrs. Lee reported a history of depressive symptoms that occurred throughout her pregnancy and during Hannahs infancy, as well as difficulty breastfeeding. She thus reported guilt due to beliefs that these difficulties were associated with Hannahs disorder. Accordingly, she harbored feelings of self-blame that had to be addressed during the course of treatment. During treatment, the therapist validated Mrs. Lees emotions while also emphasizing that mul-tiple factors contribute to child development. It was also important to consider how cultural fac-tors may have been implicated in Mrs. Lees feelings and behaviors. Finally, Hannahs father was often busy with other responsibilities and was thus less involved in treatment. Ideally, it would have been preferable if Hannahs father was more involved in treatment to encourage consistency




between parents in implementing therapy strategies outside the clinic setting. Nonetheless, it appeared that Mrs. Lee shared relevant treatment information with Mr. Lee, which facilitated treatment progress.

9 Access and Barriers to Care

A lack of competence in treating selective mutism is a common barrier to effective treatment of this disorder. Fortunately, the therapists extensive training in behavioral treatment and anxiety in children generalized well to the treatment of selective mutism. Engaging other relevant contexts (e.g., school) effectively in the treatment process is yet another challenge when working with children with selective mutism. In Hannahs case, the school and teachers were very willing to assist with treatment. The therapist was able to speak to Hannahs teachers by phone, obtain teacher-report questionnaires from them, conduct school observation, and even conduct an inter-vention therapy session with Hannah in her classroom. Such opportunity is not always possible.

Given that children with selective mutism do not speak in unfamiliar situations, assessment can be challenging. In this case, we employed a creative, multi-method, multi-informant assess-ment with Hannah to facilitate assessment. Despite the presence of some barriers, the family seemed committed to consistently attending therapy sessions, which likely facilitated Hannahs progress in treatment.

10 Follow-Up

Approximately 9 months after initial treatment participation, Hannah and her mother returned to the clinic for a booster session. Mrs. Lee indicated that Hannah did not appear to speak as much as her peers, though she was continuing to interact with others (e.g., peers, neighbors). Updated BASC-2 forms were completed by Mrs. Lee and Hannahs teacher at this time. Given that clini-cally significant difficulties were noted on the withdrawal scale of this measure at pretreatment, this scale was reviewed for comparison at this session, with results indicating that Hannah exhib-ited at-risk difficulties with withdrawal based on teacher report (T = 62) and clinically significant difficulties based on mother report (T = 77). Accordingly, though Hannah continued to exhibit symptoms of withdrawal, some improvements were noted when compared with the initial assess-ment. Treatment strategies were reviewed at this session.

11 Treatment Implications of the Case

A variety of treatment implications are noted based on this report. Specifically, this case study offers support for the use of behavioral interventions for the treatment of selective mutism in young children. In addition, this case highlights the benefits that can be achieved in therapy when using developmentally appropriate behavioral strategies (e.g., use of games, incorporating devel-opmentally appropriate knowledge) to help with the assessment and treatment of selective mut-ism. Therapists may also benefit from incorporating siblings and friends into treatment. Effective treatment also involves collaboration with schools, as in-school exposures are often necessary. Another potential difficulty may occur in bilingual children whose parents speak a different lan-guage at home than the child is expected to use at school or in other public settings. This may result in the child being more reluctant to speak the language required in the school setting. Although this did not seem to be evident with Hannah, in such cases, it may be helpful for parents to practice speaking whichever language is spoken at school or with peers to a greater degree when in the home setting (Kearney et al., 2011). Finally, it is important to recognize that cultural factors, such as particular values and/or parenting practices, may be relevant to consider when working with families of diverse cultural backgrounds.



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12 Recommendations to Clinicians and Students

Several recommendations are suggested to facilitate effective treatment when working with chil-dren with selective mutism. In assessing selective mutism, multi-informant, multi-method assess-ment is important to gain the most accurate picture of the childs functioning. Given the lack of speech toward strangers that is typically present in children with selective mutism, it is important to recognize that they are rarely the primary source of information during the initial assessment. Accordingly, it is important to gather clinical information from parents, and if possible, teachers. Behavioral observations and the use of videotaped recordings can also provide important infor-mation. It is important to conduct a functional assessment of the childs nonspeaking behavior, such as where, when, and with whom it occurs, to determine any factors associated with the nonspeaking behavior so that these factors can be addressed in treatment. Assessment of whether the child uses any nonverbal behaviors to communicate (e.g., writing, head-nodding, facial expressions) is also essential, as is the identification of any factors that maintain the refusal to speak. Assessment of language functioning is also important to determine if nonspeaking behav-ior is better accounted for by a communication or language disorder. If the child is bilingual, the clinician should also assess where the child is in the second-language acquisition process to ensure accurate assessment. Given that other conditions may also be characterized by speech difficulties (e.g., autism, mental retardation), ruling out other potential conditions is an important step in assessment (Viana et al., 2009).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies

Marni L. Jacob, PhD, is a postdoctoral fellow at the Rothman Center for Neuropsychiatry in the Department of Pediatrics at the University of South Florida. Her clinical and research interests focus on the treatment of anxiety disorders in children.

Cynthia Suveg, PhD, is an associate professor of psychology at the University of Georgia. Her research examines the ways that child (e.g., temperament) and contextual (e.g., parenting behaviors) variables inter-act to influence child development. She also applies her basic research findings to the development/refine-ment of intervention programs for children.

Anne Shaffer, PhD, is a clinical and developmental psychologist and an assistant professor of psychology at the University of Georgia. Her research focuses on aspects of developmental psychopathology, including risk and resilience in families, and she supervises doctoral trainees in child and family clinical interventions.



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