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CLINICAL
10.1177/1534650104269029
Fisak
et al. / CASE
TREATMENT
STUDIES
OF
/ October
SELECTIVE
2006 MUTISM
ARAZAIS OLIVEROS
University of Central Florida
JILL T. EHRENREICH
Boston University
Abstract: Children with selective mutism present with a complicated set of symptoms, as
they not only refuse to speak in particular social situations but are often shy, socially
isolative, anxious, and may present as oppositional and negativistic in their behavior. Limited research on treatments for selective mutism suggests a need for additional research
examining intervention possibilities. The following case description presents a 10-year-old
male with selective mutism and concurrent anxiety symptoms. Treatment included the use
of a significantly modified version of Social Effectiveness Therapy for Children (SET-C), a
manualized behavioral treatment for social anxiety. In addition to SET-C, treatment also
included concurrent parent training in the management of child anxiety. The rationale for
the treatment selection and a description of treatment course are provided. Further, a discussion is presented concerning challenges to treatment progress, including cultural differences between the primary clinician and the client.
Keywords: selective mutism; assessment; behavioral treatment; therapy
382
383
with SM are often negatively reinforced by the subsequent decrease in requests for speech
over time (Kehle et al., 1998). For example, a teacher may ask for a response in class, and
the SM child may repeatedly fail to answer. As a result, the teacher may withdraw the
requests for responses, thereby negatively reinforcing the childs lack of responding.
Although conceptualization of SM as an extreme form of SP has received empirical support, a number of studies have found other differences between children with SM
and children with SP. Dummit et al. (1997) found that social anxiety ratings of children
with SM were in the moderate range, suggesting that behavioral factors beyond social
anxiety may also be associated with the presentation of SM. When comparing parental
reports of children with SP versus those with comorbid SM and SP, via responses on the
Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001), parents of SM children indicate significantly higher scores on the Delinquency subscale and marginally
higher scores on the Aggression subscale when compared to those with comorbid presentation (Yeganeh, Beidel, Turner, Pina, & Silverman, 2003). Although Delinquency
and Aggression subscale scores observed in both groups were largely in the nonclinical
range and generally lower than scores on Internalizing subscales, the difference in scores
found in this investigation corroborates clinical observations of significant parental difficulties in managing oppositional behaviors in children with SM, particularly among
those without concurrent SP symptoms.
In summary, SM has been conceptualized as an extreme form of SP; however, this
distinction may not fully characterize SM, as those with SM may also exhibit
oppositional 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 for
successful treatment of children with SM (e.g., parent training, behavior modification,
and interventions to decrease social distress). Further, despite the potential complexities
associated with treating children with SM, structured interventions designed specifically
to treat children with SM are lacking. For example, in a review of empirically supported
treatments conducted by Chambless and Ollendick (2001), there were no specific treatments listed for SM. As a result of these challenges, further research into potentially
effective interventions for children with SM is needed.
2 CASE PRESENTATION
This case description presents the conceptualization and treatment of a 10-yearold Hispanic male diagnosed with SM whose speech was limited to the home environment. Given the potential overlap between SM and SP, and the lack of empirically supported treatment protocols specifically targeting SM symptoms, the clinicians in this
case attempted to use a modified version of a popular social skills treatment protocol for
social anxiety symptomatology (Beidel, Turner, & Morris, 1994), in conjunction with an
384
3 PRESENTING COMPLAINTS
At the time of initial evaluation, which took place as LM was entering the fifth
grade, he would not speak in class unless the teacher insisted, at which point LM spoke
in a barely audible volume and appeared fearful during speech. In the home setting, LM
spoke freely to his mother, a professional housekeeper; his father, an electrical worker
seeking employment; as well as his 13-year-old brother. According to his father, LM
would show visible distress when faced with social situations (e.g., parties, dances) and
refused to interact with neighboring children. LM did not respond when greeted, even
by familiar acquaintances, and would avoid ordering at restaurants, often having his
brother or his parents order for him. LM denied any difficulties at school (by shaking his
head to indicate no) and responded accordingly on questionnaires presented (see
Assessment section).
Mrs. M had few complaints with regard to LMs behavior, a fact that appeared to
result in disagreement with her spouse during an assessment interview. She relayed mild
concern that LM often used a baby voice at home but indicated that this only occurred
with her and that she often enjoyed this type of interaction with him. She agreed that
LMs activities were mostly limited to those in the home, but in contrast with LMs
father, Mrs. M was reportedly not bothered by LMs social constriction, as she felt he was
generally safer inside the home, although the family did not live in a neighborhood that
was considered particularly dangerous or unsafe. Both parents did agree with regard to
LMs need to speak in the classroom and in other appropriate situations (e.g., ordering
food for himself, greeting others, etc.).
4 HISTORY
LM was born in the northeastern portion of the United States, where he completed
kindergarten through third grade, and he consistently limited his speech to only family
and extremely familiar friends. From all indications, LMs developmental history was
largely unremarkable. He was the result of a normal and uncomplicated pregnancy and
delivery. All developmental milestones, with the exception of generalization of speech
to certain settings, were met within normal limits. He had no history of surgery or serious
illness and was presently in good health. According to his father, LM was a quiet and
calm baby. LMs shyness and refusal to speak were first noticed when he entered kindergarten. LMs hearing and speech were tested by his school at that time, but no organic
etiology was found. He also received a psychological assessment when he was in third
385
grade (age 8), resulting in a diagnosis of selective mutism, but there was no subsequent
treatment provided at that time.
LMs shyness became more apparent after he moved to his current residence in the
southeastern United States, at age 9, where he initially had no familiar peers except his
older brother. LM apparently chose not to initiate contact or interact with any peers in his
new neighborhood and seemingly rejected his fathers instructions to try to go out and
make friends. During the early part of the fourth grade at his new school, LM had a
female classmate who would voluntarily speak for him in class. However, LM and this
peer were then assigned to different fourth-grade teachers, after which LM reportedly did
not talk to any peers in his classroom. LM also stopped talking to the female ex-classmate,
who had made attempts to visit with him at his home.
5 ASSESSMENT
INITIAL INTERVIEW AND MEASUREMENT ADMINISTRATION
During the initial evaluation, LM displayed a variety of behaviors potentially indicative of anxiety, such as facial tension, rigid posture with crossed arms, and
hypervigilance. These behaviors slowly decreased as the initial interview progressed.
LM remained quiet throughout this interview, typically answering questions by nodding
yes or no. As the interview progressed, however, LM began to provide brief (i.e., one- to
two-word) responses to questions. In addition, when LM and his father were in the same
room, LM appeared to become more anxious and withdrawn whenever his father
directed him to speak. LMs mother was not available during initial interviews due to her
work schedule, whereas LMs father was unemployed during this period, allowing him
to attend most appointments. As treatment progressed, LMs mother was available for an
occasional one to two sessions at a time, but his father attended the majority of sessions
with LM alone.
The Parent-Report Form of the Anxiety Disorders Interview Schedule for DSM-IV
(Child Version; ADIS-IV-C/P; Silverman & Albano, 1997), a semistructured diagnostic
interview for parents of children and adolescents, was administered to LMs father to
assess the extent to which current psychopathology was clinically significant and interfering with LMs functioning. Results of this interview supported diagnoses of both social
phobia and selective mutism. LM evidenced social phobia via significant fear and avoidance in situations that require social interaction (e.g., parties, class participation),
although this was admittedly difficult to distinguish from his selective mutism symptoms. Mr. M endorsed an average severity rating of 6 (on a Likert-type scale from 0 [not at
all] to 8 [very, very much]) in his discussion of LMs social fears, with the most disturbance
evident in the school setting. Mr. M. rated LMs specific fears as 6 and above for situations such as speaking in class and speaking to unfamiliar people.
386
TABLE 1
T-Score
Percentile
T-Score
53
85a
50
66a
53
57
56
60
50
50
56
28a
25a
43
24a
62
> 97
50
95
63
76
73
84
50
50
73
<3
<3
24
<2
52
a
73
60
a
54
50
50
41
50
50
50
47
n/a
n/a
n/a
50
Percentile
58
> 97
50
92
50
50
18
50
50
50
38
n/a
n/a
n/a
50
LM also met diagnostic criteria for selective mutism, owing to his refusal to speak
or answer questions in a variety of settings such as school and parties, despite speaking
frequently 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 were
apparent at that time.
On the ADIS-IV-C/P (Silverman & Albano, 1997), LM endorsed symptoms consistent with social phobia, including fear and avoidance/distress with regard to giving a
report or reading aloud in front of the class and during musical performances. LMs
responses throughout this diagnostic interview were mostly head nods or one-word
responses.
LMs father also completed the CBCL, a questionnaire that provides both general
and more specific indices of a childs emotional and behavioral functioning (Achenbach
& Rescorla, 2001). LMs score on the Internalizing Behavior Problems scale fell within
the clinical range. More specifically, LMs score on the Withdrawn/Depressed scale fell
within the clinical range, indicating that LM often refused to speak and may be secretive, shy, withdrawn, sometimes preferring to be alone, lacking energy, and finding few
things enjoyable. All other scale scores on the CBCL, including the Externalizing and
Behavior Problems scale, fell within the nonclinical range, indicating that LM was not
experiencing difficulty in domains such as inattentiveness or aggressive behavior. LMs
Total Competence, Activities Competence, and Social Competence scores fell within
the clinical range, whereas his score on the School Competence scale fell within the
nonclinical range. Specifically, LM showed a low level of social interaction (i.e., friends,
387
TABLE 2
Mean
Standard Deviation
Scholastic competence
Social acceptance
Athletic competence
Physical appearance
Behavioral conduct
Global competence
2.81
2.87
2.89
2.91
3.04
3.04
.69
.77
.73
.76
.56
.69
Father
1.25
2.01
2.59
.80
1.32
1.32
Teacher
.28
1.56
1.67
1.43
1.71
.25
group membership) and involvement in activities (i.e., sports, hobbies). See Table 1 for a
summary 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 of
LMs tendency to experience internalizing rather than externalizing emotional and
behavioral difficulties. Specifically, LMs score on the Internalizing Behavior Problems
scale fell within the clinical range, whereas his score on the Externalizing Behavior
Problems 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 the major source of difficulty for LM, according to the
teacher. See Table 1 for a summary of the teachers TRF ratings of LM, including Tscores and percentiles.
To establish a more direct comparison with regard to reports of LMs competence
across multiple domains, his father and fourth-grade teacher also completed the revised
version of the Perceived Competence Scale for Children (Harter, 1982). This measure
allows for ratings in Scholastic Competence, Social Acceptance, Athletic Competence,
Physical Appearance, Behavioral Conduct, and Global Self-Worth. According to LMs
father, Social Acceptance and Athletic Competence scores were more than two standard deviations above the mean, indicating that LM was perceived by his father to have
difficulty making friends and playing sports as well as his peers. LMs teacher endorsed
similar elevations, but to a slightly lesser extent. Parental and teacher ratings of Physical
Appearance and Behavioral Conduct were disparate (i.e., by more than two standard
deviations), with LMs father perceiving him as much lower in these domains than his
teacher in terms of competencies related to appearance and conduct. In querying these
discrepancies, it was established that LMs behavior in the classroom was perceived by
his teacher to be very appropriate, despite his lack of speech in that environment,
whereas LM was more likely to be noncompliant with requests at home, leading to lower
overall parental ratings of LMs competencies. See Table 2 for z-scores associated with
ratings on this measure by LMs father and teacher.
388
During a clinical interview, LMs parents reported some difficulties with regard to
child discipline. Specifically, they often disagreed concerning what rules to enforce and
how to enforce them, resulting in inconsistency. Contributing to the parental discipline
difficulties was his parents basic lack of correspondence with regard to expectations for
LMs behavior. LMs father frequently instructed him to go outside and play with neighbors, whereas his mother reported that she felt uneasy with her son being outside of the
home. However, both parents also reported few interactions with neighbors or friends
outside of the home. LMs use of baby-talk instead of more comprehensible speech in
some circumstances was undesirable to the father, whereas his mother spoke of it with
endearment, indicating that such talk reminded her that LM was her baby. Disagreements like these often led to arguing during subsequent sessions, presenting an overall
picture in which his fathers attempts at behavioral control were impeded by his mothers
efforts to protect and rescue LM from being bossed around, as the mother reported she
had been as a child.
The patterns observed in LMs family are consistent with literature pertaining to
parenting strategies associated with anxious children. Becoming impatient with an anxious childs avoidant behaviors and being overly directive in response to a childs feared
behavior are common parental responses to such symptoms. On the other hand, removing a child from a feared situation and facilitating avoidance behaviors are also common
behaviors 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 case
conceptualization and treatment.
389
6 CASE CONCEPTUALIZATION
On the basis of this multimodal assessment, LMs refusal to speak was conceptualized as a strategy for avoiding feelings of anxiety in speech-related situations and also conceptualized as the result of limited exposure to opportunities that would lead to the
development of adequate social skills. LMs avoidance strategies had become so effective
that his motivation for change was understandably low. The family trend of sedentary
and nonsocial daily life was serving to maintain LMs social isolation, despite his fathers
periodic efforts to encourage outside activities. Secondary gains, including decreased
requirements at school and the baby role with his mother at home, also seemed to be
reinforcing a lack of speech outside of the home. These secondary gains and parenting
issues would eventually represent significant challenges to treatment.
To improve LMs social skills, the initial treatment strategy focused on the usage of
a manualized behavioral treatment for social anxiety in children, Social Effectiveness
Therapy for Children (SET-C; Beidel et al., 1994). The treatment manual had to be
modified from a group treatment format to an individual treatment format; however, the
order in which the educational modules were presented remained consistent with the
original SET-C manual. Sessions always began with a shaping/warm-up exercise with
LM, his parent, and two therapists. This exercise requires repeated vocalization of a
sound, a word, and then a sentence by each member of the treatment team. Following
this exercise, one therapist would meet with LM individually to review the previous sessions social skill and then present a new social skill (e.g., eye contact, greetings, asking
open-ended questions, topic transitions). After presentation of this educational component, the new skill would be role-played during the session. LM also frequently completed an exposure exercise during the session, wherein he carried out an anxiety-provoking task of increasing self-rated difficulty (e.g., giving a short speech to an audience in
a classroom setting). LMs speech frequency and volume was also reinforced in the session via his preferred reward, trading cards. His speech increased in volume throughout
treatment, 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 have
restricted treatment progress in this arena. During a behavioral observation of LM in the
classroom setting, his speech was limited to barely audible answers to questions posed by
the 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 speak
in the classroom and consistent reinforcement of his speech by his teacher.
To intervene in the family system, parent anxiety management training sessions
were concurrently conducted with LMs father (and his mother, when available). A stepby-step guide to aid parents in dealing with their childs anxiety (Rapee et al., 2000) was
primarily used to introduce both factors contributing to child anxiety and parent training
skills for managing/intervening with the childs difficulties. An important goal in this
390
form of parent training involves increasing opportunities for social interaction outside of
the home for LM and applying reinforcement for the clients speech outside of the
home. Other strategies that were encouraged include parental modeling of self-exposure to social-evaluative situations, parental modeling of positive self-talk before and
after engaging in a novel social situation, practicing social skills at home, and reinforcement of social skills practice outside of the home.
As noted, the SET-C was modified from a group treatment format to an individual
therapy format for use in this case. The implementation of the SET-C as an individual
treatment instead of a group treatment presented a notable disadvantage in that a group
setting would have provided a built-in opportunity for LM to practice skills learned in
treatment with peers. Practicing with peers facilitates generalization of skills discussed in
session and serves as a source of exposure for children who are fearful when interacting
with peers. Nonetheless, owing to the relatively small number of children being treated
for similar difficulties in this treatment setting, a group format for treatment could not be
achieved.
To compensate for the absence of group peers, the therapists used a number of
alternative exposure and skill practice strategies. One strategy included attempts to
engage LMs older brother (who was of a similar age) in treatment by encouraging him to
help LM with his practice of social skills. A second strategy was to use the clinic staff. The
clinic staff members participated in role-plays with LM and were used as an audience
when LM gave practice speeches. The therapists treating LM also actively attempted to
engage the family and the school in exposure and skills generalization exercises. Details
of how generalization and exposure were conducted will be discussed below.
SESSIONS 1-3
Treatment began after two initial assessment sessions, the latter of which included
psychoeducation concerning the nature and interaction of SM and SP, the rationale for
the SET-C, and the typical course of treatment. Starting in the first treatment session, all
sessions began with the aforementioned speech game during which each individual
involved in the treatment session (LM, the family member(s), and both of the
cotherapists) took turns making a sound, followed by a word, and then a complete sentence. The sound was first whispered by each group member, one at a time. The process
was then repeated several times with the volume of the sound gradually increasing to the
point where each member of the group yelled the sound. This process was then repeated
391
with the word and the sentence. In the typical session structure, after the speech game
was completed, LM would meet individually with his therapist, while a second therapist
would meet with LMs parent.
The primary agenda for the first session was to inquire about a reinforcement
schedule for LM that was to be used when he successfully performed target behaviors
(e.g., speaking with others, completing exposure tasks, and completing related therapy
homework tasks). Based on inquiries about LMs interests, it became apparent that his
interests revolved almost completely around a particular type of animated TV show (e.g.,
trading cards, video games, and other activities related to this show). He appeared to have
few other interests, including little interest in physical activity. It is interesting that it is
not uncommon for children with anxiety-related difficulties to have a narrow range of
interests, which may limit the number of common activities and opportunities for interaction with other children (Albano, DiBartolo, Heimberg, & Barlow, 1995). In addition
to inquiring about a reinforcement schedule, another goal of the first session was to
begin reinforcement of speech through verbal praise. This process superseded other
psychoeducational goals, as an increase in baseline in-session speech was viewed as vital
to 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 treatment, continued use of the initial assessment measures was not sufficient to track specific
behavioral progress. For example, although the ADIS-IV-C/P provides diagnostic information, symptom severity ratings obtained from the ADIS were not perceived to be sensitive enough to track subtle behavioral progress from session to session. The RCMAS
could potentially have been used to track progress; however, there was an apparent floor
effect in LMs reporting of symptoms on this measure. Another issue is that the RCMAS
does not evaluate symptoms specific to selective mutism.
In response to these limitations, the therapists decided to track the number of verbalizations that LM made during each session. A verbalization was defined as any verbal
expression in which LM spoke at least one discernible word. All speech conducted prior
to a therapist response was counted as one verbalization, meaning that each verbalization could range from one word to, on rare occasions, several sentences. All sessions were
audiotaped and the total number of verbalizations was tabulated for each session (see
Figure 1). Although the average number of words in each verbalization was not quantified, verbalizations appeared to average approximately three to five words in length. A
second way in which progress was assessed was through monitoring LMs successful
mastery of designated behavioral exposure tasks. The nature and intensity of the exposure tasks changed as treatment progressed, with a gradual increase in the intensity of
tasks presented (exposure tasks are summarized in Table 3). An early measure of LMs
comfort with speaking was assessed by asking LM to conduct a 1-minute speech about
himself and about the clinic prior to the second session. During this initial assessment,
he refused to engage in this task.
392
TABLE 3
Exposure Tasks
Session Number
Task
no
yes
yes
yes
yes
yes
yes
yes
yes
The therapeutic agenda for the second and third sessions was to further develop
rapport with LM and to begin to reinforce speech consistently throughout the session.
Contingencies for speaking included verbal praise and small rewards (i.e., trading cards
and stickers). His speech increased significantly during the second session and third sessions (see Figure 1). Based on examination of Figure 1, it is noteworthy that the number
of verbalizations during sessions peaked early in treatment and waxed and waned
throughout treatment. An explanation for this early peak in speech and the fluctuations
is that, as treatment progressed, sessions became increasingly challenging and the lack of
speech may have been, in part, a coping response or oppositional response to newly
393
Beginning with Session 8, the sessions were moved to an empty university classroom that was in close proximity to the clinic. The classroom setting was used to simulate
LMs classroom at his elementary school. During Session 8, LM practiced social skills
presented in previous sessions with his brother. One goal of including his brother in this
session was for LM to begin to practice learned social skills with his brother on a regular
basis. Because in previous sessions LM appeared to have difficulty discussing interests
other than his favorite animated series, a second goal of meeting with LM and his
brother together was to ascertain whether LM had any interests beyond those previously
discussed with his therapists. Other interests could be used to form additional reinforcers
for LM, owing to concerns that the frequency with which the therapist relied on trading
cards and other paraphernalia related to LMs preferred animated TV show might
decrease their potency as reinforcers over time. This reinforcer assessment was conducted by having both LM and his brother fill out a worksheet that included their own
interests and the interests of their sibling. In addition to the above interventions, a speech
exposure task was again conducted. LM successfully conducted a brief speech in the
mock classroom setting, in front of both his brother and the therapist.
Sessions 9 and 10 included preparing and conducting a variety of increasingly
complex 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 brief
speech with an audience of five (therapist, father, and three clinic staff members; see
Table 3).
394
SESSIONS 11-17
Between Sessions 17 and 18, LMs therapist observed LM in his regular classroom
and met with LMs teacher. Based on this meeting, the teacher agreed to include a daily
monitoring log in a folder at LMs desk. The purpose of the log was to have both LM and
his teacher monitor LMs speech and monitor his success with school-related exposure
tasks that were assigned during the therapy sessions. The log was to be sent to the teacher
after each of LMs subsequent sessions via e-mail.
Following the visit to the school, the cotherapists, LM, and his father met together
for the first part of Session 18 to discuss the school visit and plans to focus on extending
the existing treatment plan to LMs classroom. During the second portion of the session,
LM worked on further developing his fear-avoidance hierarchy, with regard to communications and interactions with peers at school. The final step of the developed hierarchy
was to give a speech in front of his class. As a first step in the hierarchy, LM agreed to write
the word hi on a piece of paper and hand it to the student who sits next to him, and he
agreed to do this task prior to his next therapy session. This information was forwarded to
LMs teacher via e-mail.
395
Although LMs teacher reported that he did not observe LM passing the note, LM
reported that he successfully passed the note to a peer in school. The therapist and LM
continued to work on the hierarchy in Session 19, and the next step on the hierarchy was
to verbally say hi to another student. This homework assignment was forwarded to the
teacher along with a self-monitoring log designed to help the teacher monitor LMs selfrecorded frequency of speech and completion of therapy homework assignments. The
log was to be completed by the teacher on a daily basis. During the next session, LM did
not 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, the
teacher reported that LM was making progress in school, primarily in terms of his interactions with the teacher. The teacher reported progress in that LM began to ask questions verbally instead of making gestures and that LM would say bye to the teacher
when prompted. During Session 20, work on the hierarchy was continued and LM
agreed to say a full sentence to another student on one occasion and say hi to a student
on another occasion. An updated log was sent to the teacher.
During Session 21, LM reported that he was successful at this homework but
reported that he again had not received the log from his teacher. Although the log was
not presented to LM, the teacher reported that LMs verbalizations had increased with
regard to brief responding to direct questions in the classroom. A Wechsler Intelligence
Scale for ChildrenThird Edition (WISC-III) was also administered during Session 21
(Wechsler, 1991). The WISC-III was administered at this time in treatment because the
therapist was not certain that LM would be responsive to items on the verbal scale of the
WISC-III in the earlier stages of treatment. Moreover, although LM appeared to have
obtained basic conversational skills, he still appeared to have difficulty during role-plays
maintaining a conversation, integrating, and using material presented in the social skills
modules. The goal was to rule out significant cognitive difficulties that may be hindering
his 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 indicated
that LM continued to make limited progress. By Session 21, LM interacted with the
teacher verbally 4 to 6 times a day; however, responses remained brief and sparse and little interaction was observed with classmates. Sessions 22 to 24 were conducted during
the summer holiday away from school. Session 23 included completion of the social
skills training modules, and both Sessions 23 and 24 focused on termination of treatment for the summer. Treatment with the SET-C was completed at this time, with LM
demonstrating progress with a variety of in-session exposure activities. At this time, it also
appeared that LM likely reached maximum benefit from treatment conducted at the
clinic. The clinicians concluded that the focus of further interventions should be schoolbased interventions.
396
PARENT SESSIONS
Parent sessions were held concurrently and in Spanish for optimum benefit to Mr.
and Mrs. M. Following the assessment phase and the session including LM and his
father 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 reinforcing speech in session and generalizing his speech behavior to other settings. Parent
training henceforth included instruction and role-play of behavioral strategies as well as
psychoeducation informed by a published guide for parents of anxious children, written
by Rapee et al. (2000).
Given Mrs. Ms report of LMs frequent baby-talk, the concept of reinforcing
appropriate speech while ignoring baby-talk was discussed in Session 2. Mr. and Mrs. M
appeared to disagree with regard to how to handle LMs avoidant behaviors (i.e.,
demanding speech versus allowing speech avoidance). In contrast to pressuring the client to speak, emphasis was placed on providing opportunities for LM to speak outside of
the home and encouraging and praising the client for any attempts at communication.
In Session 3, Mrs. M reported that despite ignoring LMs baby-talk, he was continuing to use this method of communication. This was normalized and the importance of
consistency in achieving behavioral change was emphasized. During Sessions 4 and 5,
specific parenting strategies were presented, including role-playing with both parents
concerning modeling nonanxious behavior in social situations (i.e., thinking out loud
with coping statements and then performing the interaction in LMs presence). This
strategy played a dual purpose of encouraging the parents to engage in routine social
behavior, which was reportedly at a low level, and providing a positive technique for
showing LM how one can cope with social situations despite anxiety. In discussing
praise, Mr. M cited an example of praising LMs class participation one day of the previous year by telling him that he needs to do more of that. After this, LM subsequently
ceased his participation in class. The possibility that praise linked with heightened
expectations may have increased LMs anxiety (as described by Rapee et al., 2000) was
explored. Alternative ways of praising were role-played.
Mrs. M reported during Session 6 that LM continued his use of baby-talk. The discussion revealed that she was ultimately answering his baby-talk, which was addressed
through further training and in-session practice. Despite reporting that LM had spoken
to a peer and the peers parents, Mrs. M denied providing any verbal reinforcement. The
importance of consistency and reinforcement continued to be integral topics in parent
sessions.
The next several sessions included psychoeducation about social skills that LM
was learning and practicing in his individual sessions. Mr. and Mrs. M were encouraged
to role-model and reinforce LMs use of social skills (e.g., eye-contact, greeting, asking
open-ended questions). In promoting exposure exercises for LM, frequent brainstorming and trouble-shooting sessions were required. LMs parents experienced difficulty in
initiating social contacts that would provide such exposure. During Session 8, Mrs. M
397
reported praising (without pressuring) in response to the client when he stated that he
spoke to a classmate. This new parental practice was reinforced in session.
During Session 11, Mr. M expressed anxiety about future consequences of LMs
treatment. Having filled out job applications inquiring about psychological treatment,
Mr. M was worried that records of LMs treatment would prevent him from getting a job.
Confidentiality of treatment was reiterated and concern with regard to a treatmentrelated stigma was addressed in the context of LMs relatively benign diagnosis and the
common use of psychological services.
Mr. M continued to attend the final sessions, which included mostly troubleshooting difficulties in providing exposure activities and encouraging parental reinforcement of LMs practice of social skills. Modeling use of various social skills was roleplayed, and Mr. M cited examples of his sons increasing social behavior. During the
15th week, LM responded on two occasions when greeted by new adults. The next week,
LM interacted for an hour with a peer in his neighborhood, which Mr. M admittedly
failed to reinforce. During the 18th week, LM ordered for himself at a restaurant and
continued to do so from that point on. LMs social behavior was met with reinforcement
on an increasing basis, and Mr. M stated at one point that all parents should attend similar 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 typical for many children with selective mutism, is the long history of secondary gain associated with LMs selective mutism behaviors. Regardless of the etiology of LMs selective
mutism, it became apparent that LMs refusal to speak enabled him to avoid a number of
situations and behaviors, resulting in reinforcement of his reticence. For example, he
was able to avoid answering questions in class, and this avoidance led to reduction in the
likelihood that teachers would call on him in the future. Based on the abundance of secondary gain for this client, it was challenging to motivate him to engage in increased
social interactions.
A number of family issues also provided complications for treatment. The initial
complication had to do with overall communication with LMs parents. Although LM
was fluent in English, both of his parents spoke little English. Therefore, LMs individual therapist, who was not bilingual, had difficulty directly conversing with LMs parents. This difficulty was addressed by recruiting a bilingual cotherapist to conduct concurrent sessions with LMs parents. The bilingual therapist was also able to translate for
LMs primary therapist, so that LMs primary therapist could communicate information
about LMs progress and homework assignments. In addition, the bilingual cotherapist
conducted sessions with the parents that included parent training and education to
maximize the effectiveness of treatment.
398
Another complication had to do with poor parental compliance with parent anxiety management training and minimal parental facilitation of exposure tasks for LM.
LMs father reported that economic and time constraints played a role in their inconsistencies with regard to carrying out the prescribed strategies. In addition, cultural differences associated with Hispanic families may have complicated treatment (McGoldrick,
Giordano, & Pearce, 1996). Specifically, the fathers expectation that children should
obey directives without the use of rewards contributed to resistance related to applying
positive behavior modification strategies. This expectation is consistent with the belief
commonly held in Hispanic cultures that a child should be respectful, compliant, and
well-behaved, or what is referred to as bien educado (e.g., Fontes, 2002).
Another possible factor that may have been associated with limited parental facilitation of exposure tasks and limited compliance with prescribed parent training strategies was the minimal amount of social contact outside of the immediate family environment evidenced by all family members. This isolation meant that, with the exception of
school, LM had few opportunities to practice skills with individuals outside of the core
family unit, and limited modeling of social interactions occurred. Further, the parents
not only were limited in their social interactions but also appeared somewhat resistant to
engaging in social interactions with individuals outside of the family. As a result, the parents may have been modeling avoidance of social interactions. It is interesting that social
isolation may be common for families with a socially anxious child (Burch & Heimberg,
1994).
The limited social interaction may be explained by the aforementioned economic
and time constraints; however, a number of other factors may be associated with the familys limited social interaction. First, although there is a significant Spanish-speaking
population in the area in which LMs family resides, a limited ability to speak English
may have limited the possible number of opportunities to engage in more common
forms of social interaction, especially for families who are relatively new to a particular
community. Second, both parents appeared to exhibit a relatively high degree of social
discomfort. Such social discomfort may be associated with their reluctance to take part
in the facilitation of exposure tasks for LM. The fathers social inhibition may also be a
possible explanation for his reluctance to provide positive reinforcement to LM in public settings. An additional complication was that LM and his father appeared to have few
positive social interactions. As a result, attempts on the part of the father to reinforce
LMs speaking behavior may not have been very reinforcing for LM.
The contrasting perceptions of LMs behavior on the parts of his mother and father
also posed a challenge in gaining some consistency concerning parental engagement in
treatment. Fortunately, LMs father increasingly applied prescribed techniques and
noted improvement in terms of the frequency with which LM engaged in speech outside of the home (e.g., responding to strangers greetings, ordering food).
399
400
10 FOLLOW-UP
Treatment was completed in mid-summer. At this point in treatment, all SET-C
skills were completed, significant progress was documented (both inside and outside of
the clinic), and LM appeared to reach a plateau in terms of his treatment progress. The
clinicians agreed to contact the family at the beginning of the new school year to assess
the necessity of reinitiating treatment.
401
A follow-up with LMs mother at the beginning of the new school year indicated
that LM was reportedly doing well in school and that he liked school. His mother also
reported that the teacher had not reported significant concerns and that LM was participating in after-school activities on Fridays. In addition, LMs mother reported that LM
does not seem to shy away from strangers as much as he used to and that he will respond
to strangers with a verbal greeting. His mother reported that they are satisfied with his
behavior and are no longer seeking services at this time; however, she agreed to contact
the clinic if future concerns were to arise.
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Brian J. Fisak, Jr., is an assistant professor in the Department of Psychology at the University of North
Florida. His primary research and clinical interests are in the areas of prevention and treatment of childhood anxiety disorders, developmental psychopathology, and evidence-based treatments.
Arazais Oliveros received her bachelors degree in psychology from Florida International University where
she worked in the Child Anxiety and Phobia Program. She is pursuing a doctoral degree in clinical psychology at the University of Central Florida and conducting research in the Family P.A.I.R.S. (Perception and
Interaction Research Studies) Lab.
Jill T. Ehrenreich, Ph.D., is a research assistant professor of psychology and associate director of the Child
and Adolescent Fear and Anxiety Treatment Program at the Center for Anxiety and Related Disorders at
Boston University. Her primary interests are in the etiology, assessment, and treatment of child and adolescent anxiety disorders.