Helping Children with Selective Mutism and Their Parents: A Guide for School-Based Professionals

Helping Children with Selective Mutism and Their Parents

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Helping Children with Selective Mutism and Their Parents A Guide for School-Based Professionals

Christopher A. Kearney

1 2010

1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright © 2010 by Oxford University Press Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Kearney, Christopher A. Helping children with selective mutism and their parents : a guide for school-based professionals / Christopher A. Kearney. p. cm. ISBN 978-0-19-539454-2 (pbk.) 1. Selective mutism. I. Title. RJ506.M87K43 2010 362.82—dc22 2009040629

1 3 5 7 9 8 6 4 2 Printed in the United States of America on acid-free paper

Contents

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Selective Mutism and Reluctance to Speak: Definition and Description 1

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Assessing Cases of Selective Mutism and Reluctance to Speak

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Exposure-Based Practice: Home Setting

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Exposure-Based Practice: Community and School Settings

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Contingency Management

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Strategies for Children with Communication Problems

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Relapse Prevention, Other Interventions, and Special Issues Appendix

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1 Selective Mutism and Reluctance to Speak: Definition and Description

Jenny refuses to speak around unfamiliar individuals, even at home. The only people Jenny speaks to are her parents. In private, she speaks to her parents in a clear, audible voice. When a stranger is present, however, Jenny does not speak and hides behind her mother. She uses nonverbal cues such as pointing and high-pitched noises to get her parents’ attention in public situations. Jenny’s parents communicate for her when she does not speak. Miguel comes from a bilingual household. He does not speak to classmates or teachers at school and will not speak in other public situations. He speaks often at home in a clear, audible voice. In public social situations, his voice is soft and muffled. He has greatest difficulty speaking when others approach him in social situations. He becomes upset and will not maintain eye contact. Miguel also seems somewhat angry and defiant in these situations. Sunee attends school and performs very well on nonverbal tasks. She does not speak at school, however. She refuses to answer or ask questions in class, read aloud, speak within a small group, or use the bathroom at school. Sunee has difficulty making friends and spends most of her time alone. Although she is talkative at home, she will not speak when the family has visitors. Zion has never spoken in school. He does speak at home, though not particularly well, and avoids direct conversation with his stepfather. When nonfamily members are in the home, Zion will speak only to his mother. School has recently become very difficult as a result of Zion’s refusal to speak and his grades are falling. He increasingly avoids social interactions outside of his immediate family. 1

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o these cases sound familiar to you? As a school professional, you have likely encountered children or perhaps some adolescents who do not speak to others (selective mutism) or who are quite reluctant to speak to others, especially in public situations. Youths who rarely speak pose a vexing problem for school officials, many of whom are rightly concerned about a child’s subsequent academic and social performance. As a clinical child psychologist who has worked with this population for years, as well as with educational professionals at various schools, I know how difficult and odd some of these cases can be. In this book, I hope to share my expertise to help you address this difficult population. This chapter outlines the purpose of this book, describes the characteristics of youths with selective mutism, and provides a model for understanding selective mutism to guide assessment and intervention. The chapter also covers children who are reluctant to speak but who may not have full-blown selective mutism.

Purpose of This Book

The purpose of this book is to illuminate the characteristics of youths with selective mutism and reluctance to speak and focus on methods you can use to assess this population and help these children speak more audibly and frequently. This book is written primarily for school officials who address youths with aspects of selective mutism. This includes school-based social workers, school psychologists, guidance counselors, regular and specialized teachers, principals and deans, school nurses, and other relevant personnel. The book may be useful as well when you discuss a child’s mutism with psychologists, psychiatrists, pediatricians, and other healthcare professionals. This book can also serve as a resource when you collaborate with parents to resolve a child’s selective mutism.

Types of Cases Covered in This Book

This book is best for moderate cases of selective mutism. This means that the procedures described may be less necessary for children who speak fairly well at school. Similarly, the procedures in this book may be less useful for unremitting cases of selective mutism that have lasted

Selective Mutism and Reluctance to Speak

many years or that involve intense additional problems such as severe learning disorders, depression or bipolar disorder, attention-deficit/ hyperactivity disorder (ADHD), conduct and aggressive problems, substance abuse, pervasive developmental disorder, or psychotic disorder. In these cases, referral to psychological and psychiatric services may be necessary (see box).

Referrals to Mental Health Professionals For severe cases of selective mutism, which may include extensive comorbid problems, I recommend referral to a qualified mental health professional. A clinical child psychologist has specialized training with youths with severe behavior problems. A psychiatrist is a medical doctor who can prescribe medication for severe behavior problems. For many children with behavior problems that significantly interfere with daily life, seeing a clinical child psychologist and a psychiatrist is a good idea. Other mental health professionals who may be helpful to families include social workers and marriage and family therapists. If you wish to refer a family to a mental health professional in your area, then consult with local people knowledgeable about who specializes in certain kinds of problems. Some mental health professionals, for example, have special training in substance abuse problems or depression. Others work closely with school officials to help resolve problems such as learning disorders, attention-deficit/ hyperactivity disorder, or intense selective mutism. Ideally, a mental health professional to whom you refer a family for mutism should have knowledge of how to treat the problem and perhaps have access to treatment manuals available for this population. Consulting the psychology faculty at a local university is a good start when looking for someone who best fits a family’s situation. If you live in an area where this is not possible, contact your state associations of psychologists and psychiatrists. In addition, talk to other professionals at your school who work with certain therapists or who have done so in the past. You may also consult the websites of national associations of mental health professionals, such as apa.org, abct.org, and psych.org.

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This book is helpful if no legitimate reason exists for a child’s mutism. If a child’s mutism results from bullying or another real threat to self or property, then the threat must be addressed before using the procedures in this book. Some children still have problems speaking after removal of a threat, however, so the procedures in this book may then apply. The focus of this book is on a child’s selective mutism. The following section defines selective mutism and some terms used to describe this population. Later sections discuss other characteristics of these youths and present a model that serves as the basis for assessment and intervention recommendations presented in subsequent chapters.

Selective Mutism: Diagnostic Features

You might be confused by the many terms used to refer to selective mutism. The literature regarding youths with selective mutism is diverse and scattered across disciplines such as education, psychology, psychiatry, and pediatrics. Many different terms for selective mutism have been used historically (see Table 1.1). The current accepted term is selective mutism, a key diagnostic feature of which is “persistent failure to speak in specific social situations where speech is expected, despite speaking in other situations” (American Psychiatric Association [APA], 2000, p. 125). Children with selective mutism such as Miguel most commonly fail to speak, or refuse to speak,

Table 1.1 Historical Terms Used for Selective Mutism

Speech phobia Speech shyness Speech inhibition Speech avoidance Suppressed speech Hearing mute Learned mutism Thymogenic mutism Voluntary mutism

Ideogenic mutism Partial mutism Psychogenic mutism Heinzian mutism Psychological mutism Situation-specific mutism Temporary mutism Functional mutism Elective mutism

Selective Mutism and Reluctance to Speak

in social situations and, especially public situations such as schools, restaurants, parks, shopping centers, and playgrounds. These children are unlikely to speak to people they do not know well, such as strangers, but often do not speak either to people they encounter daily, such as teachers. Such failure to speak is persistent, meaning it has lasted a long time and seems quite resistant to change. In addition, lack of speech occurs in situations where speaking is expected for most children––for example, most children obviously speak at school. If speech fails to occur only in situations where speech would not be expected, such as attending and listening to a concert, then selective mutism does not apply. An important aspect of selective mutism is that a child will often speak well in certain, usually comfortable, surroundings. Most children with selective mutism such as Miguel speak clearly and audibly at home, although some such as Zion do not. Most of the children we see and children described in the literature speak well at home and with people they know well, such as parents and siblings. Many parents say their child is a “chatterbox” at home and that they are quite surprised when the child fails to speak in public or at school (or when school personnel tell them about this). Some children with selective mutism will even speak to people they do not know well, such as school counselors, on the telephone but not in person. Other children with selective mutism will speak through doorways but not face to face with someone. The fact that many children with selective mutism speak well at home indicates two very important things. First, the problem is not specifically due to a communication disorder such as a phonological disorder, expressive language disorder, mixed receptive-expressive language disorder, or stuttering. In most cases of selective mutism, the child can speak adequately and clearly––the ability is there. However, in some cases selective mutism may be comorbid with a communication or developmental disorder. A child’s selective mutism may not be specifically due to stuttering, for example, but the two problems could coexist and obviously influence each other. Consider Justin, a 5-yearold boy with moderate stuttering who spoke to some degree in preschool but will not speak to anyone now in kindergarten. His failure to speak and thus practice his articulation may delay his recovery from stuttering, and his stuttering may contribute to his ongoing unwillingness to speak.

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A second issue surrounding a child’s ability to speak well at home is that parents often do not believe their child has a problem. Many parents attribute selective mutism to simple shyness that the child will eventually outgrow. Selective mutism is indeed linked in many cases to intense shyness or social anxiety, but mutism represents a much more intransigent and pervasive problem. Unfortunately, many parents of children with selective mutism delay or never seek treatment. The average age of onset of selective mutism is 3–6 years, but parents do not generally refer their child for treatment until age 6–8 years, if at all. The good news is that children with selective mutism show clear signs of the problem during elementary school when you and other school personnel and peers often interact with them. This is the best time for intervention. Selective mutism generally interferes with a child’s educational or occupational achievement or social communication (APA, 2000). Many children with selective mutism do not speak with peers at school, although some have nonverbal friendships. Many of these children cannot take standardized tests (verbal sections), perform academic tasks that require verbal input, answer questions in class, or even ask to attend the restroom (see the example of Sunee at the beginning of this chapter). Such difficulties may not significantly interfere with academic achievement in kindergarten or first grade, but may do so as academic tasks become more complicated and autonomous in later grades. Recall that Zion’s grades were beginning to suffer. Selective mutism must last at least 1 month and cannot be limited to the first month of attending school (APA, 2000). Many children are naturally shy and reluctant to speak when transitioning to a new setting such as kindergarten. Children with selective mutism, however, do not speak in public situations for months or years at a time – some school personnel say they have never heard a particular child in third or fourth grade utter a single word! Selective mutism is thus a pervasive and longstanding problem. A final diagnostic feature of selective mutism is that failure to speak is not due to “lack of knowledge of, or comfort with, the spoken language required in the social situation” (APA, 2000, p. 127). A diagnosis of selective mutism would not generally apply, for example, to new immigrants or to youths whose parents are non-English speakers. However, many children with selective mutism or reluctance to speak do have parents who speak English as a second language. Recall Miguel

Selective Mutism and Reluctance to Speak

Table 1.2 Diagnostic Features of Selective Mutism

Persistent failure to speak in specific social situations in which speech is expected, despite speaking in other situations Interferes significantly with educational or occupational achievement or social communication Must last at least 1 month and is not limited to the first month of school Disorder is not due to lack of knowledge of, or comfort with, spoken language required in a social situation Disorder is not better accounted for by a communication disorder and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder Adapted from the American Psychiatric Association (2000).

presented at the beginning of this chapter. I have seen many children over the years whose parents primarily speak Spanish, Tagalog, Russian, or another non-English language in the home. This could influence the speaking performance of children when they are at school and are surrounded by those who speak English. Chapter 7 provides more detailed information about this type of case. For a complete list of diagnostic features of selective mutism, see Table 1.2.

Selective Mutism: Associated Features

Children with selective mutism have other features that are not a formal part of the diagnostic criteria for the disorder, but are important to understand nonetheless. Several researchers have found that social anxiety and social phobia (fear) are key aspects of many of these cases. Children with selective mutism such as Sunee often avoid social situations that involve speaking to others, initiating conversations, answering the door or telephone, or responding to questions from people such as teachers. Some children with selective mutism are also likely to avoid evaluative situations, especially those involving some verbal performance such as reading a story in class. Others show anxiety-based behaviors such as clinging to parents, hiding, running away, crying, freezing, and throwing tantrums when asked to speak in public.

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Some children with selective mutism are also physically anxious when faced with a situation in which they must speak. Examples include muscle tension, shaking or trembling, sweating, hyperventilation, accelerated heart rate, nausea, dizziness, and other panic-like symptoms. Unfortunately, some of these symptoms are difficult to detect and many children with selective mutism obviously do not verbally report having them. Other children with selective mutism do not demonstrate any of these physical symptoms. Many children with selective mutism also do not report specific anxiety-based thoughts, perhaps because of their young age and refusal to speak. Some children, however, may believe that negative consequences will occur as a result of speaking. They may be concerned that others will ridicule them, that they cannot articulate what they want to say well, or that they will be ignored. As children with selective mutism are coaxed to speak, these concerns may be expressed and addressed. Some reports in the literature indicate that children successfully treated for selective mutism described their experience as “the words were stuck between my toes” or that speech was locked in some way. These children may thus have some insight into their own behavior. Many children with selective mutism have been described in the literature as shy, timid, reserved, reticent, and inhibited. These personality characteristics are similar to those of social anxiety. Some children with selective mutism have also been described as socially withdrawn. Symptoms of depression and selective mutism such as sadness and reduced speech may also overlap and could be comorbid in some children as well. Recall Zion, who increasingly avoided social interactions outside of his immediate family. Such an increase in social withdrawal may indicate some depression. Researchers have also found that some cases of selective mutism involve oppositional, manipulative, or willful behavior. Some children may not be anxious to speak but deliberately refuse to speak. These children may have received extensive reinforcement such as attention from parents or others for not speaking or can avoid school and other obligations by refusing to speak. Other children seem particularly willful in their refusal to speak. Consider Emma, a 5-year-old girl in kindergarten who has never spoken in public, even during her preschool years, and who throws tantrums and otherwise acts defiantly when encouraged to speak in public. Intervention for children such as Emma may focus

Selective Mutism and Reluctance to Speak

heavily on managing rewards and other consequences for speaking and not speaking (see Chapter 5). Another common aspect of selective mutism is linkage to developmental and communication problems. Recall that selective mutism cannot be attributable only to developmental and communication problems, but these problems sometimes coexist in a child. An example from our clinic is April, a 5-year-old girl who rarely spoke, even at home. In addition, her speech at home was marked by low audibility and poor articulation. Nonverbal standardized tests (see Chapter 2) indicated below average intellectual functioning, which may have contributed to her poor speech. In many of these cases, especially in younger kids, separating selective mutism from a developmental disorder can be quite difficult. Chapters 2, 6, and 7 discuss this population in more depth. Researchers have also linked some cases of selective mutism to trauma-based reactions. Youths who have experienced trauma often display social withdrawal and less verbal expression. Zion’s refusal to speak to his stepfather naturally raises a red flag, for example. I recommend assessing children for a recent history of trauma as well as schoolbased threats and other contextual factors that may lead to poor verbal expression. In addition, keep in mind that some children’s refusal to speak may be adaptive. A child who remains very quiet to avoid physical abuse, for example, would not be diagnosed with selective mutism. Other kids will have difficulty speaking even after an abusive situation is resolved and could still benefit from the procedures discussed in this book. Another common feature of children with selective mutism, regardless of subtype or associated features, is compensatory behavior, which refers to nonverbal forms of expression to communicate with others, as in Jenny’s case. Common examples include pointing, gesturing, whistling, nodding or shaking the head, stomping the feet, whispering in a parent’s ear, pulling on clothing, or writing words in the air with one’s fingers. Other compensatory behaviors may involve vocalizations such as grunts, odd or high-pitched noises, or slurred or incomplete expressions such as “ah” for “yes” and “un” for “no.” Reducing or eliminating compensatory behaviors is a key aspect of treatment for selective mutism and usually involves extensive work with parents and teachers (see Chapter 5).

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Children may display selective mutism for several reasons, all of which must be assessed (see Chapter 2). Common antecedents of selective mutism, or what comes before a failure to speak, may include desires to • decrease anxiety • increase social or sensory feedback from others • avoid having to display inefficient or underdeveloped speaking skills.

These antecedents intersect to some degree with the social anxiety component of selective mutism discussed earlier. Consider the case of Sarah, a 7-year-old girl who fails to speak because she is concerned about how others will respond to her voice. Sarah’s parents also report that their daughter enjoys soliciting hugs and other forms of physical affection from people she knows, perhaps by not speaking. Common consequences of selective mutism, or what happens after a child does not speak, usually involve parents, peers, and teachers who may • complete tasks for a child or try to communicate for the child • rearrange a setting to accommodate a child’s mutism • allow whispers or other compensatory behaviors.

Consider the case of Colby, a 6-year-old boy who does not speak in public. His parents order his food at restaurants, explain to school personnel that he does not speak, and allow him to avoid birthday parties and other social events where he might be asked to speak. In addition, Colby’s friends at school tell people that “Colby doesn’t talk” and try to “translate” or otherwise communicate what Colby might need. Colby’s teacher also allows him to point to pictures of things he needs, such as having to attend the restroom. Finally, some cases of selective mutism are so severe that a child may refuse to attend school. School refusal behavior is not directly addressed in this book, but you may wish to consult some resources in this area. One resource is a self-directed book for parents of youths with acute or mild attendance problems (Getting Your Child to Say “Yes” to School: A Guide for Parents of Youth with School Refusal Behavior, Oxford University Press, 2007). Another resource is a book designed for schoolbased professionals for moderate cases of school refusal behavior (Helping School Refusing Children and Their Parents: A Guide for SchoolBased Professionals, Oxford University Press, 2008). A third resource is a set of treatment manuals for psychologists and other clinicians who

Selective Mutism and Reluctance to Speak

Table 1.3 Associated Features of Selective Mutism

Social anxiety and social phobia (fear) Physical symptoms of anxiety Concern about negative consequences of speaking Shy or sad or socially withdrawn Oppositional, manipulative, or willful behavior Developmental and communication problems Trauma-based reactions Compensatory behavior Desire to decrease social anxiety, increase social or sensory feedback from others, or avoid displaying inefficient or underdeveloped speaking skills Significant others who complete tasks for a child, rearrange settings to accommodate a child’s mutism, or allow compensatory behaviors such as whispering School refusal behavior

address severe attendance problems [When Children Refuse School: A Cognitive-Behavioral Therapy Approach, 2nd ed. (Therapist Guide and Parent Workbook), Oxford University Press, 2007]. Full references for these books and other supporting materials on selective mutism can be found in the bibliography at the end of the book. For a full list of associated features of selective mutism, see Table 1.3.

Selective Mutism: Epidemiology, Course, and Family Factors

Selective mutism occurs in about 0.2–2.0% of children and adolescents and is somewhat more common in girls than boys (about a 1.5:1 ratio). As mentioned, the disorder typically begins during preschool years, but treatment is often delayed. Selective mutism may have a chronic course for some children and can produce significant problems with respect to peer rejection, incomplete verbal academic tasks or standardized tests,

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or inadequate language or social skills. An infamous example of someone previously diagnosed with selective mutism is Seung-Hui Cho, the student responsible for the Virginia Tech massacre. Obviously children with selective mutism will not generally become mass murderers, but the social alienation and potentially poor academic performance that could result from the disorder can be quite debilitating for a child. Family functioning for children with selective mutism is not dramatically different from children in the general population, although I and other researchers have noted some issues that can interfere with treatment. Some parents of children with selective mutism are quite shy, meek, or reserved themselves and often have to be coaxed to participate in treatment and help conduct exposures (see Chapter 5). Other parents need an extensive rationale as to why their child needs treatment, or perhaps an extended behavioral observation session of their child at school, to convince them of the seriousness of the issue at hand (see Chapter 2). Keep in mind as well that most parents have never heard of selective mutism and need a detailed description of the disorder and its associated features.

Reluctance to Speak

Selective mutism, the primary focus of this book, is a very serious disorder. Some children, however, do speak to some degree in public situations, but only reluctantly, infrequently, at a barely audible level, or only to certain people. These kids might be described as excessively shy and may or may not have friends. Many of these children have intense levels of social anxiety and may avoid some social situations but may not meet formal diagnostic criteria for selective mutism. The problems covered in this book may thus be seen along a continuum. Figure 1.1 outlines a sample spectrum of normal speaking, reluctance to speak, and selective mutism in school. You can see from Figure 1.1 that different levels of appropriate speaking exist prior to full-blown selective mutism. Most children speak normally to peers and teachers. Some children, however, are quite shy but do speak to others in a low but audible voice. Greater reluctance to speak occurs at the next two levels. Some children hesitate to speak to others and limit their speech to a select group of people at school. Some kids, for example, enjoy speaking to friends on the playground

X-------------------------X----------------------------X----------------------------------X---------------------------------X--------------------------------X--------------------------------X Normal speaking to peers and teachers

Child speaks to peers and teachers using low audible voice

Child reluctantly speaks to peers or teachers but not to both using low audible voice

Child reluctantly speaks to peers or teachers but not to both by whispering

Child communicates to peers or teachers only by speaking to a parent

Child will not speak to anyone at school, even with a parent present, and will not participate nonverbally in social and academic activities

Figure 1.1. Sample spectrum of normal speaking, reluctance to speak, and selective mutism at school.

Selective Mutism and Reluctance to Speak

Child will not speak to anyone at school, even with a parent present, but will participate nonverbally in social and academic activities

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but seem quite intimidated by teachers and other school personnel. Other kids prefer talking to adults more than classmates. In either case, communicating with a select group of people is difficult for a child. The first level of this reluctance to speak to either peers or teachers involves low audible speech, but the second level involves barely audible whispering. The next level of difficult speech involves children who will not speak to peers or teachers at school, but will convey information via a parent. Children at this level will often whisper what they want to say in a parent’s ear and the parent will then convey the information to others. Obviously this is an unwieldy practice, so most communication occurs immediately before or after school. In some cases, a child will also choose a peer or sibling who will serve the same function as the parent when the parent is absent. The final two phases on the spectrum in Figure 1.1 involve formal selective mutism. Many children with selective mutism will not speak but will participate nonverbally in social and academic activities as much as possible. Children with severe selective mutism, however, will not speak or even participate nonverbally in these activities and may actively refuse to attend school. Children with great reluctance to speak may not have formal selective mutism but could still benefit from the techniques discussed in this book. The pace of your intervention could be a little faster for these children than for those with formal selective mutism because some speech is already evident. Many of the procedures discussed in this book can be applied to youths who are reluctant to speak (see the later treatment section and Chapters 3–7). In addition, a working model of selective mutism generally applies to youths who are reluctant to speak.

A Working Model of Selective Mutism and Reluctance to Speak

Researchers are still developing a comprehensive model of selective mutism, but available studies and treatment outcome evaluations do allow for a working model that can be used to guide intervention. This model focuses on key antecedents (what comes before) and consequences (what comes after) of selective mutism or reluctance to speak (see Fig. 1.2). These antecedents and consequences were discussed earlier and serve as the basis for the intervention techniques described in this book.

Selective Mutism and Reluctance to Speak

Key antecedents of selective mutism or reluctance to speak

Selective mutism or reluctance to speak

Key consequences of selective mutism or reluctance to speak

Decrease social anxiety, increase social or sensory feedback from others, avoid aversive directives (oppositional), avoid displaying inadequate social or speech skills (communication problems), contextual factors such as trauma or depression

Refusal or failure to speak or difficulty speaking in public settings, despite speaking well in other settings such as home; problems have lasted at least one month and interfere with functioning; not specifically due to developmental or communication disorder

Completing tasks for a child, rearranging settings to accommodate a child’s lack of speech, allowing whispers or other compensatory behaviors, peers speaking for the child or informing others that the child does not speak, allowing the child to avoid social settings

Figure 1.2. Model of selective mutism and reluctance to speak.

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As mentioned, selective mutism appears to be closely linked to social anxiety in many cases. The primary treatment for social anxiety in children involves exercises to manage physical aspects of anxiety, cognitive therapy to manage problematic or irrational thoughts about social and evaluative situations, and exposure-based practice to help children build interactive skills and become more comfortable in social and evaluative situations. Successful treatment for many children with selective mutism is based on these same principles and techniques. A possible exception is cognitive therapy, or modifying problematic thoughts, which usually requires a verbal component and greater intellectual development. Cognitive therapy is thus not a central feature of this book. If a child with selective mutism or reluctance to speak does improve, however, then discussions about what they may fear when speaking may be productive (see Chapter 4). As mentioned, other kids with selective mutism are not necessarily anxious but seem adamant about not speaking, perhaps in a deliberate refusal or manipulative kind of way. Anxiety management approaches in these cases may not be helpful. Instead, speech will likely need to be brought forth by managing contingencies – this likely involves providing incentives for speaking appropriately and disincentives for refusing to speak appropriately. This contingency management approach demands a highly coordinated effort between parents and school personnel. Still other children with selective mutism have comorbid problems or developmental delays that impact their ability to speak appropriately. Anxiety and contingency management techniques for these children may be helpful but not necessarily sufficient. These kids may require phonics training and other academically-based language interventions to improve articulation, comprehension, and speaking and cognitive ability. The chapters in this book are largely designed to address these three major classes of youths with selective mutism or reluctance to speak (anxiety-based: Chapters 3 and 4; oppositional: Chapter 5; and communication problem: Chapter 6). Introduction to Intervention Techniques Discussed in this Book

The most common and empirically supported interventions for selective mutism are behavioral in nature and comprise the main basis of

Selective Mutism and Reluctance to Speak

Table 1.4 Key Intervention techniques for Selective Mutism

Exposure-based practice Stimulus fading Shaping and prompting Self-modeling Relaxation training and breathing retraining Contingency management Negative reinforcement/escape Social skills training Language training Family therapy Group therapy Pharmacological intervention (medication)

this book. These interventions are designed to address the major subtypes of selective mutism described previously: anxiety-based, oppositional, and communication problem. Because many cases of selective mutism can involve more than one of these key subtypes, I strongly recommend that you read all the chapters. A brief description of the intervention techniques that are presented in much greater detail in Chapters 3–7 is next (Table 1.4). Exposure-Based Practice

Exposure-based practice refers to a collection of techniques that require a child to say words in gradually but increasingly difficult or anxietyprovoking situations. Exposure-based practice is a mainstay of treatment for children with social anxiety and selective mutism and is the main focus of Chapters 3 and 4. The practice is most suited for kids whose selective mutism has an anxiety component. Exposure-based practice is not as helpful for children who have intense oppositional or communication problems. Kids with oppositional or communication problems may still have anxiety about speaking, however, so exposurebased practice is a cornerstone of intervention for many with selective mutism.

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Exposure-based practice usually involves a hierarchy of speaking situations. A hierarchy is a list of situations that range from least to most anxiety-provoking (or least difficult to most difficult). A typical hierarchy for a child with selective mutism might include speaking to a school-based social worker in the child’s home, speaking to the social worker and others in community situations, speaking to the social worker and others in a school office setting, and speaking to the social worker and others at school. Many smaller steps within each of these larger steps are obviously necessary as well (see the later section on stimulus fading). Exposures may involve community situations such as convenience stores, shopping malls, pet stores, and parks. School-related situations may include classrooms, hallways, offices, cafeteria and gymnasia, playgrounds, and special classes such as music. Expectations for speaking in school can also involve peers, teachers, administrators, and other personnel. Hierarchies can also involve expectations for speaking that range from mouthing words to whispering to barely audible speech to low-volume speech to full-volume speech. The goal of exposure-based practice is to gradually develop a child’s ability to speak frequently and audibly in all public situations while at the same time helping a child manage her anxiety. Exposure-based practice is often used in conjunction with other techniques that are briefly described next. Relaxation Training and Breathing Retraining

As mentioned, youths with selective mutism may have uncomfortable physical feelings of anxiety such as muscle tension and hyperventilation or shortness of breath. To help a child manage these symptoms in speaking situations, he may be taught to relax muscles or breathe more correctly. Muscle relaxation training involves teaching a child to tense and release different muscle groups when preparing to speak before or to others. Breathing retraining involves teaching a child to breathe in slowly through her nose and exhale slowly through her mouth. Both techniques are portable and can be taught with little or no verbalization from the child. These techniques are typically performed as a child is exposed to increasingly more difficult speaking situations in exposure-based practice. The goal is to replace anxious physical feelings with greater relaxation when a child communicates verbally with others.

Selective Mutism and Reluctance to Speak

Stimulus Fading

Stimulus fading involves systematically increasing the difficulty of an exposure by fading in new stimuli such as verbal academic tasks, peers, or teachers. Consider Juan, a 7-year-old boy who rarely speaks at school. Juan might be initially asked to speak to someone he knows and speaks to well, such as a school psychologist, in an empty classroom for 30 minutes a day. In this way, Juan’s speaking is associated with the classroom and his anxiety can be limited by having no one around. Certain stimuli can then be faded into the exposure to make it more challenging. Juan could be asked to engage in a verbal academic task such as reading aloud to the school psychologist. As he becomes proficient at this, the psychologist may add a friend to the classroom who sits several feet away or the psychologist may ask the teacher to sit at a desk on the other side of the room. As Juan’s speech becomes proficient under these conditions, more tasks, peers, or other components of the classroom can be added. Stimulus fading can be used as well in a child’s home or in community settings. Stimulus fading is usually done in conjunction with exposure-based practice and ongoing rewards and prompts for speech. Shaping and Prompting

Shaping refers to reinforcing successive approximations of a desired response, in this case audible and frequent speech. School-based mental health professionals may initially reward a child’s vocalizations such as humming and then gradually shape these sounds into verbalizations. The shaping process is usually accompanied by prompting or prodding a child to use words to communicate, speak more articulately and loudly, establish eye contact, and extend the duration of speech. The child may be encouraged as well to express speech in common situations such as greeting or thanking someone. Shaping and prompting are key elements of exposure-based practice as a child engages in increasingly difficult speaking scenarios. Self-Modeling

Self-modeling involves asking parents to audiotape or videotape a child as he speaks clearly and well in a comfortable situation such as home.

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helping children with selective mutism and their parents

The recording is then replayed in a low-frequency speaking situation such as your office at school. Others may be present, such as family members. The child is given substantial verbal praise or tangible inducements during this process to reward the clarity, volume, and beauty of her voice. The child is essentially viewing herself as a model for appropriate and audible speech. The process is also aimed at rewarding speech, easing discomfort, and helping a child recognize that no negative consequences will result from speaking publicly. Contingency Management

The techniques described so far focus largely on a child’s anxiety-based symptoms. As mentioned, however, some children display more oppositional tendencies by refusing to speak in public situations. Contingency management is a key aspect of intervention for these types of cases, although the approach can also be used for anxious children during exposure-based practices. Contingency management refers to establishing rewards and disincentives for a child’s speech or a child’s refusal to speak, respectively. These rewards and disincentives are typically provided by parents, teachers, and the person primarily responsible for handling the child’s intervention. Rewards and disincentives are mostly geared toward frequency and audibility of speech, although they can also target compensatory or other problematic behaviors such as tantrums or clinging. Jenny’s highpitched noises to try to communicate to others, for example, could be ignored by significant others to extinguish the behavior. Contingencies can be contrived, such as a sticker chart, or can be more natural. An example of the latter would be asking a child to order a treat in an ice cream parlor – appropriate speech leads to ice cream and refusal to speak leads to no ice cream. Negative Reinforcement/Escape

Another behavioral technique for cases of selective mutism that involve oppositional tendencies is negative reinforcement. Negative reinforcement refers to rewarding a behavior by removing aversive consequences. In this approach, a child is required to sit in a low-frequency speaking situation (such as your office) for an extended period of time until he speaks one word, and is then allowed to leave. Speaking thus allows the

Selective Mutism and Reluctance to Speak

child the opportunity to escape a boring and potentially stressful situation (negative reinforcement). This process can last several hours, however, and there is no guarantee the child will speak. This approach is described in greater detail in Chapter 5. The approach is not welltested, however, and can be burdensome and ineffective. Language Training

Another key subtype of selective mutism involves kids with language or communication problems. These children may benefit from phonics or other language training that can be integrated into exposure-based practice. Recall the case of April, the 5-year-old girl who rarely spoke, even at home. Her speech at home was marked by low audibility and poor articulation. April could benefit from using gestures to imitate sounds and then practice other sounds for basic three-phoneme words such as “dog.” This process could intersect with exposure-based practice by having April initially mouth the words and later progress to whispering, barely audible speech, and normal voice volume. Language and other types of academic training could also involve close collaboration with a speech pathologist and specialized education teachers to build articulate language and generalize speech. Other Interventions

Other interventions have been utilized for children with selective mutism and are included in this book. Social skills training refers to building basic skills such as establishing and maintaining eye contact, starting and maintaining conversations effectively, and introducing oneself to peers (see Chapter 4). Such training may be useful for children with selective mutism whose development of social skills and friendships has been hampered by the disorder. Social skills training can be extended as well to social-academic tasks such as asking or answering a question in class, responding to instructions on a standardized test, or participating in music or other specialty classes. Family therapy regarding this population refers to educating family members about selective mutism, exploring family patterns of communication, addressing enmeshed or overcontrolling parent–child relationships, and reducing family member pressure on a child to speak. You may not have the time or resources to conduct formal family therapy for

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helping children with selective mutism and their parents

a particular case of selective mutism, but addressing family dynamics to some extent in many of these cases is crucial for success. Addressing these dynamics can often be done in the context of contingency management practices. Family interventions are discussed in greater detail in Chapter 7. Group therapy has not been extensively tested for children with selective mutism but involves conducting many of the procedures described here for several children at one time. Children in the group could benefit by modeling the accomplishments of others or engaging in exposures together. Children could also practice social skills on one another. A key advantage of group therapy is its cost-effectiveness – multiple children can be seen at one time. A potential downside, of course, is that children may progress at different speeds. Finally, you may not have enough children with selective mutism at your school to constitute a group. Group therapy is discussed at greater length in Chapter 7. Finally, pharmacological intervention refers to the use of medication. Some researchers have found that antidepressants and other medications can help some children with severe selective mutism. The medications may help reduce anxiety or depression that stifles speech, although other mechanisms may be at work as well. Referral to a pediatrician or psychiatrist may be necessary in some very difficult cases of selective mutism (see the box on page 3). Try the procedures in this book before seeking a solution involving the use of medication (see Chapter 7 for more details).

Final Comments and What Is Next

Selective mutism and reluctance to speak are complex and difficult problems that can lead to serious consequences for a child. The first step in addressing a child with these issues is to fully understand the forms and function of the behavior as well as contextual variables that may contribute to the behavior. Assessment methods for this population are discussed in Chapter 2, with a particular emphasis on key questions you can ask as well as other time-efficient methods of data collection such as questionnaires and worksheets. Chapters 3 and 4 outline recommended procedures for youths whose selective mutism or reluctance to speak appears to be based on

Selective Mutism and Reluctance to Speak

anxiety. A heavy emphasis is placed on exposure-based practice, or having a child practice speaking in various situations. Many techniques can be utilized in conjunction with exposure-based practices, such as relaxation training, self-modeling, and shaping and prompting. Chapter 3 focuses on exposure-based practice at a child’s home. Chapter 4 focuses on exposure-based practice in community settings and at your school. Chapter 5 outlines recommended procedures for youths whose selective mutism or reluctance to speak appears to be more oppositional in nature. A heavy emphasis is placed on contingency management practices using incentives for speaking and disincentives for refusing to speak. Chapter 6 outlines recommended procedures for youths whose selective mutism or reluctance to speak may relate to specific language impairment or developmental delay. Emphasis is placed on integrating phonics and other language training with techniques specific to selective mutism. Chapter 7 covers relapse prevention for children with selective mutism and reluctance to speak, including strategies for handling a new school year. This chapter also includes a discussion of group, family, pharmacological, and other treatments for these children. The chapter concludes with a discussion of special issues regarding this population such as bilingualism, difficult parents, comorbidity, and developmental delay.

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2 Assessing Cases of Selective Mutism and Reluctance to Speak

Gabriella is an 8-year-old student in third grade who moved to her current elementary school 2 years ago. She does not speak to anyone in school but has several friends who speak for her. She also points to pictures of things she wants or will tug on the teacher’s clothing if necessary. Gabriella’s parents say their daughter speaks well at home and is very quiet in public. She seems to be a good student but adamantly refuses to participate in academic tasks that involve speaking to peers or others. She often prefers to sit quietly at her desk, keep her head down, and focus on her work. Nash is a 5-year-old boy in kindergarten who speaks only in a whisper in class. His classmates say “Nash doesn’t talk” and do try to play with him, but Nash prefers to be by himself. Nash’s parents say their son is quiet even at home but also say they can usually understand what he is trying to convey. Other people, however, say they can barely hear Nash speak, that he does not articulate well, and that he will not attempt to speak again when people ask him to repeat what he said. Nash also appears sad much of the time and does not seem to enjoy school.

S

chool officials are commonly faced with children such as Gabriella and Nash. Chapter 1 discussed different aspects of selective mutism and reluctance to speak and presented a working model for understanding this population. Recall that many of these kids have some degree of social anxiety, oppositional behavior, or communication problem. Methods of assessing children such as Gabriella and Nash are described in this chapter. Some of these assessment methods are less time-intensive for school officials with little opportunity for conducting a detailed 24

Assessing Cases of Selective Mutism and Reluctance to Speak

assessment. Other methods are time-intensive and might be under the purview of someone who can conduct a detailed assessment, such as a school-based social worker or school psychologist. Some methods are very specific to selective mutism and others are broader instruments to assess global aspects of functioning such as intelligence or language ability. This chapter begins with interview questions that are specifically geared toward core aspects of selective mutism. Later sections cover measures such as questionnaires and worksheets that generally require little time. These basic and less time-intensive methods must be part of any assessment for a youth with selective mutism or reluctance to speak. Later in the chapter, measures that relate to key associated features of selective mutism (social anxiety, oppositional behavior, and communication problems) are discussed. These measures may be a bit more timeintensive and include other questionnaires, formal testing, behavioral observation, and review of records. A final section of the chapter involves suggestions for collating your assessment data to develop an intervention plan.

Interview Questions Specific to Selective Mutism and Reluctance to Speak

One assessment method that you may wish to emphasize first with this population is the interview. You may wish to interview the child, parents, teachers, and others who regularly interact with the child. You might be surprised at the suggestion to interview a child with selective mutism—after all, what is he going to say? Many children with selective mutism, however, will respond nonverbally to yes or no questions by nodding or shaking their head. This allows you to collect at least some information about their nonspeaking and what maintains their failure to speak. Other children such as Nash may not respond even at this level, and I do not recommend pushing a child to answer if he does not want to. In these latter cases, information will have to be gleaned primarily from parents and teachers and possibly from peers and others. Ideally you should interview different parties separately, but time pressures may force you to meet with parents and teachers together. If only a group meeting is feasible, then try to interview the child separately.

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Doing so may reduce the child’s anxiety by avoiding a large group and help you obtain a good indication of how reluctant she is to speak. Following are some key questions recommended for the interview process. The questions are designed to help you decide whether a child does indeed have selective mutism, what subtype of selective mutism a child may have, and what associated features of selective mutism a child may have. Does the Child Meet Criteria for Selective Mutism?

A good way to start your interview is to ask questions that directly match specific diagnostic criteria for selective mutism. Answers (Yes/ No) that support a diagnosis of selective mutism follow the questions: • Does the child show a persistent failure to speak in public situations where speaking is expected? (Y) • Does the child speak well in other situations, especially at home? (Y) • Does the child’s refusal to speak interfere significantly with her educational or occupational achievement or social communication? (Y) • Has the child’s failure to speak lasted at least 1 month and not just during the first month of school? (Y) • Is the child’s failure to speak due to lack of knowledge of, or comfort with, the spoken language required in a social situation? (N) • Is the child’s failure to speak better accounted for by a communication disorder? (N) • Does the child’s failure to speak occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder? (N)

Selective mutism is generally indicated if the answers to questions 1–4 are yes and the answers to questions 5–7 are no. Bear in mind, however, that some gray areas may be present, especially with respect to the presence of a communication disorder. Not all children with selective mutism neatly fit these diagnostic criteria. Keep in mind as well that a child may not have formal selective mutism but may still be quite reluctant to speak. A child may have some willingness to whisper in class, as Nash does for example (see also Fig. 1.2 in Chapter 1). The assessment methods presented in this chapter can still apply to a large degree to children such as Nash who are reluctant to speak.

Assessing Cases of Selective Mutism and Reluctance to Speak

What Specific Settings Involve Failure to Speak?

Children with selective mutism will not speak in specific social situations where speaking is expected. These situations often include restaurants, malls, supermarkets, parks, other recreational settings, and school. You should work to discover exactly which speaking situations involve the greatest difficulty for a child. You should also detail at length the specific settings at school that involve the greatest difficulty for a child. You may wish to use Worksheet 2.1 in this regard to determine the extent of a child’s selective mutism or reluctance to speak. School-based situations involving failure to speak should be detailed at length. Some children will speak a bit on the playground or other highly social settings such as the cafeteria but never in class. Other kids will speak to peers a bit but never to adults. Some kids will speak to a favorite teacher, such as the music teacher, but to no one else. Many kids with selective mutism, however, never speak to anyone at school in any situation. Establishing a baseline of speaking behavior––knowing the minimum amount of speech a child is willing to produce, and where, and how loud––will help you determine the starting point for intervention. What Circumstances Surround Failure to Speak?

Many of the questions described to this point surround the form of nonspeaking behavior, such as whether and where it occurs. Of equal importance is discovering factors that maintain a child’s refusal to speak––in other words, what motivates the child to continue to refuse to speak? What is the function of nonspeaking behavior for the child? To help ascertain function, ask the following questions: • Is the child’s refusal to speak due to a desire to decrease anxiety? • Is the child’s refusal to speak due to a desire to increase social or sensory (physical) feedback from others? If so, what type of feedback? • Is the child’s refusal to speak due to a desire to avoid aversive directives from others? • Does the child refuse to speak because of inefficient or underdeveloped speaking skills?

Keep in mind that many parents and teachers have trouble answering these questions. As such, ask about a child’s behavior in situations where he does speak well to see what patterns could reveal the function

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helping children with selective mutism and their parents Worksheet 2.1 Situations Involving Selective Mutism or Reluctance to Speak

Does the child refuse/fail to speak or have great reluctance speaking in the following situations? Mutism Reluctance to speak Home Answering the door or telephone Speaking to parents Speaking to siblings Speaking to visitors the child knows well Speaking to visitors the child does not know well Speaking to peers inside the home with the parents present Community/public

Y/N _____ _____ _____

Y/N _____ _____ _____

_____

_____

_____

_____

_____

_____

Y/N

Y/N

Speaking to parents or siblings in markets and similar places Speaking to peers at social events or extracurricular activities Speaking to clerks or waiters

_____

_____

_____ _____

_____ _____

School

Y/N

Y/N

Speaking to peers on the playground Speaking to peers in hallways and related situations Speaking to peers in the classroom Speaking to peers at lunch/cafeteria Speaking to peers on the school bus Speaking to parents at school

_____

_____

_____ _____ _____ _____ _____

_____ _____ _____ _____ _____

Assessing Cases of Selective Mutism and Reluctance to Speak

Speaking to teachers on the playground Speaking to teachers in the classroom Speaking to other staff members at school Speaking during academic activities Speaking or reading before classmates

_____ _____

_____ _____

_____ _____ _____

_____ _____ _____

of nonspeaking. For example, does the child often seek attention from his parents at home? If so, refusal to speak in public may be designed to gain attention. Does the child often refuse to do things such as chores that she does not want to do? If so, refusal to speak in public may be motivated by a desire to avoid directives from others. Are the child’s social or speech skills at home not well developed? If so, the child may be unwilling to display these rudimentary skills in public. Look for patterns of behavior and how the child may be reinforced for nonspeaking. Bear in mind that more than one issue, such as attention-seeking and poor communication skills, may be pertinent. You should also ask questions about contextual factors that may influence a child’s refusal to speak. Recall that some children will not speak following a traumatic event or ongoing difficulties, so questions surrounding this possibility should be posed. Other children experience episodes of sadness or even depression. Ask whether recent changes have occurred in a child’s life, such as parental divorce, that could lead to decreased speaking. If a child experiences traumatic or difficult events and did speak well prior to these events, then a diagnosis of selective mutism would not likely apply. In these cases, helping the child adjust to trauma or other changes in his life may be best. Other contextual factors involve the parents, family, and school. An important question to ask parents is whether English or another language is primarily spoken in the home. Parental emphasis on Spanish in the home, for example, could influence a child’s willingness to speak English at school. Family dynamics could also be probed. Are family members themselves meek or shy? Do family members communicate well and solve problems effectively? Is there substantial conflict in the home? Have any recent changes in the parents or family potentially affected a child’s willingness to speak? School-related factors such as possible threats from others should be explored as well.

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helping children with selective mutism and their parents Can the Child Be Encouraged to Speak Audibly in Certain Public Situations?

Recall from Chapter 1 that normal speaking, reluctance to speak, and selective mutism occur along a dimensional spectrum of severity (Fig. 1.2). Try utilizing this spectrum as an assessment tool during your evaluation of a child. Where on the spectrum does the child fall? How severe is the child’s refusal to speak in different situations? Does the child fluctuate in his type of speaking across different situations? A child might whisper in a mall, for example, but remain completely mute at school. Be sure to chart all instances of nonspeaking or reluctance to speak. Determining where a child falls on this spectrum will involve knowing whether a child can be encouraged to speak audibly in certain public situations. Some children will whisper or even speak in certain situations if prompted by parents or others or if some substantial motivation is present (e.g., toy, ice cream). Children with selective mutism who can speak to some extent in public situations may have a better prognosis than those who do not. Knowing whether a child will speak in response to a prompt or tangible reward such as a toy is also important for intervention purposes. If a child is receptive to prompts, then utilizing this technique heavily during intervention is suggested. Other children actually become more closed and unwilling to speak if verbal praise or prompts are given, however, so knowing this allows you to emphasize alternative motivators such as tangible rewards. A child’s willingness or unwillingness to respond to prompts will also help you determine how quickly or slowly your intervention must proceed. What Symptoms Surround a Child’s Failure to Speak?

Many children with selective mutism and reluctance to speak show problems in addition to the core diagnostic criteria of the disorder (see associated features in Chapter 1). Interview questions should surround these related problems and may include the following: • Does the child seem generally anxious or nervous? Does the child have physical symptoms of anxiety such as trembling, sweating, or crying? Does the child report being scared or anxious in different situations?

Assessing Cases of Selective Mutism and Reluctance to Speak

• Does the child seem socially anxious? Does the child commonly avoid situations such as birthday parties or soccer games that involve social interaction or some type of evaluation? • Has the child expressed concerns about speaking such as negative reactions from others? • Does the child have a history of separation anxiety from significant others such as parents? Does the child often cling to parents, cry when separation occurs or is anticipated, or refuse to attend school? • Does the child seem depressed? Does the child show sad mood, poor self-esteem, poor eating or sleeping habits, social withdrawal, or tendencies to self-harm? • Does the child show oppositional tendencies? Does the child often show defiance or noncompliance, argue with parents, or throw temper tantrums? • Does the child have a history of poor communication such as inarticulate speech, stuttering, or other expressive or receptive language problems? • What is the child’s general level of intellectual functioning? • Can the child engage in basic adaptive self-care skills such as dressing, washing, eating, and using the toilet appropriately and independently? • Does the child show compensatory behaviors such as whispering, pointing, gesturing, high-pitched noises, grunts, incomplete words, or other nonverbal methods of communication? • Does the child have health problems that may specifically impact his ability to speak?

Regarding the last question, I strongly recommend that a child with selective mutism or reluctance to speak be referred to a pediatrician for a full medical examination. Medical conditions are not commonly linked to selective mutism, but conditions such as asthma, pain, or anatomical problems could influence the condition. If medication becomes an option (see Chapter 7), then referral to a pediatrician or psychiatrist will be necessary as well. How Do Others Respond to a Child’s Failure to Speak?

A very important part of your assessment will be to discover how other people respond to a child’s refusal or reluctance to speak. By others, I mean parents, teachers, peers, siblings, relatives, and people who interact

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or see the child on a regular basis. Recall the common consequences of selective mutism covered in Chapter 1. Ask the following questions in this regard: • Do others commonly complete tasks for a child after he fails to speak? • Do others rearrange settings for a child to accommodate her mutism? • Do others allow whispering or other compensatory behaviors? • Do peers help the child communicate to others at school or in other places?

Many kids with selective mutism have grown accustomed to having other people complete tasks for them, and many parents, teachers, and others have grown accustomed to compensating for a child’s lack of speech. This will have to change during intervention. In the meantime, discover exactly what accommodations are commonly made for a child. For example, parents may habitually order food for a child, allow the child to avoid activities such as answering the door or telephone, ask a peer or sibling to help the child communicate at school, or keep the child away from birthday parties and other social events. Teachers may habitually decline to call on a child in class, allow the child to point to pictures or use hand gestures to communicate, or stop assigning work to the child that requires verbal input. As mentioned, peers will also be happy to tell others that “Nash doesn’t talk” and try to communicate the child’s desires to others. These interview questions will help give you a broad perspective of a child’s selective mutism and reluctance to speak. If you desire a more structured approach, the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions is available via Oxford University Press. This is a structured diagnostic interview that emphasizes anxietyrelated disorders but has sections for externalizing problems such as oppositional defiant disorder as well. The interview also contains a section on selective mutism that mirrors DSM-IV criteria. Another interview format for selective mutism is the Functional Diagnostic Protocol (Schill, Kratochwill, & Gardner, 1996). This brief interview assesses for conditions under which selective mutism occurs and what reinforcers maintain mutism over time. If you decide to use these interviews, you should still ask the questions posed in this chapter for a complete picture of a child’s mutism or

Assessing Cases of Selective Mutism and Reluctance to Speak

reluctance to speak. Interview questions should be supplemented as well by measures specific to selective mutism and reluctance to speak. These measures include questionnaires and worksheets and are described next.

Measures Specific to Selective Mutism and Reluctance to Speak

Some measures have been designed specifically for selective mutism and can apply to youths who are reluctant to speak. A strong one from the research literature is the Selective Mutism Questionnaire (SMQ), a measure that contains three main factors: school, home/family, and public/social (see Fig. 2.1). School items surround a child’s willingness to speak to peers, teachers, and groups at school. Home/family items surround a child’s willingness to speak to family members when others are present or in unfamiliar situations, to extended family members and family friends and babysitters, and on the telephone to parents and siblings. Public/social items surround a child’s willingness to speak to unfamiliar peers or family friends, medical personnel, store clerks and waiters, and in clubs or teams outside of school. Parents rate each item on a 0–3 scale of never, seldom, often, and always. Questions 18–23 surround how much interference or distress is associated with a child’s pattern of nonspeaking. These items are rated as not at all, slightly, moderately, and extremely. Lower scores on the SMQ generally reflect a lower frequency of speaking behavior. The measure has strong psychometric properties (Bergman, Keller, Piacentini, & Bergman, 2008). A supplemental measure is the School Speech Questionnaire (SSQ), an eight-item instrument completed by the teacher that surrounds school-based speaking behavior in different situations (see Fig. 2.2). The SMQ and SSQ are good measures of the severity of a child’s selective mutism, but the scales do not supply information about a child’s daily fluctuations in terms of speech, audibility, or anxiety. In our work with youths with selective mutism, we utilize several daily monitoring forms developed for children, parents, and teachers. These forms were developed by a colleague of mine, Jennifer Vecchio, who has investigated this population with me (see Vecchio & Kearney, 2005, 2007, 2009).

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helping children with selective mutism and their parents Please consider your child’s behavior in the last two weeks and rate how frequently each statement is true for your child. AT SCHOOL 1. When appropriate, my child talks to most peers at school. Always

Often

Seldom

Never

2. When appropriate, my child talks to selected peers (his/her friends) at school. Always

Often

Seldom

Never

3. When my child is asked a question by his/her teacher, s/he answers. Always

Often

Seldom

Never

4. When appropriate, my child asks his or her teacher questions. Always

Often

Seldom

Never

5. When appropriate, my child speaks to most teachers or staff at school. Always

Often

Seldom

Never

6. When appropriate, my child speaks in groups or in front of the class. Always

Often

Seldom

Never

HOME/FAMILY 7. When appropriate, my child talks to family members living at home when other people are present. Always

Often

Seldom

Never

8. When appropriate, my child talks to family members while in unfamiliar places. Always

Often

Seldom

Never

9. When appropriate, my child talks to family members that don’t live with him/her (e.g., grandparent, cousin). Always

Often

Seldom

Never

10. When appropriate, my child talks on the phone to his/her parents and siblings. Always

Often

Seldom

Never

11. When appropriate, my child speaks with family friends who are well-known to him/her. Always

Often

Seldom

Never

12. My child speaks to at least one babysitter. Always

Often

Seldom

Never

N/A

Figure 2.1. Selective Mutism Questionnaire (SMQ)©. Created by and the property of R. Lindsey Bergman, Ph.D. Reprinted with permission.

Assessing Cases of Selective Mutism and Reluctance to Speak

IN SOCIAL SITUATIONS (OUTSIDE OF SCHOOL) 13. When appropriate, my child speaks with other children who s/he doesn’t know. Always

Often

Seldom

Never

14. When appropriate, my child speaks with family friends who s/he doesn’t know. Always

Often

Seldom

Never

15. When appropriate, my child speaks with his or her doctor and/or dentist. Always

Often

Seldom

Never

16. When appropriate, my child speaks to store clerks and/or waiters. Always

Often

Seldom

Never

17. When appropriate, my child talks when in clubs, teams, or organized activities outside of school. Always

Often

Seldom

Never

N/A

Interference/Distress* 18. How much does not talking interfere with school for your child? Not at all

Slightly

Moderately

Extremely

19. How much does not talking interfere with family relationships? Not at all

Slightly

Moderately

Extremely

20. How much does not talking interfere in social situations for your child? Not at all

Slightly

Moderately

Extremely

21. Overall, how much does not talking interfere with life for your child? Not at all

Slightly

Moderately

Extremely

22. Overall, how much does not talking bother your child? Not at all

Slightly

Moderately

Extremely

23. Overall, how much does your child’s not talking bother you? Not at all

Slightly

Moderately

Extremely

Figure 2.1. continued *These items are not included in the total score and are for clinical purposes only.

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helping children with selective mutism and their parents Name of Teacher Who Completed This Questionnaire: ________________________ When responding to the following items, please consider the behavior of your student, __________________, and activities of the past month and rate how often each statement is true. 1.

When appropriate, this student talks to most peers at school. Always

2.

Often

Seldom

Never

Often

Seldom

Never

Often

Seldom

Never

Often

Seldom

Never

When appropriate, this student participates non-verbally in class (i.e., points, gestures, writes notes). Always

8.

Never

When appropriate, this student speaks in groups or in front of the class. Always

7.

Seldom

When appropriate, this student speaks to most teachers or staff at school. Always

6.

Often

When appropriate, this student asks you (the teacher) questions. Always

5.

Never

When called on by his/her teacher, this student answers verbally. Always

4.

Seldom

When appropriate, this student talks to selected peers (his/her friends) at school. Always

3.

Often

Often

Seldom

Never

How much does not talking interfere with school for this student? Not at all

Slightly

Moderately

Extremely

Figure 2.2. School Speech Questionnaire.* *Reprinted with permission.

One set of forms requires children, parents, and teachers to rate the degree of anxiety a child feels each day on a scale of 0–10 (see Worksheets 2.2 to 2.4). Recall that anxiety is a key feature of most cases of selective mutism and reluctance to speak. Young children may be unable to grasp the concept of anxiety or the rating system, so information from parents and teachers can be emphasized. In other cases, young children may understand related words such as nervous or scared and attempt to rate these constructs. Some children also respond better to facial expressions

Assessing Cases of Selective Mutism and Reluctance to Speak

Worksheet 2.2 Child Daily Ratings of Anxiety

DIRECTIONS: Rate your anxiety (nervous, tense, scared, fearful) on a 0–10 scale where 0 = none and 10 = extreme. Use any number from 0 to 10. 0 1 2 3 4 5 6 7 8 9 10 None Some Extreme DATE ANXIETY _____ _________ _____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

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helping children with selective mutism and their parents Worksheet 2.3 Parent Daily Ratings of Child Anxiety

DIRECTIONS: Rate your child’s anxiety (nervous, tense, scared, fearful) on a 0–10 scale where 0 = none and 10 = extreme. Use any number from 0 to 10. 0 1 2 3 4 5 6 7 8 9 10 None Some Extreme DATE _____

ANXIETY _________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

Assessing Cases of Selective Mutism and Reluctance to Speak

Worksheet 2.4 Teacher Daily Ratings of Student Anxiety

DIRECTIONS: Rate the student’s anxiety (nervous, tense, scared, fearful) on a 0-10 scale where 0 = none and 10 = extreme. Use any number from 0 to 10. 0 1 2 3 4 5 6 7 8 9 10 None Some Extreme DATE ANXIETY _____ _________ _____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

_________

_____

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than to numerical scales to rate anxiety, which is perfectly acceptable. Encourage children to supply independent ratings and encourage parents and teachers not to influence their child’s ratings. The other set of forms requires children, parents, and teachers to record the number of words spoken, mouthed, or whispered that day across several situations (see Worksheets 2.5 to 2.7). These situations primarily include school, telephone, and public, but other situations could be added as relevant. Each party also rates, on a 0-10 scale, how audible the child’s speech was for words produced that day, if any. On this scale, 0 reflects the fact that no one could hear the child and 10 reflects the fact that everyone could hear the child. The scale also requires each party to record to whom the child spoke that day. These forms can be quite useful for monitoring daily fluctuations and progress in a child’s audibility and frequency of speech. Young children can complete the forms with help, though in many cases the most useful data will come from parents and teachers. You may wish to chart or graph a child’s daily progress in speaking, especially as you engage in the intervention procedures listed in the next several chapters. These forms could also be used as you conduct behavioral observations of a child (see later section). Feel free to photocopy these worksheets as needed for your case or redesign them to better fit your setting and case.

Measures of Behaviors Most Commonly Associated with Selective Mutism

An important part of your assessment of a child with selective mutism or reluctance to speak is to utilize measures of behaviors most commonly associated with these problems. A full description of all possible relevant measures is beyond the scope of this chapter, but the following sections provide an overview of common, useful, and practical instruments with solid psychometric properties. References for these measures are in the bibliography at the end of the book. Measures of General and Social Anxiety and Depression

General and social anxiety clearly relate to many cases of selective mutism. Depression can be related to these cases as well. Measures of

Assessing Cases of Selective Mutism and Reluctance to Speak

Worksheet 2.5 Child Daily Ratings of Behaviors DIRECTIONS: Record the numbers of words you spoke, whispered, or mouthed today in the following situations. Rate how loud your speech was on a 0 to 10 scale where 0 = no one could hear you and 10 = everyone could hear you. Use any number from 0 to 10. 0

1

2

3

No one

4

5

6

7

8

Some

9

10 Everyone

SCHOOL No. words spoken No. words whispered _______________ _________________

No. words mouthed ________________

Audibility rating _____________

TELEPHONE No. words spoken ______________

No. words whispered _________________

No. words mouthed ________________

Audibility rating _____________

PUBLIC No. words spoken ______________

No. words whispered _________________

No. words mouthed ________________

Audibility rating _____________

DIRECTIONS: Record the people to whom you spoke, whispered, or mouthed today in the following situations, by answering yes or no. Yes indicates that you communicated with the person and no means you did not. Please circle Yes or No. SCHOOL Mouthed

Teacher Yes No

Classmate Yes No

Other Person Yes No

Whispered

Teacher Yes No

Classmate Yes No

Other Person Yes No

Spoken

Teacher Yes No

Classmate Yes No

Other Person Yes No

TELEPHONE Whispered

Family member Yes No

Friend Yes No

Teacher Yes No

Which family member (s)_______________________________ Spoken

Family member Yes No

Friend Yes No

Teacher Yes No

Which family member (s)_______________________________ IN PUBLIC Mouthed

Family Yes No Friend Yes No

Teacher Yes No Other Person Yes No

Whispered

Family Yes No Friend Yes No

Teacher Yes No Other Person Yes No

Spoken

Family Yes No Friend Yes No

Teacher Yes No Other Person Yes No

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helping children with selective mutism and their parents Worksheet 2.6 Parent Daily Ratings of Child Behaviors DIRECTIONS: Record the numbers of words your child spoke, whispered, or mouthed today in the following situations. Rate how loud your child’s speech was on a 0-10 scale where 0 = not at all audible and 10 = completely audible. Use any number from 0 to 10. 0

1

2

3

Not Audible

4

5

6

7

8

Moderately Audible

9

10 Completely Audible

IN PUBLIC No. words mouthed

No. words whispered

No. words spoken

Audibility rating

_______________

________________

______________

_____________

ON THE TELEPHONE No. words mouthed

No. words whispered

No. words spoken

Audibility rating

_______________

________________

______________

_____________

No. words mouthed

No. words whispered

No. words spoken

Audibility rating

_______________

________________

______________

_____________

AT HOME

DIRECTIONS: Record the people to whom your child spoke, whispered, or mouthed today in the following situations, by answering yes or no. Please circle Yes or No. IN PUBLIC Mouthed

Family Yes No Friend Yes No Teacher Yes No Other Person Yes No

Whispered Family Yes No Friend Yes No Teacher Yes No Other Person Yes No Spoken

Family Yes No Friend Yes No Teacher Yes No Other Person Yes No

TELEPHONE Whispered Family member Yes No

Friend Yes No

Teacher Yes No

Spoken

Family member Yes No

Friend Yes No

Teacher Yes No

Family member Yes No

Friend Yes No Other Person Yes No

Whispered Family member Yes No

Friend Yes No Other Person Yes No

Spoken

Friend Yes No Other Person Yes No

AT HOME Mouthed

Family member Yes No

Did your child mouth, whisper, or speak to someone to whom he or she does not normally speak? Yes No If yes, please indicate who and describe the amount and audibility of the words communicated ______________________________________________

Assessing Cases of Selective Mutism and Reluctance to Speak

Worksheet 2.7 Teacher Daily Ratings of Student Behaviors DIRECTIONS: Record the numbers of words the student spoke, whispered, or mouthed today in school. Rate how loud the student’s speech was on a 0-10 scale where 0 = not at all audible and 10 = completely audible. Use any number from 0 to 10. 0

1

2

3

Not Audible

4

5

6

7

8

Moderately Audible

9

10 Completely Audible

No. words mouthed No. words whispered

No. words spoken

Audibility rating

________________ ________________

______________

______________

DIRECTIONS: Record to whom the student spoke, whispered, or mouthed today in the following situations, by answering yes or no. Please circle Yes or No. IN THE CLASSROOM Mouthed

Classmate Yes No

Friend Yes No

Teacher Yes No

Whispered

Classmate Yes No

Friend Yes No

Teacher Yes No

Spoken

Classmate Yes No

Friend Yes No

Teacher Yes No

DURING RECESS Mouthed

Classmate Yes No

Friend Yes No

Teacher Yes No

Whispered

Classmate Yes No

Friend Yes No

Teacher Yes No

Spoken

Classmate Yes No

Friend Yes No

Teacher Yes No

AT LUNCH Mouthed

Classmate Yes No

Friend Yes No

Teacher Yes No

Whispered

Classmate Yes No

Friend Yes No

Teacher Yes No

Spoken

Classmate Yes No

Friend Yes No

Teacher Yes No

Mouthed

Classmate Yes No

Friend Yes No

Teacher Yes No

Whispered

Classmate Yes No

Friend Yes No

Teacher Yes No

Spoken

Classmate Yes No

Friend Yes No

Teacher Yes No

DURING SPECIALS

Did the student speak directly to his or her teacher in the classroom? Yes No If yes, please indicate how many other students were present ____________ (none, entire class, etc.).

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internalizing problems such as these are often assessed via child selfreport measures. I have found that youths with selective mutism are generally willing to complete these measures, though younger children may need someone to read the items to them. Five psychometrically strong and practical child self-report measures of these constructs follow: • Children’s Depression Inventory is a 27-item scale that measures negative mood, interpersonal problems, ineffectiveness, anhedonia, and negative self-esteem. • Multidimensional Scale for Children is a 39-item scale that measures harm avoidance and physical anxiety, separation/panic, and social anxiety. • Screen for Child Anxiety-Related Disorders is a 41-item scale that measures somatic/panic symptoms, general anxiety, separation anxiety, social anxiety, and school-related fear. • Social Anxiety Scale for Children-Revised and Social Anxiety Scale for Adolescents are 26-item scales of social anxiety that measure fear of negative evaluation from peers, social avoidance and distress specific to new situations, and generalized social avoidance and distress. • Social Phobia and Anxiety Inventory for Children is a 26-item scale of social anxiety that contains items surrounding assertiveness, general conversation, physical and cognitive symptoms, avoidance, and public performance. Measures of Oppositional Behavior

Oppositional behavior can also be a feature of selective mutism and reluctance to speak. Most measures of oppositional behavior involve parent- and teacher-based questionnaires and checklists that cover internalizing and externalizing behavior problems. The following have excellent psychometric strength and practicality: • Child Behavior Checklist and Teacher’s Report Form are 113-item measures of several factors of misbehavior: anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior, and aggressive behavior (this scale also has an adolescent self-report version for 11-18-year-olds, the Youth Self-Report). • Conners Ratings Scales (Parent and Teacher Versions-Revised) are 80-item (long version) or 27-item (short version) measures of

Assessing Cases of Selective Mutism and Reluctance to Speak

several factors of misbehavior: oppositional, cognitive problems/ inattention, hyperactivity, anxious-shy, perfectionism, social problems, and psychosomatic (for long version). • Child Symptom Inventory-4 (Parent Checklist: 97 items and Teacher Checklist: 77 items) screens for the following problems: attention deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, generalized anxiety disorder, social phobia, separation anxiety disorder, obsessive–compulsive disorder, specific phobia, major depressive disorder, dysthymic disorder, schizophrenia, pervasive developmental disorder, and motor and vocal tics. Measures of Communication Problems

Recall that some children with selective mutism or reluctance to speak have communication or developmental problems. If you suspect this to be so for a particular child, you should conduct an assessment of the child’s intellectual/achievement and speech/language abilities. Intellectual/ achievement and speech/language assessments for youths with selective mutism and reluctance to speak are obviously going to be a challenge. Many tests have nonverbal scales, however, that allow you to glean some information about a child’s cognitive and language ability. A full description of all relevant measures is beyond the scope of this chapter, so I encourage you to access current textbooks on nonverbal assessment to keep abreast of ongoing developments in this area. Some common, psychometrically strong and useful tests for children with selective mutism and reluctance to speak are described in the following paragraphs. The intelligence/achievement tests listed here are available through major testing companies. The most common intelligence tests for children and adolescents are the Wechsler Preschool and Primary Scale of Intelligence and Wechsler Intelligence Scale for Children. Most children with selective mutism and reluctance to speak will obviously fare poorly on the verbal tasks of these tests, so I recommend utilizing the performance subtests to secure at least a basic understanding of the child’s intellectual capability. Performance or otherwise nonverbal subtests of these measures generally surround perceptual reasoning, working memory, and processing speed. Other measures can also help comprise an intellectual/achievement assessment of a child with selective mutism because some tasks do not require verbal input. For children with selective mutism, nonverbal

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aspects of these tests must be emphasized. For children who are reluctant to speak but may speak to some degree, some verbal aspects of the tests may be possible. The following instruments may be helpful: • Kaufman Assessment Battery for Children-II measures general cognitive ability and achievement; the nonverbal scale of the measure allows students to respond using gestures. • Peabody Individual Achievement Test-Revised measures reading, mathematics, and spelling that requires only a pointing response for most multiple-choice items. • Raven’s Progressive Matrices measure abstract reasoning via multiplechoice tests that require identifying a missing segment of a matrix. • Test of Nonverbal Intelligence-3 measures intelligence, aptitude, abstract reasoning, and problem solving in a nonverbal format that requires only pointing, nodding, or gesturing. • Wide Range Achievement Test-Expanded measures reading comprehension and mathematics and contains a nonverbal reasoning component.

Speech and language assessment is obviously challenging for youths with selective mutism and reluctance to speak. Some researchers recommend the use of written narratives (McInnes et al., 2004), and the nonverbal aspects of the following tests may be helpful as well: • Children’s Communication Checklist-2 is a parent-completed measure of a child’s nonverbal communication, speech, syntax, coherence, semantics, use of context, and other language-based abilities. • Clinical Evaluation of Language Fundamentals-4 measures a wide range of expressive and receptive language skills as well as phonological awareness and other abilities. • Lindamood Auditory Conceptualization Test-3 measures the ability to perceive and conceptualize speech sounds using a visual medium. • Peabody Picture Vocabulary Test-III measures receptive vocabulary by requiring the student to point to correct responses. • Preschool Language Scale-4 measures auditory comprehension, expressive communication, and other language abilities in young children up to age 6 years, 11 months. • Test of Auditory Comprehension of Language-3 measures vocabulary, grammar, and syntax by asking a child to point to correct answers. • Token Test for Children-2 measures receptive language dysfunction by having the child manipulate tokens in a prescribed way.

Assessing Cases of Selective Mutism and Reluctance to Speak

• Utah Test of Language Development-4 measures receptive and expressive language skill. Behavioral Observations

Because your time is very limited (school officials are among the most time-burdened people I know!), I have tried so far to suggest assessment methods that either (1) require as little time as possible, such as interview questions, questionnaires, or worksheets, or (2) can be conducted within the parameters of a normal working environment for schoolbased social workers and psychologists, such as formal testing. Another form of assessment that will be quite valuable for evaluating kids with selective mutism is behavioral observation. Behavioral observation involves watching a child and her parents in a natural setting, such as a home or playground, to obtain information about forms and function of behavior. This assessment method can be time-intensive because, ideally, we want to watch a child long enough to fully understand the mutism problem and what maintains the problem. In other words, we want a good sample of behavior. Observing a child with selective mutism or reluctance to speak does not necessarily have to be complicated given what is usually a limited amount of behavior to watch. If possible, you should observe the child at home, in two or three public situations, and in various situations at school. Conducting behavioral observations at a child’s home and in public situations obviously requires much of your time and energy, but the information will go a long way toward deciding how and where to target your intervention approach. You may see, for example, that a child physically withdraws or shrinks when someone tries to speak to him—this may indicate some social anxiety. Or you may observe a child throw a temper tantrum or scowl when verbally addressed, praised, or asked to do something—this may indicate some oppositional behavior. If you can secure parental consent and conduct a behavioral observation of a child at home, then watch for the following: • Whether and how the child interacts with people she knows well, such as parents, siblings, and relatives who often visit the home (e.g., during games, mealtime, preparations for school). • Whether other family members, especially older siblings, tend to dominate conversations within the home, thus providing little room for the child to speak.

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• Family communications and dynamics such as conflict. • What language is primarily spoken in the home. • Whether the child is expected to answer the telephone or door and if the child avoids such activities. • Whether the child appears to have any communication problem or developmental delay when speaking or otherwise engaging in adaptive behaviors. • Whether the child is disturbed by your presence in the home.

If you can conduct behavioral observations of a child in public situations, then watch for the following: • • • •

The child’s interactions with parents and other family members. The child’s interactions with strangers such as waiters or clerks. Compensatory behaviors. How parents and others respond when a child fails to speak (e.g., accommodations, reprimands, ignoring). • Whether and how parents expect or command a child to speak.

If you can conduct behavioral observations of a child at school, which is strongly recommended, then watch for the following: • Parent–child interactions before, during, and after school. • Teacher–child interactions in class and unstructured settings such as the playground. • Peer–child interactions in class and unstructured settings such as the playground, including if and how peers help convey information to others for the child. • Compensatory behaviors. • Whether the child’s level of speaking behavior differs across situations (e.g., playground versus classroom). • Whether the child is willing to speak to a parent to convey information to people at school. • Specific social or evaluative situations avoided by the child. • Threats or other problems that may lead to a legitimate reluctance to speak. • The child’s performance in academic, social, music/art, and athletic tasks. • Behavior that may indicate anxiety, oppositional behavior, or communication problems. • School refusal behavior.

Assessing Cases of Selective Mutism and Reluctance to Speak

You may be in a situation where extensive behavioral observations such as these are not feasible. If so, then I recommend observing key behaviors in parents and a child as you interview them in your office. Children who are nervous or upset in this situation may have considerable social anxiety. Other children cling tightly to parents and may have considerable separation anxiety or attention-seeking behavior. Still other children show oppositional behavior because they wish to maintain the “status quo” of not speaking in school. I also recommend observing how much a child can be coaxed to speak in various situations at school. This information will help you determine at what point intervention can begin. No “cookbook” strategy exists to indicate exactly what observed behaviors reveal a particular function of selective mutism. You must use your best judgment and supplement your observations with information from other methods described in this chapter. Still, I strongly recommend that you watch for aspects of social anxiety, oppositional behavior, communication problems, attention-seeking behavior, compensatory behaviors, and other key features of selective mutism described in this chapter and in Chapter 1.

Reviewing Records

I recommend reviewing a child’s attendance, academic, and other school-based records to note whether selective mutism has resulted in additional problems. As mentioned, selective mutism can be severe enough to lead to school refusal behavior, can interfere with academic functioning if verbal participation is required, and can preclude attempts at formal testing. Most children with selective mutism are fairly young, however, so discussions with parents and teachers as well as behavioral observations may have already covered these areas.

Putting the Assessment Information Together

This chapter has discussed many different ways to collect information about a child with selective mutism or reluctance to speak. Putting all of this information together, however, can be a bit of a challenge.

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Once you have conducted as thorough an assessment as possible, look for patterns of behavior among your data. For example, are parent reports and your observations of behavior consistent? Does the child’s failure to speak occur in most situations, as might be expected for a case of selective mutism? As you search for patterns in your data, form an opinion about what maintains a child’s selective mutism. Concentrate on the main reasons for selective mutism described in this chapter and in Chapter 1. Consider the possibility as well, especially in more chronic cases, that a child refuses to speak for more than one reason (e.g., anxiety and a communication problem). As you form this opinion, talk again to parents, teachers, and knowledgeable others about your hypothesis and see if they agree. You may find at this point that the picture of a child’s selective mutism is unclear. This may indicate that people cannot supply you with good information because they are not sure what is happening. Recall as well that some parents may not believe their child has a problem. In other cases, parents disagree with one another or parents and children disagree about the forms and function of selective mutism. In these cases, you will have to consider the preponderance of evidence in one direction or another. In addition, your own behavioral observations will become more critical in these kinds of cases. Once the assessment process is as complete as possible, meet with a child’s parents and fully explain your thinking. Provide specific examples of how a child’s behavior is maintained over time as well as evidence of social anxiety, oppositional behavior, communication problems, or other factors that seem to influence the child’s unwillingness to speak. Encourage parents to challenge your findings, but provide as much evidence for your opinion as possible. Finally, provide parents with a rationale for the intervention you decide to choose. If a child’s selective mutism is anxiety-based, then point out how an anxiety management strategy might be helpful (see Chapters 3 and 4). If a child’s selective mutism seems related to oppositional behavior, then point out how incentives and disincentives may be useful (see Chapter 5). If a child’s selective mutism seems related to communication or developmental problems, then point out how a school-based academic program may be helpful (see Chapter 6). If a child’s selective mutism or reluctance to speak seems related to other special circumstances such as trauma, depression, or family issues, then

Assessing Cases of Selective Mutism and Reluctance to Speak

discuss these at length and propose an appropriate remediation plan. Ask parents to commit to whatever strategy you outline and fully answer their questions.

Final Comments and What Is Next

Assessing a child’s forms and function of selective mutism can be arduous, but it is extremely important. In fact, the assessment process should continue throughout your intervention and even beyond. Indeed, extensive monitoring of a child’s frequency and audibility of speech should remain intact indefinitely in cases of selective mutism because slips and relapse can happen (see Chapter 7). This chapter provided you with a general framework and some tools for assessing youths with selective mutism and reluctance to speak, but you must use an approach that is feasible within your particular setting. Even so, focusing on the daily “nuts and bolts” of a child’s behavior is critical. The next two chapters (Chapters 3 and 4) are devoted to exposurebased practice for children whose selective mutism or reluctance to speak seems related to social anxiety, which is the case for most of these children. Chapter 3 focuses on home-based intervention procedures and includes discussions of hierarchy development, relaxation and breathing training, specific exposures, and shaping and prompting. Chapter 4 focuses on community- and school-based intervention procedures and includes further discussions of exposure-based practice, stimulus fading, self-modeling, social skills training, and cognitive work, among other topics.

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3 Exposure-Based Practice: Home Setting

Chase is a 7-year-old boy who rarely speaks at school and even then only whispers quietly to others. His parents are surprised by this behavior because Chase speaks well at home with his older brothers. Chase is now in second grade and still cannot answer questions in class or ask the teacher for help. His grades are average but could be higher if he participated more in academic activities such as the class spelling bee and multiplication teams. He also struggles in music because some verbal repetition of rhythmic patterns is required. Chase clearly seems anxious in these situations, avoiding eye contact and trembling, and an assessment has revealed substantial nervousness before others he does not know well. Ling is a 9-year-old girl in fourth grade who is quite reluctant to interact with others. She moved to this school from South Korea 2 years ago and remains extremely shy and reclusive around others. Ling does speak English well but often keeps her head down in class and rarely speaks, though she does run around with classmates on the playground. Ling’s parents say their daughter seems fine at home and is “appropriately” quiet in public places. Ling will speak on the telephone to people from school but not in person. Her teacher says that Ling seems “petrified” at school, sometimes tearful in class, and is usually the first to leave. An assessment revealed substantial social and evaluative anxiety on Ling’s part.

R

ecall from Chapters 1 and 2 that social anxiety is a key feature of many cases of selective mutism and reluctance to speak. Chase and Ling appear to have aspects of social anxiety such as avoidance, 52

Exposure-Based Practice: Home Setting

trembling, and tearfulness. A key task for you when addressing these kinds of cases will be to help a child lower anxiety to a manageable level, become more comfortable in speaking situations, and speak more audibly and frequently in these situations. Speaking situations primarily involve home, community, and school settings. The key intervention to accomplish these goals will be exposure-based practice, in which a child is required to say words in gradually but increasingly difficult or anxiety-provoking situations. This chapter focuses on exposure-based practice and other techniques in home situations. Chapter 4 discusses exposure-based practice and other techniques in community and school settings. Although you may not be able to conduct intervention in a child’s home or in community settings, doing so may improve the prognosis for a particular child. Speaking at school is usually the most difficult task for many children with selective mutism. Developing rapport and a history of speaking at home and in public settings often ease the intervention process at school. If you feel a school-based intervention is the only available option to you, then you will have to emphasize the procedures described in Chapter 4. You may wish to review this chapter, however, because of its coverage of anxiety, rapport building, and key aspects of intervention in this population. At a minimum, the procedures mentioned in this chapter can be conveyed to parents so that they can practice them at home. The following section provides an overview of anxiety, exposurebased practice, and consultation with parents and the child.

Overview of Anxiety

To best implement the interventions discussed in this chapter and the next chapter, it is necessary to understand the different aspects of anxiety and how exposure-based practice is designed to work. Anxiety refers to worry, uneasiness, discomfort, nervousness, dread, or apprehensiveness about something; in this case speaking before others in a clear and audible voice. Children may show anxiety or distress in different ways, such as crying, withdrawal, clinging, tantrums, irritability, restlessness, and trembling.

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Anxiety is composed of three main parts. One part of anxiety is physical feelings of distress such as aches, trembling, shaking, “butterflies” in the stomach, and shortness of breath or hyperventilation (breathing too quickly). Recall that Chase seemed to have some physical aspects of anxiety and that Ling was tearful in class. A second part of anxiety is uncomfortable thoughts or worries a child may have, especially about something bad happening. Anxious children are often apprehensive, and children with selective mutism may have concerns that others will react negatively in some way to their voice or to what they say. A third part of anxiety is a behavioral component, or what a child does when anxious. Many anxious children avoid situations or withdraw from people so they can reduce or eliminate anxious feelings. Chase withdrew from participation in the class spelling bee, for example. Children with selective mutism often avoid speaking to others or attending events that require extensive social interaction. Such avoidance is often designed to reduce anxious feelings––think of someone who is terrified of the dentist and then cancels a scheduled appointment and feels great relief. Such relief rewards the avoidant behavior, which is likely to be repeated in the future. Some children with selective mutism may not speak in order to reduce the physical aspects of anxiety. Recall from Chapter 1 that many children with selective mutism display the first and third aspects of anxiety––physical feelings of distress and avoidance of speaking. Some may have uncomfortable thoughts or worries about speaking, but young children, especially those with selective mutism, typically do not express these thoughts. Some of these thoughts may become apparent as a child begins to speak more frequently, so addressing these thoughts later in the intervention process may be a good idea (more information on this is provided later in this chapter). Recall also that social anxiety or failure to speak on the part of a child with selective mutism must not be the result of a legitimate threat at home, school, or elsewhere. Children who are silent to avoid maltreatment, who are intimidated by peers at school, or who are bullied or otherwise threatened by classmates will not respond well to the exposure-based techniques described in this chapter or the next chapter. Instead, the threat must be removed prior to your intervention. Some children will continue to have difficulty after a threat is removed, so exposure-based practice may then be more appropriate. The following is an overview of exposure-based practice.

Exposure-Based Practice: Home Setting

Overview of Exposure-Based Practice

Recall from Chapter 1 that exposure-based practice refers to a collection of techniques that requires a child to say words in gradually but increasingly difficult or anxiety-provoking situations. Exposure-based practice is designed to help a child replace anxious feelings in a specific situation with more relaxed feelings. In addition, exposure-based practice is designed to increase a child’s self-efficacy by gradually building her ability to speak clearly and audibly in different situations. Once a child becomes comfortable speaking in one situation, this ability can be generalized to another, more difficult situation. This process continues until the child can speak well in all situations. Exposure-based practice occurs along a hierarchy of situations that range from least to most anxiety-provoking in nature (or least to most difficult). Most children with selective mutism can speak fairly well at home, with low anxiety, so intervention often begins here. A schoolbased mental health professional may begin by speaking with the child at home and then gradually extend this process to other situations such as community settings. The process can continue over time to include various school-related situations as well. Exposure-based practice can also involve a hierarchy whereby a child mouths words, then whispers words, then speaks words softly, and then speaks words with full volume in these situations. Exposure-based practice is sometimes combined with methods to help a child reduce physical aspects of anxiety. Recall from Chapter 1 that relaxation training and breathing retraining may be used to help children manage physical aspects of their anxiety. Some children respond to these relaxation exercises quite well and others do not, but the techniques are portable and are easily learned in a nonverbal manner. A child may practice the relaxation techniques as he is exposed to each speaking item on the hierarchy. Over time, exposure-based practice should help a child decrease social anxiety and increase her ability to speak more frequently and audibly in various situations. Exposure-based practice thus helps you address two main components of anxiety: the physical feelings of distress and the avoidance of speaking. As mentioned, cognitive or thinking aspects of anxiety can be addressed later in the process of exposure-based practice.

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helping children with selective mutism and their parents Consultation with Parents and the Child

Conduct a detailed consultation with the parents and the child (if possible) regarding your assessment findings, a description of anxiety, and a rationale for exposure-based practice. When discussing your assessment findings, concentrate on behavioral patterns you have found in the data (see Chapter 2). If you have determined that a child’s selective mutism relates closely to social anxiety, then focus on which aspects of questionnaires, worksheets, observations, or other assessment data support your claim. You may wish to discuss particular anxiety sequences that seem most relevant to a child. Concentrate on multiple, specific, and recent examples from the child’s behavior. Consider Reginald’s case, for example: Reginald is an 8-year-old boy who has many concerns about attending school and speaking to others at school. His mother says Reginald seems irritable and shaky in the morning before school and reportedly has stomachaches and feels sick on some days. She drives her son to the playground before school, at which time Reginald clings to her and cries softly. Reginald does enter class after some reluctance but will not speak to teachers or peers at school. He appears nervous in class, and an assessment reveals several aspects of social anxiety, especially around people Reginald does not know well. He has asked his mother to place him in a home schooling program.

Reginald’s sequence of anxiety appears to begin with physical feelings such as shakiness, stomachaches, and irritability. For many children, these physical feelings are quite uncomfortable and naturally lead to behaviors designed to reduce them. For Reginald, clinging to his mother, subtle school refusal behavior, the desire to be home-schooled, and of course failure to speak in class represent behavioral aspects of his anxiety (see Fig. 3.1). Reginald may have cognitive aspects of anxiety as well, such as those listed in Figure 3.1, but again you may not be able to access these at this early point in the intervention. A child’s anxiety sequence can be illustrated and presented to parents and the child for review. You should encourage the child and parents to disagree with you if their observations differ radically from yours. If necessary, collect additional information from family members to modify your view of the child’s anxiety sequence. Most importantly,

Exposure-Based Practice: Home Setting

Physical component of Reginald’s distress

Shakiness and stomach pain; irritability; feeling sick

Possible cognitive component of Reginald’s distress

I don’t want to go to school; I don’t want to talk to people there; I hate being in class

Behavioral component of Reginald’s distress

Reluctant to go to school; not speaking; crying; wants home schooling

Figure 3.1. Illustration of Reginald’s sequence of anxiety.

be sure all relevant family members fully understand the sequence you outlined because the sequence will serve as the rationale for the intervention you will propose. Specifically, you will recommend to family members that each component of the child’s anxiety––particularly physical and behavioral components––be addressed so the child can speak fully in all situations. Use this sequence to convince family members to address each aspect of anxiety and encourage family members to commit to a plan of action. You should also convey to family members the need to practice all interventions described in this chapter. The analogy I commonly give

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to children and parents is that managing anxiety involves learning a new skill. Ask the parents to give you an example of a skill the child has recently learned, such as riding a bicycle or playing a song on the piano (the child may also communicate a recently acquired skill via writing or whispering to parents). Ask the family members to describe the learning process, which surely required some adult help at the beginning as well as some pratfalls. With practice, however, the child was able to complete the skill more independently. The same is true for anxiety management. Initially, speaking to others and managing upsetting feelings will be difficult. With practice, however, speaking to others will become much easier. Once everyone is on the same page, outline the expected course and timeline of your intervention. The general course of intervention will include hierarchy development (discussed next), relaxation training and breathing retraining, and home-based exposures. Home-based exposures involve requiring the child to interact with you in his home at various levels such as whispering, using soft voice, and using full volume voice. Later exposures will involve community- and schoolbased settings (Chapter 4). The timeline of your intervention is hard to predict––some cases are resolved in just a few weeks, some take several months, and some require very intense intervention for an extended period of time. Explain to parents and the child that the intervention will require substantial effort on their part but that frequent practice generally leads to quicker results. The intervention will likely last at least several weeks and possibly several months. We have noticed in many of our cases, however, that once a child begins speaking clearly in one situation, speech quickly generalizes to other situations. Of course, your case will be affected by many different variables such as parent motivation, how often you can visit the home, other behavior problems in the child, and teacher willingness to help implement the exposure-based procedures (see the special issues section in Chapter 7).

Developing a Hierarchy

A key first step in exposure-based practice is developing a hierarchy. A hierarchy is a list of items that range from least to most anxiety-provoking or least to most difficult for a child to speak audibly. Hierarchies are

Exposure-Based Practice: Home Setting

important for structuring the exposure-based process and provide you, parents, teachers, and the child with a “roadmap” for how treatment will progress and what the end stage will look like. Hierarchies typically begin with relatively easy tasks such as asking a child to speak to someone in his bedroom or in another area of the home. As the intervention continues, greater expectations are gradually placed on the child to speak in more difficult situations. As mentioned, hierarchies can also involve types of speech, such as mouthing words, whispering, speaking softly, and speaking with full volume. Let us consider Austin’s case and then develop a sample hierarchy. Austin is a 6-year-old boy in first grade who has never spoken in school. He spoke rarely in an academic preschool but his parents simply considered their son to be shy. Austin speaks well at home with his older brother and younger sister but relies on his parents to communicate for him in public places. Austin will speak softly to others on the telephone but only for 30 seconds or so. Austin’s teacher says that Austin does interact to some extent with classmates on the playground but that he stays by himself in class. An assessment by the school psychologist revealed normal intelligence and achievement functioning for Austin but also a diagnosis of selective mutism. Some anxiety features were also noted. For example, Austin seems to shake and lowers his head when others try to speak to him.

Austin would seem to be a good candidate for exposure-based practice because his selective mutism appears to contain elements of social anxiety. Developing a hierarchy for Austin should involve input from his parents and teachers and possibly from Austin himself. Items on the hierarchy should start in situations where Austin is relatively comfortable and will speak to others, such as home. A sample hierarchy for Austin is shown in Figure 3.2. You can see that Austin’s least difficult items are at the bottom of the hierarchy and his most difficult items are at the top of the hierarchy. This is only a sample. You will have to design your own hierarchy for the child you are addressing, which may or may not include these steps. In addition, some of these sample steps must be subdivided for some children. A child may have great difficulty making the transition from (1) speaking to a school official in a public place and (2) speaking to the official at school. In this case, smaller steps may need to be added, such

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Speaking situations

Anxiety Avoidance Rating Rating

1. Reading aloud to all classmates and the teacher or engaging in show-and-tell

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2. Speaking to the teacher in the classroom, such as asking or answering a question or requesting help

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3. Speaking to peers in the classroom during small group activities or during free time as appropriate

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4. Speaking to a school official in Austin’s classroom with all classmates present plus the teacher

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5. Speaking to a school official in Austin’s classroom with ten classmates present plus the teacher

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6. Speaking to a school official in Austin’s classroom with five classmates present plus the teacher

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7. Speaking to a school official in Austin’s classroom with two friends and the teacher sitting at his or her desk

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6 4

5 4

10. Speaking to a school official in his or her school office

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11. Speaking in a public place to a clerk or waiter, such as ordering food or asking for directions or time

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12. Speaking in a public place to a school official without family members present

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14. Speaking at home in person with a school official

3 2

2 2

15. Speaking at home on the telephone with a school official

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8. Speaking to a school official in Austin’s classroom with two friends on the other side of the room 9. Speaking to a school official in Austin’s empty classroom

13. Speaking in a public place to a school official with family members present

Figure 3.2. Sample hierarchy for Austin’s speaking behavior.

as speaking to the school official in the school parking lot or school entrance prior to speaking in the office. Items from the hierarchy should come naturally from your assessment, but work closely with parents and teachers to finalize and finetune the hierarchy. Ask parents, teachers, and the child to supply ratings of anxiety and avoidance to each hierarchy item if possible (see Fig. 3.2). On a 0– 10 scale, where 0 = none and 10 = an extreme amount, try to glean average ratings of the child’s anxiety and degree of avoidance for each hierarchy item. Doing so will help you organize and prioritize the items. If this is not possible or workable, then simply consult with parents and teachers to generally organize the hierarchy items from least to most difficult. In some cases, you may have to develop a sample

Exposure-Based Practice: Home Setting

hierarchy yourself for a particular child and present it to the parents for review. If so, the hierarchy presented for Austin could serve as a basic template. Austin’s hierarchy could also contain speaking steps within each item. These steps could involve aspects of speech that range from mouthing to whispering to soft speech to full-volume speech. Consider, for example, the item surrounding speaking to you at the child’s home. In this case, initial speaking could simply involve mouthing words in an effort to communicate. Subsequent sessions with the child could involve asking him to gently whisper in your ear or, at a minimum, to speak to someone else in an effort to communicate with you. Greater expectations are then placed on the child for each session. Austin may eventually be required to whisper softly in your ear, perhaps even just a word or two, and later whisper more words or two or three sentences. After that, Austin would be expected to speak softly to you and eventually speak frequently and audibly as he does with his parents and siblings. An example of this mini-hierarchy for this item is illustrated in Figure 3.3. Be sure that all parties agree to the hierarchy before proceeding. Parents and teachers should be fully aware of what the hierarchy looks like and agree to provide support for the exposure-based practice

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Speaking all words audibly and clearly to the school official Speaking most words audibly and clearly to the school official Speaking 1 or 2 words audibly and clearly to the school official Speaking all words softly to the school official Speaking most words softly to the school official Speaking 1 or 2 words softly to the school official Whispering all words to the school official Whispering most words to the school official Whispering 1 or 2 words to the school official Whispering to others in the presence of the school official Communicating vocally but not verbally, such as grunting, making high-pitched sounds, or using incomplete words such as “eh” for yes and “un” for no 12. Communicating nonverbally but mouthing words or phrases such as “hello” or “please” 13. Communicating nonverbally or without mouthing words or phrases (e.g., writing words in the air, pointing, gesturing) 14. Communicating by writing or drawing on paper

More difficult ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ Less difficult

Figure 3.3. Sample minihierarchy for Austin’s speaking behavior to a school official at home.

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to come. Children can also be made aware of the hierarchy, though their input and understanding is not as necessary. Also keep in mind that the hierarchy is fluid, meaning it could change as the intervention proceeds. You may find that you will need to (1) add steps to the hierarchy, such as those smaller steps described previously, (2) change the hierarchy based on how the child is responding and whether familybased changes or other changes occur, and (3) skip steps if the child is progressing well. Regarding the latter, some children respond quickly to exposure-based practice and may not require extensive practice of some steps on the hierarchy. Once the hierarchy has been developed and sanctioned by everyone, a good next task is to teach the child to relax. Methods of relaxation training and breathing retraining are described next. These relaxation exercises are also a good way for you to help establish rapport with a child with selective mutism. The techniques can be taught without the need for verbalizations on the child’s part and allow you and the child to get to know each other a bit better.

Breathing Retraining and Relaxation Training

Recall that many children with selective mutism and reluctance to speak have physical aspects of anxiety that need to be reduced. These physical feelings often trigger distressing thoughts and avoidance behaviors such as failure to speak. Therefore, helping a child control her physical feelings of anxiety is important. Different methods of helping a child control physical feelings are available, but only the most feasible, portable, and time-efficient are presented here. Two methods in particular involve managing one’s breathing and engaging in progressive muscle relaxation. Breathing

A simple way to help children reduce physical feelings of distress is to teach them to breathe correctly. Many children experience shortness of breath, breathe shallowly, or hyperventilate when upset. Doing so actually makes the feeling of anxiety worse, so helping a child regulate breathing is important. Have the child sit before you in a comfortable position. Then ask the child to breathe in slowly through the nose (with

Exposure-Based Practice: Home Setting

mouth closed) and breathe out slowly through the mouth. As the child does so, encourage him to breathe deeply into the diaphragm (between the abdomen and chest and just below the rib cage). The child may need to push two fingers into the diaphragm to experience the sensation of a full, deep breath. The child can then breathe slowly out of his mouth. Parents may even join the process to help their child practice at home. For younger children such as Austin, you may wish to create an image during the breathing technique. Austin could imagine blowing up a tire or pretend he is a large, floating balloon. As Austin breathes in, he can imagine filling up with fuel and energy. As he breathes out, he can imagine losing fuel or energy (or tension). The child must come to understand the difference between feeling tense when the lungs are full of air and feeling more relaxed after breathing out. The following breathing script adapted from Kearney and Albano (2007) may be helpful: Pretend you are a hot air balloon. When you breathe in, you are filling the balloon with air so it can go anywhere you want. Breathe in through your nose like this (show for your child). Breathe slowly and deeply––try to breathe in a lot of air! Now breathe out slowly through your mouth like air leaving a balloon. Count slowly in your head as you breathe out…1…2…3…4…5. Let’s try this again (practice at least three times).

Key advantages of the breathing method are its ease, brevity, and portability. The child can use this method in different stressful situations and usually without drawing the attention of others. I recommend that a child practice this breathing method at least three times per day for a few minutes at a time. In addition, the child should practice in the morning before school and during particularly stressful times at school. Some children benefit as well by practicing this technique whenever they are around other people and an expectation for potentially speaking is present. For example, a child could use the breathing technique prior to and during a church service. Muscle Relaxation

Another method of helping a child reduce physical feelings of anxiety is progressive muscle relaxation (PMR). Youths such as Austin are

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usually quite tense in different areas of their body, especially in the shoulders, face, and stomach. Different methods of muscle relaxation are available, but a preferred one is a tension-release method in which a child physically tenses, holds, and then releases a specific muscle group. For example, a child may ball his hand into a fist, squeeze as tightly as possible and hold the tension for 10 seconds, and then suddenly release the grip (try it). When this is done two or three times in a row, people generally report feelings of warmth in the muscle as well as relaxation. Muscle relaxation via tension-release can be done in different ways. When I work with children, I use a relaxation script that covers most areas of the body. I first ask the child to sit in a comfortable position and close her eyes. I then read the script slowly and ask the child to participate. You may wish to use the following script adapted from Ollendick and Cerny (1981) with a child: (Speaking slowly and in a low voice) Okay, sit down, try to relax, and close your eyes. Try to make your body droopy and floppy, as if you are a wet towel. Take your right hand and squeeze it as hard as you can. Hold it tight! (Wait 5 to 10 seconds.) Now let go quickly. Good job. Let’s do that again. Take your right hand and squeeze it as hard as you can. Hold it. (Wait 5 to 10 seconds.) Now let go quickly. See how that feels. Nice and warm and loose. Now take your left hand and squeeze it as hard as you can. Hold it tight! (Wait 5 to 10 seconds.) Now let go quickly. Good job. Let’s do that again. Take your left hand and squeeze it as hard as you can. Hold it. (Wait 5 to 10 seconds.) Now let go quickly. See how that feels. Nice and warm and loose. Now shrug your shoulders hard and push them up to your ears. Make your shoulders really tight. Hold them there. (Wait 5 to 10 seconds.) Now let go quickly. Great. Let’s do that again. Shrug your shoulders hard and push them up to your ears. Make your shoulders really tight. Hold them there. (Wait 5 to 10 seconds.) Now let go quickly. Great job. Now scrunch up your face as much as you can. Make your face seem really small and tight. Now hold it there. (Wait 5 to 10 seconds.) Now let your face go droopy. Good. Let’s do that again. Scrunch up your face as much as you can. Make your face seem really small and tight. Now hold it there. (Wait 5 to 10 seconds.) Now let your face go droopy. Good job.

Exposure-Based Practice: Home Setting

Now I want you to bite down real hard with your teeth. Make your jaw really tight. Hold it there. (Wait 5 to 10 seconds.) Now open your jaw. How does that feel? Good. Let’s try that again. Bite down real hard with your teeth. Make your jaw really tight. Hold it there. (Wait 5 to 10 seconds.) Now open your jaw. Try to make it as loose as you can. Good practicing! Let’s go to your stomach now. Bring in your stomach as much as you can––make it real tight! Press it against your backbone. Now hold it there. (Wait 5 to 10 seconds.) Now let go quickly. That feels better. Let’s try that again. Bring in your stomach as much as you can––make it real tight! Press it against your backbone. Now hold it there. (Wait 5 to 10 seconds.) Now let go quickly. Great job. Okay, one more. Push your feet onto the floor real hard so your legs feel really tight. Push hard! Now hold it. (Wait 5 to 10 seconds.) Now relax your legs. Shake them a little. Let’s try that again. Push your feet onto the floor real hard so your legs feel really tight. Push hard! Now hold it. (Wait 5 to 10 seconds.) Now relax your legs. Shake them a little. Good practicing! Now try to make your whole body really droopy––pretend you are a wet towel! Relax your whole body and see how nice that feels. You did a great job relaxing. Okay, open your eyes.

You may wish to audiotape this script so a child can play it back when practicing. I recommend that a child practice this script at least twice per day in the beginning of your intervention and then once or twice per day as he becomes more adept and independent. In addition, the child could practice the method during times of the day when she feels most distressed. Austin could practice relaxation as he speaks with you at school or in his home. The idea is to replace anxious feelings with more relaxed ones so the child may feel more comfortable speaking.

Other Recommendations Regarding Relaxation Training

Because of time constraints, you may wish to teach a child relaxation techniques immediately after developing the anxiety hierarchy (see earlier section). In addition, you may wish to teach breathing and

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muscle relaxation at one time so the child can use one or both immediately. Some children prefer one approach over the other, which is fine. The important thing is that a child practice and use the techniques as soon as possible. In situations where time is highly constrained, using breathing and partial muscle relaxation may be preferred. In partial muscle relaxation, you or the child chooses one or two areas of the child’s body that are particularly tense and the child practices the tension-release method only on those areas. Austin, for example, may say his shoulders and stomach are tensest when asked to speak. To save time, therefore, you could concentrate your efforts on these two areas only. If time is very short, then you could recommend commercially available breathing and relaxation tapes. In addition, you could help a child practice relaxation techniques during times you know he is particularly distressed at school. Helping a child relax in your office immediately before class, for example, might be feasible. You may also need to solicit the help of teachers who can take an anxious child aside and help her practice relaxing.

Home Visits and Exposure-Based Practice

Now that you have developed a hierarchy and helped a child with the relaxation training exercises, the real heart of the exposure-based practice begins. Most of your early exposures with a child will be conducted within the child’s home, but there may be some preliminary exposures you could do to ease this process. As mentioned, some children with selective mutism or reluctance to speak will communicate to others as long as they do not have to endure face-to-face contact. Your assessment should indicate what these situations are, but common examples include the following: • Speaking on the telephone. • Speaking to someone with a door or other obstruction in between. • Speaking to someone from a far distance, such as across a parking lot. • Emailing or otherwise sending a video of yourself speaking to someone. • Communicating in nonverbal ways such as writing an email or texting.

Exposure-Based Practice: Home Setting

Recall that the first item on Austin’s hierarchy was speaking at home on the telephone to a school official (you). The school official could arrange times to speak to Austin on the telephone, preferably during times when he is most relaxed, such as on the weekend or right after dinner. The conversation could be kept to light topics such as current school events, pets, dinner, and play activities. These conversations do not have to last long––perhaps a few minutes or so. Intermittent praise and gratitude should be provided to the child to reward the speaking behavior. Such exposures can be quite helpful for establishing rapport and setting the stage for the next set of home-based exposures. These conversations or communications can serve as a springboard for conversation within the home. For example, you may ask the child to show you his dogs that he described at length on the telephone. The child could point, nod, or shake his head to yes–no questions, and comply to requests to interact with the dogs in some way. Again, the major goal here is to replace anxiety about speaking with a greater comfort level. The first stage of face-to-face (in vivo) exposure-based practice is best conducted within a child’s home where he feels most comfortable and has a history of speaking well to others, albeit to those the child knows well. Arrange with the parents a suitable time to spend 60–120 minutes at their home. Inform the parents that you will be interacting with the child in his bedroom or another area of the house in which the child and the parents feel most comfortable. Try to arrange regular home visits as well––preferably once or twice a week if possible. Some children and parents prefer a Saturday morning or other time of the week when they are not so rushed, so consider their input on this issue. The child should be fully informed by you or by his parents that you will be visiting and talking and playing with him – no surprises. Parents should also convey the expectation to the child that he is to interact with you at least nonverbally while you are there. If the child refuses to do so, then specific contingencies should be given (see Chapter 5). I fully understand the difficulties, extensive resources, logistical and safety issues, and administrative obstacles that may be associated with home visits. I do strongly recommend home visits but understand that, for some locales and circumstances, this is simply not feasible. If this is the case, then emphasizing exposure-based practice in public or just

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school-based situations (Chapter 4) may be necessary. If you can conduct home visits, then the following sections apply. Initial Home Visits

Your initial set of home visits should be relatively unstructured and carefree for the child. I recommend simply playing with the child either by imitating what he is doing (e.g., building something out of blocks) or by inviting him to play a game or draw together. In our experience, most children are willing to do this, but some kids may require more time and patience. Gently prompt the child to show you something he is doing and encourage him to use nonverbal ways of communicating such as pointing or gesturing. These nonverbal methods of communicating will eventually be faded, but they are allowable for now. Try to establish good eye contact with the child as well and smile at him. Refer again to the sample mini-hierarchy developed earlier for Austin (Fig. 3.3). Initial home visits may concentrate on the lower items on this hierarchy: communicating by writing or drawing on paper, communicating nonverbally, and communicating vocally but not verbally. You can begin to encourage the child, as you play with him, to communicate to you by writing words in the air, pointing, gesturing, or via other nonverbal means. The child may already be doing this on his own, so smiling and offering praise is a good idea. You can also encourage the child to communicate to you by using his mouth to form words such as “hello,” “please,” and “bye.” You may wish to model this for the child. You should reward any vocal communications the child may present such as grunting, high-pitched noises, or incomplete words. These vocalizations will be extinguished later in your intervention, but the sounds do give you the opportunity to praise the child’s voice and his attempt to communicate at a rudimentary level. Tactics that often work for my cases include using substantial humor to make kids laugh out loud and asking kids to hum a favorite song. A child who engages in regular vocalizations such as these at this level may verbalize quickly in later sessions. As you interact with the child, pay close attention to how he responds to your presence. Does he seem tense and uncomfortable or relaxed and nonchalant? If the child seems tense, offer to do the breathing and muscle relaxation exercises you taught him earlier (if applicable).

Exposure-Based Practice: Home Setting

Do not push the child to do so, but I have found that most kids are willing to do the exercises. Gently praise the child for engaging in the exercises and smile often. Be sure to thank the child for allowing you to play with him and do the exercises together. Remember that the initial home visits, perhaps two or three or so, are simply designed to help the child acclimate to your presence in the home. You will hopefully become someone the child is comfortable being around, especially because you are being associated with a comfortable setting (child’s house or bedroom). Remember that the purpose of exposure-based practice is to replace tense or anxious feelings about communicating with more relaxed feelings. You may find during these initial home visits that feedback to the parents is necessary as well. You may have to ask the parents, for example, to avoid hovering around you and the child, quell siblings or other noisy distractions in the home, or supply materials for play or drawing. If parents do wish to observe from a distance, this is fine because it allows you to serve as a good model for their later behavior with the child (see Chapter 5). In particular, you will model how to talk to the child without criticism or lecturing, how to gently encourage speech, and how to praise speech appropriately. As mentioned, you may need to devote two or three home visits simply to interacting nonverbally with a child, but this timeline is not set in stone. Some children, especially those simply reluctant to speak, will acclimate to your presence quickly and may even speak to you in the first session at home. Other children require more early home visits to become comfortable with you, and that is fine. As noted earlier, intervention for some children with selective mutism can last several months. Intermediate Home Visits

As the child appears to be more comfortable with your presence in the home, you can begin to gradually increase expectations for speech. Refer again to Figure 3.3 and items 4–10 on the hierarchy – these items will constitute the bulk of your intermediate home visits. The main goals of these visits are to help the child begin to whisper words and phrases and then speak softly to you. This is where shaping and prompting, initially discussed in Chapter 1, become important. Recall that shaping refers to reinforcing successive approximations of a desired

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response, in this case more audible speech. Prompting refers to gently prodding a child to use words to communicate, speak more articulately and loudly, establish eye contact, and extend the duration of speech. As you play and otherwise interact with the child, see if she will respond to subtle prompts to whisper words. Such whispering can initially be low-key and indirect, such as asking the child to whisper something in a parent’s ear that the parent then conveys to you. This is acceptable for now. Be sure to thank the child for communicating to you and respond by speaking directly to her. If possible, have the child extend the amount of information conveyed to a parent to simulate an actual conversation. Be animated in your responses, such as laughing, smiling, and otherwise injecting humor into the “conversation.” Once the child is comfortable with this process, then shaping and prompting can be used to help the child utilize speech directly toward you. This part might be a little tricky. Be sure to tell the child that you expect her to begin whispering to you directly but that she may choose which words or phrases to use. The child may also be allowed to whisper softly in your ear, whisper with her head turned to the side, or whisper to the floor. As this process continues and the child’s comfort level grows, then you can gradually build eye contact, smiling, and other social nuances. One thing we commonly do to elicit whispers is to deliberately make mistakes during games played with the child. Think of a game that requires a roll of the dice and movement of a game piece, for example. If you roll a “5” on the dice, you could move your piece the incorrect number of spaces (e.g., 1 or 9 spaces––something obvious). Most young children are quite attentive to the rules of the game and will become annoyed by this kind of error. If the child is trying to nonverbally convey a sense of unfair play, then “play dumb” and encourage the child to say what she wants to. At this point, remind the child to use words and that it is necessary to at least whisper to you what it is she wants to say. Some children will pout or throw something, but ignore inappropriate behavior and simply continue playing the game as if nothing happened. Following are some additional tactics you can use to try to solicit whispers or beginning speech: • Ask a child how a game is played. Many children are quite adept at a certain game and are eager to share the rules, so take advantage of this. Asking yes–no questions and receiving a verbal “yes” or “no” response at this point is acceptable.

Exposure-Based Practice: Home Setting

• Concentrate on topics of conversation a child is most willing and eager to discuss, especially pets, siblings, and favorite foods, toys, activities, and television shows. • Have the child say what reward she would like for interacting with you. You might bring stickers or candy and ask the child to indicate which one she would like, contingent on verbal speech. The child at this point cannot be allowed to simply point but must, at a minimum, whisper in your ear which item she wants. Failure to do so means no reward is given, and the child can be encouraged to try harder during the next visit. • Use puppets; ask the child to speak to the puppet rather than to you directly, and have the “puppet” praise the child for speaking. You will need to eventually fade the stimulus (puppet) in favor of having the child speak directly to you. • Alter your proximity and eye contact. Some children find it easier to speak initially if your face is turned from them, if your eyes are lowered, or if you sit on the other side of the room. You may also choose to speak to the child only when looking at something else, such as when you roll dice or flip a spinner for a game. Eye contact can be gradually increased as the sessions continue. • Make mistakes in your knowledge that the child may wish to try to correct. For example, you could give the wrong name for the child’s sibling or dog, say the child’s incorrect favorite color or game, or say it is raining when actually it is sunny. • To help increase audibility, blame the child’s inability to convey speech adequately on your inability to hear her due to some environmental stimulus such as an airplane flying overhead or siblings making noise in another room. This allows you to absolve the child of blame but, at the same time, prompt speech again at a higher volume level.

Later Home Visits

Later home visits involve items at the top of a mini-hierarchy (see again Fig. 3.3). These visits involve requiring the child to speak clearly and audibly to you, beginning with one word, then several words, and then all words. The goal of these later home visits is to reach a point where you and the child can have positive, extensive, and clearly audible conversations. In addition, the child should be quite comfortable with these conversations. Being able to converse freely with a child at this

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point will be a strong lead-in to the more difficult exposures to come in public and school settings. Your conversations with a very young child––a 5-year-old for example––will necessarily be quite brief. If the child can describe some things to you, such as a picture she drew, that is fine. The conversation could primarily involve the child speaking to you, but the conversation should not be dominated by your speaking. Continue to practice the relaxation and breathing exercises if applicable and reward the child often––via praise or tangible rewards––for speaking to you. Continue as well to model for the parents how speech is encouraged and prompted (see also Chapter 5). Later home visits should set the stage for community- and schoolbased exposures (Chapter 4). During these visits you should remind the child and the parents of the next steps on their hierarchy, such as going to malls and restaurants and talking to people at school. Remind the child and parents that this will be a gradual process and that practice is required to learn new skills (e.g., anxiety management, social interactions, using an audible voice). Be sure as well to express confidence that the child can do these things given her progress and work during your home visits.

Final Comments and What Is Next

This chapter focused on many of the initial intervention steps you may need to address a child with selective mutism or reluctance to speak. Chapter 4 covers various procedures to help a child speak in more challenging situations outside the home. These challenging situations involve community-based settings such as malls and restaurants as well as school-based settings such as the playground and classroom. As you navigate these situations with a child, other supportive techniques will be implemented. These include self-modeling, stimulus fading, and social skills training, among others.

4 Exposure-Based Practice: Community and School Settings

Avery is a 7-year-old girl who has been in second grade for 3 months but will not speak in school. She has attended her current elementary school since the beginning of first grade but does not speak to peers or teachers. Her parents say Avery seems like a shy and normal child who speaks clearly and well at home. Avery’s comments in public places, however, are limited and people usually say they cannot hear what Avery says even when she does attempt speech. Avery’s parents have resisted intervention in the past but now recognize that their daughter’s failure to speak is affecting her academic and social performance. An assessment indicated some social and evaluative anxiety on Avery’s part. She does interact nonverbally with children on the playground, but their games have become more complicated and dependent on speech. Avery has thus grown more socially withdrawn in the past several weeks.

R

ecall from Chapter 3 that a key aspect of intervention for children such as Avery with anxiety-based selective mutism or reluctance to speak is exposure-based practice. Exposure-based practice refers to a collection of techniques that requires a child to say words in gradually but increasingly difficult or anxiety-provoking situations. Exposurebased practice is often accompanied by relaxation training, hierarchy development, and shaping and prompting to increase the frequency and audibility of speech (Chapters 1 and 3). This chapter focuses much more on exposure-based practice in community and school situations. If you were able to conduct home visits and exposures there (Chapter 3), then hopefully you have established a good rapport and a speaking foundation with the child. If not, then you may need to begin exposure-based practice at the community 73

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setting level. Community settings include places such as malls, restaurants, parks, church events, and entertainment facilities. If you were able to conduct home-based exposures, then the procedures described in this chapter are a natural next step. If you were not able to conduct home-based exposures, then I recommend establishing good rapport with a child by meeting with him frequently in your office or in a community setting where he feels comfortable. Some of the procedures described in Chapter 3 can be modified and replicated in your office, such as relaxation training, hierarchy development, and telephone and play-based exposures. The goal of these office-based interactions is to have the child become comfortable speaking with you, learn how to relax, and replace anxiety in speaking situations with greater comfort while increasing frequency and audibility of speech. These interactions will hopefully set the stage as well for the communitybased exposures to follow. This chapter outlines hierarchy development for community- and school-based exposures, exposure-based practice in these settings, and accompanying techniques such as self-modeling and stimulus fading. Intervention strategies that can be used in conjunction with exposurebased practice are also discussed. These strategies include social skills training and cognitive intervention. Let us proceed next with hierarchy development using Avery as our primary example throughout the chapter.

Hierarchy Development

Recall that a hierarchy involves a list of speaking-related situations that range from least to most anxiety-provoking or least to most difficult in nature. Various hierarchies can be developed during exposure-based practice, and hierarchies can include levels of speaking such as mouthing, whispering, speaking softly, and speaking in a normal tone. Recall from Chapter 3 that we designed a hierarchy for Austin that included various situations and a mini-hierarchy that more specifically focused on different expectations for speaking within the home. We can use a similar approach for Avery. We want to focus on community and school settings, so it makes most sense to have two hierarchies. The first hierarchy can include public situations (see Fig. 4.1). Avery’s parents indicated from their assessment that their daughter

Exposure-Based Practice: Community and School Settings

Speaking situations* 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Anxiety Rating

Avoidance Rating

Asking a stranger in a public place for the time or for directions 10 9 Using 2 or 3 sentences to order food from a waiter or clerk 8 Answering a question during Sunday School class Speaking to several potential friends (unknown peers) at 8 soccer practice or a birthday party or other social event Speaking to one potential friend (unknown peer) at soccer 7 practice or a birthday party or other social event 7 Greeting others (known and unknown) at church 6 Speaking to potential friends (unknown peers) at a park 6 Using one word to order ice cream from a clerk Speaking to friends at soccer practice or a birthday party 4 or other social event 4 Speaking to parents and siblings at the mall 3 Speaking to parents and siblings at church 3 Speaking to neighborhood friends at a park 2 Speaking to neighborhood friends in your driveway 2 Speaking to parents in a public place such as a market Answering the door or telephone at home 1

10 9 9 8 8 7 6 5 4 3 3 2 2 2 1

*Items may be divided as necessary into levels of voice volume such as mouthing words, whispering, speaking softly, and speaking in a normal tone; items may be reordered as necessary; items may be added or divided as necessary.

Figure 4.1. Sample hierarchy for Avery’s speaking behavior in community settings.

commonly fails to speak in places they frequently visit. These include restaurants, parks, malls, birthday parties, church, and other places where Avery might be expected to interact with parents, siblings, peers, family friends, or clerks. These public situations, and various levels of speech within these situations, may comprise a good hierarchy. You can see from Figure 4.1 that lower-level items generally involve potentially easier tasks such as speaking within one’s home on the telephone, speaking to parents and siblings in some public settings, and speaking to neighborhood friends the child knows well in familiar situations such as their driveway or a nearby park. Middle items surround forays into speaking with others using limited speech or in situations such as church in which the child is slightly less comfortable. Higher items surround more difficult tasks such as using more words (sentences), speaking to people more independently, and speaking to people the child does not know. Any item may be divided as necessary—Avery, for example, might initially use just one sentence to order food from a waiter instead of two or three sentences. This is perfectly acceptable as

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long as she eventually completes the full hierarchy item (i.e., two or three sentences). The second hierarchy can include school situations and may rely heavily on the hierarchy developed in Chapter 3 for Austin, with some embellishments (see Fig. 4.2). Note that the classroom-based exposures at the middle and top of the list (items 1–9) are the same—these hierarchy steps are often essential when addressing kids with selective mutism or reluctance to speak. The hierarchy steps near the lower part of the list (items 10-15) are new and specific to Avery. Many children with selective mutism are more willing to initially speak to you in relatively quiet and familiar surroundings such as your office or other settings outside the classroom. I strongly recommend beginning your exposures away from the classroom, which has likely been associated with significant anxiety for a child. Instead, begin exposures in situations that generally cause the child less anxiety, such as the playground, and especially areas in which no one is around. Once a child is comfortable in these situations, you can ease him into the classroom and gradually add others as he speaks. The sample hierarchy in Figure 4.2 is Speaking situations

Anxiety Avoidance Rating Rating

1. Reading aloud to all classmates and the teacher or engaging in show-and-tell 2. Speaking to the teacher in the classroom, such as asking or answering a question or requesting help 3. Speaking to peers in the classroom during small group activities or during free time as appropriate 4. Speaking to a school official in Avery’s classroom with all classmates present plus the teacher 5. Speaking to a school official in Avery’s classroom with ten classmates present plus the teacher 6. Speaking to a school official in Avery’s classroom with five classmates present plus the teacher 7. Speaking to a school official in Avery’s classroom with two friends and the teacher sitting at his or her desk 8. Speaking to a school official in Avery’s classroom with two friends on the other side of the room 9. Speaking to a school official in Avery’s empty classroom 10. Speaking to a school official in the cafeteria with others present 11. Speaking to a school official in an empty school cafeteria 12. Speaking to a school official in the library with others present 13. Speaking to a school official in an empty school library 14. Speaking to a school official in his or her school office 15. Speaking to a school official on the playground at school

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6 4 4 3 3 2 3 1

5 4 3 3 2 2 4 1

Figure 4.2. Sample hierarchy for Avery’s speaking behavior in school settings.

Exposure-Based Practice: Community and School Settings

a general one that could contain many more items specific to the needs of a child, so feel free to add items as necessary and in conjunction with your assessment findings. Keep in mind that some kids will need to engage in nonverbal interactions with peers and teachers before any verbalizing is possible. Some children, for example, prefer to complete class projects with peers, point or gesture to answer a teacher’s question, or write on the blackboard or complete some other task before the entire class before speaking can be prompted. Other children have already done these things, albeit nonverbally, and so exposures for speaking can occur sooner. Avery did interact with her peers nonverbally but was starting to show some social withdrawal. Prompting Avery to reengage her peers at least nonverbally for now might be a good idea. Note that the hierarchies in Figures 4.1 and 4.2 contain anxiety and avoidance ratings that can come from one or more sources. If a child can rank these items for you, then consider these rankings with others received from parents, teachers, and yourself. If the child cannot rank these items, which is often the case for younger children, then rely on others’ reports or rank the items yourself based on assessment data. In some cases, you will need to develop the hierarchy yourself and present it to parents for review. In other cases, you may have little assessment data on which to rely and may use the hierarchies presented here as a general template for intervention. Recall as well that mini-hierarchies can be designed to address voice volume. Each step on the hierarchies in Figures 4.1 and 4.2 could include smaller, subdivided steps that focus on mouthing words, whispering, speaking softly, and speaking with normal voice volume. Hierarchies are fluid entities, meaning frequent changes usually occur during exposure-based practice. Some children become stuck on one step and need considerable practice, and other children zip through multiple hierarchy items in a short time. Be flexible in your approach as you engage in exposure-based practice and understand that the expected timeline could shift unexpectedly.

Exposure-Based Practice in Community Settings

Exposure-based practice in community settings can hopefully flow naturally from home-based exposures discussed in Chapter 3. That is,

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community exposures will involve your supervision and interaction with the child, ongoing rapport development, prompts for speaking in progressively more difficult situations, and continued practice of relaxation and breathing exercises. You should review with parents and the child the rationale for exposure-based practice in community settings. Again, the goal is to help the child feel more comfortable in these settings and gradually increase the frequency and audibility of his speech in less difficult and then more difficult situations. In addition, the community-based exposures are to serve as practice for more difficult school-based exposures later on. Initial Community-Based Exposures

Your first set of community exposures should be in fairly close proximity to the child’s house. The child at this point should be comfortable speaking to you within his home, so a good first step is to have him talk to you outside of his home. Examples include the backyard, courtyard, driveway, or even a few steps from the front door. Most children will be able to make this transition fairly easily, though you may need to prompt some additional speech and volume and use some of the tactics discussed in Chapter 3 (e.g., alter your proximity and eye contact, make mistakes in your knowledge, blame the inability to hear the child on environmental stimuli). Keep the conversations light, perhaps asking the child to describe the neighborhood and what he commonly does and with whom he interacts (e.g., neighborhood friends). In conjunction with these conversations, have the child practice answering the door or telephone, which is sometimes an easier step on the hierarchy. The child should be familiar with you at this point, so you can call him on the telephone for chats and practice coming to the door, ringing the doorbell, greeting him, and providing him with feedback about what he can say, his volume level, and other relevant behaviors such as eye contact. Be sure to practice these tasks until the child becomes proficient and seems at ease. Have the child practice relaxation and breathing exercises (Chapter 3) as appropriate to reduce anxious arousal. Your next step in the community-based exposure process will be to systematically approach each item on the child’s hierarchy. Refer again to Figure 4.1. Initial steps on the hierarchy usually involve asking a child to speak to people he knows well such as parents, but in situations

Exposure-Based Practice: Community and School Settings

where he does not commonly speak such as a local market. The exposures to follow will be somewhat structured, meaning you will conduct the exposure with the parents, child, and relevant others such as friends or other peers. Sometimes this requires effort with respect to scheduling, so take advantage of normally occurring events. If parents shop for groceries on Saturday afternoon, for example, then this would be a good time for a naturally occurring exposure session. Note that hierarchy item number 14 for Avery is “speaking to parents in a public place such as a market.” For this exposure, explain to parents and the child what is expected from everyone. You, at least one parent, and the child will go to the market and shop for groceries (choose a place that is well-known to the child). During the shopping experience, the child is expected to say at least one word to her parent—the word can be any she chooses and can initially involve a whisper or barely audible expression. The child must say the word to her parent during the normal shopping time—no special time extensions should be given. Speaking success should be met with praise and tangible rewards and failure to speak should be met with admonishment and loss of privilege (see Chapter 5). The child should be prompted for speech and reminded of this obligation several times during the exposure. The child can also practice relaxation and breathing exercises as needed. This exposure may require several practices, many of which the parents can accomplish on their own as homework assignments during the week. You need not be present for all exposures. Once the child has met the criterion for speaking one word, then expectations for speaking in this setting should increase. The child should eventually be expected, for example, to say a few audible words and later a few sentences to his parents in the market. Be sure that parents carefully track the number of words spoken (see forms in Chapter 2) and that consequences are administered consistently (see Chapter 5). Intermediate Community-Based Exposures

The next set of exposures on the child’s hierarchy can occur in similar fashion. Avery’s next set of exposures involve talking to familiar neighborhood friends near her house and at a park near her house. Some kids want less formal supervision (i.e., less hovering) during these exposures, so you or the parents can stand several feet away to monitor the child’s progress. In some cases, you may find it beneficial to inform the friends

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about what you are trying to do and encourage them to prompt the child for speech. Again, expectations for speech can be initially low (e.g., one word, whisper) but must progress to at least two or three sentences of audible speech before moving to the next hierarchy item. Your demeanor (and the demeanor of the parents) during these exposures should be nonchalant, neutral, and matter-of-fact. Some kids will balk at increasingly difficult exposures at this time, so use subtle phrases such as “You can do it,” “You know what you need to do,” or “You need to use your words.” Do not attend to disruptive, noncompliant, or defiant behaviors. Instead, consequences for failing or refusing to speak should be established previously, should be known to the child, and should do your talking for you (or the parents) (see Chapter 5). Do not criticize, lecture, berate, or adopt a negative tone with the child. In addition, be patient and pleasant during these exposures, repeatedly prompting the child to fulfill his speaking obligation for that day. I have found that many kids with selective mutism eventually “wear down” after an hour or two and fulfill their obligation during the exposure. Middle items on Avery’s hierarchy also involve speaking to people she knows well (parents, siblings, friends) in a wider array of settings (church, mall, soccer practice, birthday party). The goal is to have the child practice speaking in various situations to achieve a sense of selfefficacy, manage anxiety appropriately, and receive praise and feedback for speaking. Split the hierarchy items into two or three smaller steps if necessary and continue to ask the child to describe how anxious she feels. Continue to help the child practice relaxation and breathing techniques to lower arousal. These lower and middle items set the stage for the much more difficult community-based exposures to come. Make sure the child is proficient at these levels before proceeding. As mentioned earlier, the timeline for these exposures may be several weeks or months, though some children progress well and quickly. Trying to progress too quickly, however, without adequate practice at this intermediate level, will damage the chances for success in the even more difficult exposures discussed next. Later Community-Based Exposures

Higher items on the community-based exposure hierarchy generally involve greater independence, discussions with less familiar people, and

Exposure-Based Practice: Community and School Settings

speaking before a larger number of people. Refer again to Avery’s hierarchy in Figure 4.1. As you engage in these more difficult exposures, try to make them as natural as possible. That is, the exposures can be less contrived (such as the market) and blended more into situations the child normally encounters during the week. Family members who regularly attend church, for example, often meet and greet people before and after the service. Such interactions could also serve as subtle exposures for the child. Consider an example of a naturally occurring exposure with a natural consequence for speaking that involves taking a child to an ice cream parlor. In this situation, the child is required to use one word to convey to the clerk the type of ice cream he wants. The child could, for example, say “cone” or “bowl” or “chocolate” or any other general descriptor— adults at this stage are allowed to fill in the rest of the description for the child as he points to what he wants. The important point to convey to the child is that speaking will result in ice cream and that no speaking will result in no ice cream. Parents must then refrain from giving ice cream to a child who fails to speak, so this type of exposure is recommended only if you are confident the parents can comply with your instructions. This type of exposure often requires some repetition. I have found that most clerks are quite patient and willing to prompt a child for speech, so sending a child up to the counter for several attempts at speaking is often feasible. Other difficult steps on the hierarchy include speaking to or greeting other people less known to the child, such as potential friends at a park or birthday party or to adults at church. Give the child suggestions ahead of time regarding what words or statements he can make to others. Some kids need only say “hello” and “hi” during initial exposures or answer yes–no questions audibly. A child should always be prepared for different social situations by having options for what he can say to others (see also the social skills training section later in this chapter). The highest or most difficult items on Avery’s hierarchy (Fig. 4.1) involve more proactive speaking, such as approaching others or volunteering to speak. A good exposure for Avery is answering a question during Sunday school class because this may help facilitate later exposures in her regular classroom setting. I strongly recommend conducting exposures at this point that will at least partly mimic what will occur next in school-based situations. Examples include initiating speech with

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others, speaking with sentences and not simply single words, and speaking before larger numbers of people. A common exposure I often end with at the community level requires the child to approach strangers to ask for the time or for directions. Obviously this is done only under your supervision or parental supervision. The exposure requires the child to excuse himself, establish eye contact, clearly and audibly ask for time or for directions, and thank the person for their information. I have found that most strangers are willing to accommodate a child’s request, although you and parents must always judge the safety of the situation (I prefer a college campus). In addition, I have found that a child’s success in each of these steps greatly facilitates school-based exposures, which are described next.

Exposure-Based Practice in School Settings

The final step of exposure-based practice is often the most difficult and involves school settings. Hopefully you have been able to conduct home- and community-based exposures to help facilitate school-based interventions, but I recognize you may not have been able to because of administrative, logistical, legal, safety, or other constraints. If your intervention can begin only at the school level, then I still recommend teaching the child to engage in muscle relaxation and proper breathing (Chapter 3) and constructing a hierarchy of speaking-related situations at school. Another technique that may serve as a good preamble to exposurebased practice at school, especially if this is where you must begin the intervention, is self-modeling. Recall from Chapter 1 that self-modeling involves asking parents to audiotape or videotape a child as he speaks clearly and well in a comfortable situation such as the home. The recording is then replayed in a low-frequency speaking situation such as your office at school. As you play the recording, give the child substantial verbal praise or tangible incentives to reward the clarity, volume, and beauty of her voice. The child is essentially viewing herself as a model for appropriate and audible speech. The process is also aimed at rewarding speech, easing discomfort, and helping a child recognize that no negative consequences will result from speaking publicly. Some children are initially resistant to self-modeling, so you may need to include parents, allow a child to sit several feet away, ignore

Exposure-Based Practice: Community and School Settings

tantrums or other misbehavior, or avoid eye contact with the child. Repetitive self-modeling should ease a child’s resistance with time and allow you to develop better rapport. You may wish to continue selfmodeling during the hard work of school-based exposures. Selfmodeling may be a good technique, for example, when first interacting with the child in his classroom. The following sections discuss schoolbased exposures at different levels. Initial School-Based Exposures

Initial school-based exposures can follow naturally from later communitybased exposures that required a child to speak before or to others in some context outside the home. I recognize, however, that school-based exposures may be the first exposures you are able to conduct with a child. In either case, I recommend conducting initial school-based exposures that are somewhat removed from the child’s classroom, which is usually the most difficult place to increase speech. You may need to enlist the help of parents who can initially serve as a mediator between you and the child. Refer again to Figure 4.2 and the school-based hierarchy for Avery. You can see that the initial exposures involve discussions with you in an area that is hopefully less anxiety-provoking for the child, such as your office or the school playground. Other examples include the school bus loading area, the school bus itself, a courtyard, or even an area near the school campus if necessary. Exposures in these settings should generally match what was done at home and in community settings—help the child relax, discuss simple and fun topics, and prompt and reward speech and audibility. I strongly recommend conducting these exposures when few if any other children are around. You could, for example, conduct the exposure after school, during the morning when the playground is empty, or on weekends or very early in the morning. Remember that a child may need several sessions and many prompts before adequate speaking occurs. Do not progress to the next step until a child is quite proficient at speaking with you in a given setting. Once a child can speak to you well in these settings, which are relatively external to the main school complex of classrooms, the next set of exposures can occur within the heart of the school (but still outside the classroom). Examples include the school library, gymnasium, cafeteria,

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or even hallways. As the child engages in these exposures, she will continue to attend class and be allowed to interact with classmates and peers nonverbally. The child should be reminded, however, that she is expected to eventually speak well and independently in class and to people there. This can be the point in the school-based exposure process at which stimulus fading can begin. Recall from Chapter 1 that stimulus fading refers to systematically increasing the difficulty of an exposure by fading in new stimuli such as verbal academic tasks, peers, or teachers. Your initial exposures can include situations outside and inside the main school complex and with you and the child alone. Once the child can speak to you well in these situations, then other stimuli can be added to make the exposure more challenging. If you have shaped and prompted good speech at the playground, for example, then you can begin exposures there when just a few other children are around. These children may be off in the distance playing but later can move closer to you and the child. Over time, playground exposures can systematically include more children and greater proximity. Young children will be naturally curious about your attempts to help a child speak and will often offer to “help.” Take advantage of this as appropriate. For example, you could ask the peers to stand 20 feet away, then 10 feet away, and then 3 feet away as you conduct your exposures. You can also vary what the peers are doing, to whom they are speaking, and what they can say to the child. You may also have to adopt firm rules about what the peers are allowed to do when you are in the middle of an exposure. Stimulus fading can occur during your exposures within the main school complex as well (see Fig. 4.2). For example, you could ask a child to speak with you in the school cafeteria when just a few other people are around and gradually progress to busier times. You could also begin exposures in an empty hallway and gradually work your way up to times of the day when there is more foot traffic. A child could initially speak to you as well in the library and later read to you while other kids or teachers are present. Keep in mind that you should also increase the length of your exposures as the child progresses. A child may be able to read to you in the library for only a minute or so at first, but this can gradually be increased to 2, 5, and 10 or more minutes. The idea is that you are always “pushing the envelope” with the child, always prompting more

Exposure-Based Practice: Community and School Settings

speech, more audible speech, and speech that occurs in a normal social context with others around. Always see if the child is willing to give you just a bit more, but recognize as well when a child seems tired, frustrated, unmotivated, or upset about continuing. You may also choose to conduct two or three “mini-exposures” throughout the day. All of these initial school-based exposures set the stage for what might be your toughest battle: the classroom. School-based exposures in the classroom should progress in two main stages. The first stage involves developing speech in a fairly empty classroom or one that has only a few people in it. The second stage involves developing speech in a full classroom, especially within the context of expected academic activities such as reading aloud to classmates. The first stage is referred to here as intermediate school-based exposures and the second stage is referred to here as later school-based exposures. Intermediate School-Based Exposures

Your first exposures with a child within the classroom can generally follow some items listed on the hierarchy in Figure 4.2. Avery’s schoolbased social worker, for example, initially brought Avery into her classroom during a recess period when no one was there. She asked Avery to show her where her desk was, identify pictures on the wall that were drawn by her, and point out favorite books and class projects. She also asked Avery to practice again the relaxation and breathing techniques discussed in Chapter 3. The idea here was to lower Avery’s anticipatory anxiety about speaking in her classroom, associate her classroom with greater relaxation and less pressure, and continue to develop rapport. The first two or three sessions within the classroom can be nonverbal and relaxed. Intermediate school-based exposures will largely involve interacting with the child in the empty classroom and then gradually fading in more stimuli. So, your first few sessions are simply an extension of what you did earlier – have the child converse with you, read to you, talk about favorite class activities or peers, and answer your questions. Be sure to specifically praise the child for speaking in his classroom, something Avery and many of these kids have never done before. Keep in mind that this step can be quite difficult, so patience and ongoing practice may be necessary. Initial sessions within the classroom can be short and then perhaps extend to an entire recess period.

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Your next set of exposures involves stimulus fading. Note Figure 4.2, items 4–8, as an example. Avery was asked to speak to the social worker in her classroom as two classmates sat on the opposite side of the room. Let the child choose which classmates, hopefully good friends, initially sit in the classroom. The peers should be specifically instructed to remain quiet during your work with the child – they can read silently, complete school work, or play on the computer, for example. You can generally ignore the peers as you interact with the child, but you should praise the child for speaking to you with others present. You can also make the exposures more challenging by asking the peers to gradually sit closer to you and the child. Two caveats here. One, some kids prefer that the teacher be the first person to be in the room as they speak, and this is perfectly acceptable as long as the teacher is willing. Two, if peers are employed during the exposure, spontaneous social interactions could occur later. For example, the peers may be excited that the child spoke and tell others, may try to converse with the child once the exposure is done, or may compliment the child on his voice. These are not necessarily bad things, but some kids with selective mutism are uncomfortable about the added attention. You may find it necessary to include instructions to the teacher and peers about what they should (and should not) do following exposure sessions. Once Avery became comfortable with this scenario and was speaking appropriately to the social worker, more stimuli were faded into the situation. Avery’s next step was to speak when the teacher and two friends were in the classroom, then speak with the teacher and 5 classmates present, then speak with the teacher and 10 classmates present, and then speak with the teacher and all classmates present. The latter exposure can be conducted any time class is in session. In this scenario, you simply work with the child in a corner of the room as she reads or otherwise interacts verbally with you. If the child responds well to spontaneous reinforcement from others, then point out how her voice and speech create positive reactions and that nothing bad is happening (see also the cognitive intervention section later in the chapter). Later School-Based Exposures

Your last set of school-based exposures should mimic academic and social activities that children are expected to engage in during class time.

Exposure-Based Practice: Community and School Settings

Note that Avery’s hierarchy items in this regard included speaking to peers in the classroom during small group activities and during free time, asking and answering questions in class and otherwise speaking clearly to the teacher, and reading aloud to classmates or engaging in center-of-attention tasks such as show-and-tell. Later school-based exposures sometimes progress very quickly because some kids generalize speech to other situations with ease. Other kids demand a more measured, structured, careful, and time-consuming approach. Allow a child to choose a classroom-based activity during which he would like to speak first. Some kids choose interactions with a teacher and other kids choose group activities with peers because they can blend in better and not necessarily be the center of attention. Either option, or another suitable and equivalent one, is fine. Your exposures during these activities can be less formal and direct – you may wish, for example, to stand several feet away and prompt speech or give feedback as necessary. You may also wish to further engage peers who can prompt and reward a child’s speech. For these exposures the child should have some good ideas about what she can say to teachers and others (see next section on social skills training). You may wish to role play with a child some statements she can make to peers, questions she can ask others in class, and appropriate methods of responding to requests and statements from others. You can also help a child practice speaking before others by subtly reminding them to lift her head, maintain eye contact, and speak audibly. You may wish as well to surreptitiously monitor a child’s conversations with peers and others during recess time, lunchtime, and in special classes such as music and physical education. The final steps to school-based exposure should involve regular practice speaking to peers and teachers throughout the school, perhaps generalizing to school staff members, custodians, and other school personnel. The idea is to help a child reach a point where speaking to others is a natural and reinforcing event, not one that continually has to be prompted and reinforced. Pay close attention as well to the child’s academic and social status, especially the child’s ability to make and keep friends. The child should be emphasizing verbal interactions and not compensatory behaviors by the end of your exposure program (see Chapter 5). Finally, you may need to engage in relapse prevention strategies that are covered in greater detail in Chapter 7. Following is a description of interventions that may be employed in conjunction with exposure-based practice.

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Many kids with selective mutism or reluctance to speak have not spoken to other kids, at least in public settings, either most of their life or for a long time. Once a child is speaking with other kids following your exposure-based practice, it may be necessary to help expand his social skills to some degree. Some children with selective mutism may already have good social skills, so this step may not be necessary in all cases. Other children with selective mutism either do not have good social skills or simply do not have much practice using their good social skills with others (recall Avery’s recent withdrawal from others). Once a child is speaking regularly, you should be able to determine which scenario applies. If you feel a child could benefit from some training in social skills, refer to the basic template for doing so described next. Social skills training largely involves learning a new skill, so the rationale for exposurebased practice also applies here—that a child will need to practice how to interact with others, initially with some help and later more independently. The goal is to help a child speak well to others, but in an effective way to form and keep friendships. A social skills training approach largely consists of modeling, practice, and feedback in a repetitive cycle. Modeling in this case refers to having a child watch socially skilled peers engage in key behaviors such as establishing eye contact and conversing. The best models for a particular child are those close to the child’s age and may include siblings, relatives, neighbors, classmates, or other peers. Ideally, these children should be those the child knows fairly well and with whom the child is comfortable. These models should be socially skilled and not overly shy and must be willing and able to carry out whatever social practices you ask them to do. A basic modeling scenario is to have the child with whom you are working observe two children (models) having a conversation. The models can talk about whatever they want as long as they are polite to one another and make good eye contact with each other. The conversation should be brief, perhaps less than a minute, and could even be videotaped to show the child afterward. Ask the child to pay close attention to whatever skill you decide to focus on first, such as eye contact. If necessary, ask the models to repeat their conversation a couple of times as the child watches.

Exposure-Based Practice: Community and School Settings

An important next step is practice. Once a child sees how others perform a certain skill, she is asked to practice the skill herself. This early practice can come with some help in the form of a very brief session. The child may be asked to have a short conversation with one of the peers for perhaps 10 seconds or so. Instruct the child that what she says is not as important as establishing eye contact and making sure her voice volume is sufficient. Practicing social skills is also a way to reinforce skills learned for speaking frequently and audibly to others. Social skills training can thus be partly an extension of exposure-based practice. The other important part of social skills training is feedback. Feedback refers to information given to a child about how a skill is performed. As your student models and practices different social skills, feedback from you, teachers, parents, and others will be important to correct major flaws or help the child understand what needs some minor adjustment. Feedback should also include much praise for the child’s efforts and successes. Some children who have emerged successfully from selective mutism will need to practice many different social skills. Important social skills and a brief summary of ideas when addressing these skills are listed in Table 4.1. Social skills can also be practiced in situations in which the child learned to speak better, such as ordering food in a restaurant. Social skills training may also involve helping a child recognize and label his emotions and the emotions of others and to take the perspective of others. Social problem solving has also been used by some researchers to specifically assist children with selective mutism. O’Reilly and his colleagues (2008) treated selective mutism in two sisters aged 5 and 7 years. Their intervention involved collaboration between a therapist and teacher. The teacher provided the therapist with a lesson plan for class that day as well as five questions the teacher would ask (from the study, for example: “If I had 12 bananas and a monkey ate 7, how many bananas would I have left?”). The therapist then role played the lesson and suitable answers with the children as well as social rules such as speaking clearly in class. The children evaluated their responses and noted how others responded to them, such as the teacher expressing praise. Practice over 21 observation sessions resulted in substantially more audible responses to teacher questions. The study was helpful in showing that elements of exposure-based practice and social skills training could be blended to increase appropriate speech in the classroom.

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helping children with selective mutism and their parents Table 4.1 Suggestions Regarding Important Social Skills in Children

Accepting invitations from others for play or other social interaction → Maintain eye contact and smile, ask what others are doing, say “thank you,” and begin to play Accepting praise and compliments from others → Maintain eye contact and smile, say “thank you,” perhaps offer a compliment to the other person in return Answering the door or telephone → Clearly say “hello” or “how can I help you?,” maintain good distance, take a message Asking others for help or information → Know exactly what information is needed, ask appropriately (“Excuse me”), be clear in asking for help Being assertive in saying “no” or when asking for something → Make eye contact, be brief in saying no, state your intention clearly and with good voice volume Calling someone on the telephone or inviting someone for a fun activity → Speak clearly and articulately, know ahead of time what the topic is, use manners Controlling impulses and anger instead of acting on them quickly → Count silently to 10, relax the body, exit the situation appropriately, talk to someone Cooperating with others in a game or project → Use manners, take turns, engage in small conversation, thank others for playing Dealing with being sad or anxious → Relax the body, think about difficult thoughts, understand that the feeling is temporary, talk to someone Dealing with embarrassing or stressful situations such as teasing → Ignore the provocation, walk away, go to a safe area, talk to someone if the teasing is severe Delaying gratification, such as completing schoolwork before playing or television → Schedule a time to do homework, focus on the future reward of doing the work first, praise yourself for waiting

Exposure-Based Practice: Community and School Settings

Eating appropriately around others → Chew food slowly, speak when your mouth is empty of food, relax your body, listen to others Giving affection → Know the right situation to give affection, know what kinds of affection are acceptable and to whom, keep affection small in scope, mix affection with compliments Greeting others appropriately → Say “hello” and smile, keep your head up, speak articulately and with good voice volume Identifying emotions in yourself and others, such as happiness, sadness, fear/anxiety, and anger → Watch your body posture and facial expressions, listen to statements made by a person, study the context of the situation (what is happening around the people involved) Initiating and maintaining conversations with others → Think about the topic on which you want to focus, make eye contact, speak clearly, ask questions Introducing yourself or other people → Use an appropriate greeting, select a good time, use a full sentence, follow-up with questions Joining activities with peers → Introduce yourself, ask others if they want another person to join, speak clearly and with confidence Keeping your head up when speaking to others → Maintain eye contact with the person, smile, maintain the conversation, ask questions Listening to others appropriately → Nod your head occasionally, maintain eye contact, smile, do not interrupt Maintaining eye contact with others during a conversation → Keep your head up, watch the facial expression of the person talking, smile Maintaining personal hygiene and grooming → Wash and brush your teeth appropriately, dress nicely, use deodorant, comb your hair, fix your clothes Continued

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helping children with selective mutism and their parents Table 4.1 cont’d

Ordering a meal in a food establishment → Keep your head up, maintain eye contact, speak articulately and with good voice volume, listen attentively to the person taking the order Performing athletically before others → Stay involved with the group activity, try doing your best, talk to others, have fun Refraining from interrupting or inappropriately touching other people → Maintain eye contact, wait for the other person to stop talking, maintain appropriate distance (2 to 3 feet) from the person talking Refraining from rude behaviors such as yelling, insults, sarcasm, or hitting → Watch your own behavior closely, use manners, listen carefully, control anger Resisting group pressure to do something inappropriate → Think about whether someone is asking you to do something inappropriate, say “no” clearly, give a reason for saying no, walk away from the situation, avoid tempting situations Resolving conflicts with others → Negotiate solutions to problems without force, listen carefully to others’ opinions, think about all sides of the problem, develop a solution agreeable to everyone Sharing feelings appropriately → Discuss feelings when you are not angry, use manners, speak articulately and listen carefully to others’ reactions Speaking articulately → Speak slowly and pronounce each syllable clearly, maintain eye contact, watch others’ reactions, speak with good voice volume Speaking in a clear and audible tone of voice → Speak slowly, listen to yourself to see if your voice volume is strong, maintain eye contact, watch others’ reactions Speaking or reading before others → Speak slowly and articulately, speak with good voice volume, relax your body, practice beforehand, be well prepared

Exposure-Based Practice: Community and School Settings

Taking the perspective of other people → Actively observe and listen to others, think about what others may be thinking and feeling in a certain situation, ask others what they were thinking and feeling Taking turns when playing a game → Wait patiently, smile, thank others for playing and for your turn, be gracious in winning or losing Using manners → Make eye contact, use “please,” “thank you,” and “excuse me” appropriately in complete sentences, watch others’ reactions Writing before others → Relax your body and fingers, write slowly and carefully, focus on the task at hand

Addressing Problematic Thoughts about Speaking

As mentioned in earlier chapters, some children with selective mutism or reluctance to speak may have maladaptive thoughts or worries about speaking before others. Most young children will not or cannot say what bothers them about speaking, so pressing the issue with them is unnecessary and can even be counterproductive. Other children, however, will discuss their concerns about speaking once speech is developed, especially with you. If this is the case, then there are some steps you can take to address the child’s worries. Your first step would be to ask the child several questions. Some of these questions are general and some are specific: • What do you think about when you speak to someone? • Do you think bad things will happen when you speak to someone? • How does your body feel when you speak to someone? Do you worry about blushing or feeling nervous? Do you think about how your body feels when speaking to someone? • Do you worry someone will laugh at you, tease you, or make fun of you if you speak to them? • Do you worry you will look foolish or dumb if you speak to someone? • Do you worry you will be ignored by others if you speak to them?

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• Do you worry others will make you do things you do not want to do if you speak to them? • Are you afraid to speak to others because you do not know what to say?

These are sample questions. You may have to ask more specific questions or other questions depending on the circumstances surrounding the child you are addressing. If a child is worried that bad things will happen if she speaks, such as being ridiculed by others, first make sure this is not actually happening. If a child is ridiculed for speaking or some other negative consequence is occurring, then this situation must be resolved first. I have found that most peers and classmates are generally quite supportive of a young child who is speaking to them for the first time, but it is possible some adverse event has occurred. Consultations with teachers and peers will be important in this process to resolve problematic circumstances that prevent a child from speaking. Once you have discovered the primary worry a child has about speaking, and found that no legitimate reason exists for the worry, then work with the child to allay the concern. There are several general methods for doing so, especially for younger children: • Discuss with the child the likelihood that someone will laugh at them for speaking and concentrate on the number of times (hopefully near zero) that this has actually happened. Use this latter number to help predict the poor likelihood of this happening in the future. • Discuss with the child what should be done if indeed he is ridiculed for speaking; the child should certainly inform the teacher, avoid socially isolated situations, and play with supportive peers. • Talk to the child about how he cannot know ahead of time what will happen when he speaks to others; he should not try to guess how people will react. • Talk to the child about how embarrassment is a temporary and manageable condition; any discomfort he has about speaking will be short-lived (will go away soon) and can be handled. • Talk to the child about the fact that speaking does not always mean you will have to do something you do not want to do, such as chores. • Remind the child that practice speaking to others will help her become a better talker and that other people will generally respond positively (e.g., smile, return compliments); help the child think

Exposure-Based Practice: Community and School Settings

about topics for discussions with peers such as movies, school projects, family activities, and pets.

If you are addressing a child with substantial concerns about speaking, and the child is willing to discuss these concerns with you, keep in mind that these methods will need to be conducted on a regular basis. Try to involve parents and others as well in this process so the child receives accurate information about the consequences of speaking. Parents and others should also continue to praise the child for speaking in public situations and occasionally remind the child that speaking led to positive outcomes (e.g., receiving food, smiles from others) and not negative outcomes (e.g., no one laughed or screamed at the child after she spoke).

Final Comments and What Is Next

Exposure-based practice is typically an essential aspect of intervention for children with selective mutism or reluctance to speak, especially children with substantial general or social anxiety. Recall from earlier chapters that some children with selective mutism have oppositional tendencies as well, perhaps refusing to speak in public and school situations. A primary focus of Chapter 5 is contingency management, or establishing incentives and disincentives for speaking and refusing to speak, respectively. A contingency management approach is useful for addressing oppositional tendencies and is helpful for rewarding youths who follow through on exposure-based practice. Contingency management can also be used to help parents create greater structure in the home and to reduce compensatory behaviors common to this population.

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5 Contingency Management

Brody is a 6-year-old boy with selective mutism who actively refuses to speak in any situation outside his home. Brody’s parents claim their son speaks fine at home but does seem particularly defiant about speaking in public. They tried to cajole their son to speak publicly when he was a preschooler but several temper tantrums largely ended their attempts. Brody communicates by writing words in the air, pointing, growling, gesturing, or making odd facial expressions. When someone asks him to speak, which is rare, Brody issues a defiant look and shakes his head. Brody’s kindergarten teacher let her students communicate nonverbally, but Brody’s first-grade teacher has begun to insist that Brody read in class. This resulted in several disruptive behaviors from Brody. An assessment revealed little social anxiety for Brody, and he does play with friends on the playground. His level of oppositional behavior, however, is moderate to high.

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ecall from earlier chapters that some children with selective mutism, such as Brody, display oppositional characteristics regarding speaking in public. Some children seem defiant about not speaking, show disruptive behaviors to avoid having to speak, force others such as parents to acquiesce to their demands, insist on using compensatory behaviors such as pointing to communicate, and appear to be particularly willful, stubborn, or manipulative in their behavior. Children such as Brody may have elements of social anxiety, but their unwillingness to speak clearly has some oppositional components. A key aspect of intervention for children such as Brody with selective mutism or reluctance to speak is contingency management.

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Contingency Management

Recall that contingency management refers to establishing rewards and disincentives for a child’s speech or refusal to speak, respectively. These rewards and disincentives are typically provided by parents, teachers, and the person primarily responsible for handling a child’s intervention. However, peers, siblings, and others may be involved as well. Rewards and disincentives are mostly geared toward increasing the frequency and audibility of speech but are often targeted toward reducing compensatory or other problematic behaviors such as tantrums, clinging, or classroom disruption. Rewards and disincentives may be contrived or more natural in nature, as will be discussed. Contingency management is especially useful when a child displays oppositional components to his selective mutism, but the method applies to other conditions as well. Contingency management is a valuable strategy for addressing compensatory behaviors such as Brody’s pointing, gesturing, or writing words in the air. In addition, many children with anxiety-based selective mutism or reluctance to speak have initial difficulty responding to exposure-based practice and prompts to speak. Extensive use of rewards and disincentives are sometimes necessary to prod the exposure-based process. This chapter focuses on contingency management practices for each of these conditions (oppositional behavior, compensatory behavior, linkage to exposure-based practice). This chapter also provides a description of the negative reinforcement/escape intervention tactic introduced in Chapter 1. The interventions discussed in this chapter have been shown to be effective for children with selective mutism and reluctance to speak, but keep in mind that contingency management is often used in conjunction with exposure-based practices. As such, I strongly recommend that you review Chapters 3 and 4, especially if the child you are addressing has even a small degree of general or social anxiety. If you feel the child you are addressing clearly has oppositional characteristics and you are beginning your reading here, then be sure you have properly consulted with relevant family members and developed sufficient rapport with parents, teachers, and the child if possible. As mentioned previously, establish rapport with a child by meeting with him frequently in your office or in a community setting in which the child feels comfortable. Let us proceed next with steps for contingency management using Brody as our primary example throughout the chapter.

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helping children with selective mutism and their parents Consultation with Parents and the Child

As mentioned in Chapter 3 regarding exposure-based practice, I strongly recommend that you have a detailed consultation with parents and the child (if possible) regarding your assessment findings, a description of oppositional behavior, and a rationale for contingency management. When discussing assessment findings, concentrate on behavioral patterns you have found in the data (see Chapter 2). If you have determined that a child’s selective mutism relates closely to oppositional behavior, then focus on which aspects of questionnaires, worksheets, observations, or other assessment data support your claim. You may wish to discuss particular aspects of the child’s behavior that seem most relevant to your choice of contingency management. Concentrate on multiple, specific, and recent examples from the child’s behavior. One characteristic common to some children with selective mutism or reluctance to speak is a pattern of manipulative or attentionseeking behavior. A child who defiantly refuses to speak is also likely to behave similarly in other situations. The child may refuse to complete chores, go to bed on time, or even attend school. In addition, the child may throw tantrums, refuse to move, or cry to gain attention in various situations. A pattern of oppositional or attention-seeking behavior such as this is good evidence that the child might benefit from contingency management. Keep in mind, however, that some children with selective mutism are defiant only about speaking in public and may be rather compliant to other adult requests. Some children listen well to parents and teachers but are quite adamant about not speaking in public. Contingency management in this case may thus concentrate more on speaking and less on a widespread pattern of oppositional behavior. Brody’s sequence of selective mutism and oppositional behavior is a common one and is illustrated in Figure 5.1. When asked to speak, Brody engages in several defiant behaviors such as shaking his head, throwing tantrums, and becoming disruptive in class. The key aspect of this sequence is what occurs next—how do parents, teachers, and others respond to the child’s refusal to speak? Acquiescence to a child’s demands to refrain from speech is a common response in this population. Recall that Brody’s parents largely abandoned their attempts to get Brody to speak in public and that Brody’s kindergarten teacher allowed him to use nonverbal means to express himself. In addition, adults in

Contingency Management

Brody’s main behaviors when asked to speak

Defiant look, shaking head, tantrums, compensatory behaviors, disruptiveness

Parent and teacher responses to Brody’s refusal

Acquiescence, responding to and allowing compensatory behaviors, calling on Brody less in public or class

Long-term consequences of child/parent/teacher behaviors

Ingrained selective mutism, defiance in other areas, poor social skills

Figure 5.1. Illustration of Brody’s sequence of oppositional behavior and selective mutism.

Brody’s life have likely come to rely on his compensatory behaviors to communicate – some parents become quite adept at “translating” a child’s facial expressions, grunts, and odd sounds for others. In addition, teachers will sometimes call on a child less in class to compensate for his lack of speech.

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All of these parent and teacher behaviors serve to reinforce the child’s refusal to speak. A child such as Brody is heavily invested in the status quo because he can avert obligations to talk or participate more in class. As such, selective mutism or reluctance to speak becomes more ingrained over time. The fact that such defiance is rewarded also means a child may extend disruptive behavior and other misbehaviors to other situations such as refusing to complete homework. In addition, refusal to speak for an extended period of time, or using defiance to manipulate communication, may lead to poor social skill development and lack of friendships (see Fig. 5.2). A child’s sequence of selective mutism and oppositional behavior can be illustrated and presented to parents and the child for review. Encourage the child and parents to disagree with you if their observations differ radically from yours. If necessary, collect additional information from family members to modify your view of the child’s sequence of oppositional behavior. Most importantly, be sure all relevant family members fully understand the sequence you outlined because the sequence will serve as the rationale for the intervention you propose. Specifically, you will recommend to family members that key reinforcers of the child’s behavior—especially acquiescence to compensatory behaviors and refusal to speak—must be addressed so that a child is encouraged to speak fully in all situations. Use this sequence to convince family members and teachers to address each aspect of oppositional behavior, and their own behavior, and encourage family members and teachers to commit to a plan of action. Parents and teachers must understand that the bulk of the work of contingency management falls on them. Recall from Chapter 3 that anxiety management is a new skill that parents and children need to learn. The same principle applies here—parents and teachers and relevant others must be willing to change their method of responding to a child’s behavior and continue to practice all interventions described in this chapter. I do recommend informing the child of the upcoming process, but do not allow the child to have much input into the structure of the process. Once everyone is on the same page, outline the expected course and timeline of your intervention. The general course of intervention will include identifying key rewards and disincentives, linking these rewards and disincentives to expectations to speak, linking rewards and disincentives to compensatory behaviors, and other parent-based

Contingency Management

practices such as commands and daily routines. As mentioned in Chapter 3, the timeline of your intervention is hard to predict, but children with defiant behavior sometimes require extended effort and a longer timeline. Be prepared for a potentially difficult process and be sure that parent and teacher motivation during the process is maintained. The first step of contingency management is discussed next.

Identifying Rewards and Disincentives

The first step of the contingency management process will be to talk to parents and teachers and possibly others about what rewards and disincentives are most salient for a child. Some of this information may have already been culled from your assessment or you may know the child well and have some idea. Keep in mind, however, that some children are motivated by one thing at home and quite another thing at school. Children with selective mutism, for example, may enjoy attention from parents but not teachers. Some children, especially those with substantial attention-seeking behavior, are motivated by praise and time with parents and possibly teachers. These children enjoy compliments, one-on-one conversations (albeit one-sided sometimes), and running errands or taking walks with adults, for example. Other children, however, are much more motivated by tangible rewards such as toys, candy, access to television or computer time, or even money (though I do not recommend paying a child for speech). Tangible rewards can be contrived, such as a sticker chart, or more natural, such as an extension of bedtime for speaking appropriately. You will also want to discover what disincentives are particularly salient for a child. Examples include loss of privileges, early bedtime, failure to earn stickers or toys, or fines. Another important disincentive will be to ignore compensatory behaviors. Parents, teachers, and others such as classmates will eventually have to ignore Brody’s pointing, gesturing, and other nonverbal means to communicate. This is the basis for extinction. Once a child learns that nonverbal behavior is ineffective and ignored, the frequency of the behavior should decrease. I do not recommend harsh disincentives for refusal to speak. These cases do not require physical punishment, loss of privileges for days on end, or outlandish responses such as canceling a birthday or holiday.

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Instead, the best rewards and disincentives are those that can be applied daily, that are most salient for a child, and that can be administered well and consistently by parents, teachers, and others. Keep in mind that the strength and type of a reward or disincentive may need to change as your intervention progresses. More difficult expectations for speaking, for example, may require more powerful incentives.

Contingency Management for Defiant Behaviors and Selective Mutism: Parents

I find it helpful if specific rewards and disincentives are linked to specific expectations for speech in different situations. I do not recommend a general approach of waiting to reward a child when he speaks because speech may be too infrequent. Nor do I recommend rewarding a child only at the end of the day for words spoken earlier. Rewards for speaking should be immediate and linked to clear expectations for speech. Let us discuss Brody as an example. Brody speaks well at home, so we can reasonably expect him to speak frequently and audibly in public situations. We next have to decide whether we want initial contingencies for speaking to be administered only in public (nonschool) situations, only at school, or in public (nonschool) and school situations. I recommend beginning with situations in which the child is most likely to speak and with situations in which an adult is most likely to administer consequences appropriately and consistently. Brody seems most defiant about speaking in school, but his parents have a history of acquiescing to his nonverbal behavior in public (nonschool) situations. Options here include working with the parents to educate them about the need to properly administer consequences, go with them and Brody to public situations to model how contingencies should be given and provide feedback, or begin the contingency management approach at school. In this situation, which is a common one for this population, I recommend that you attend public situations with the parents and child to facilitate contingency management and serve as an appropriate model. Begin the process with a specific situation, a specific requirement for speech, and a specific reward and disincentive for fulfilling or not fulfilling the speaking requirement, respectively. Be sure to fully inform the child of all expectations and consequences. Brody was initially required to go to the supermarket with his parents and say one audible

Contingency Management

word to the person who was giving free samples of juice. Brody was instructed to approach the clerk, smile, and say “please.” If he did so, he was allowed to stay up an extra 30 minutes past his bedtime, a particularly salient reward for him. If he failed to do so, then he was required to go to bed 30 minutes earlier than usual. You should be sure to budget extra time in these initial situations for multiple attempts. Brody, for example, was allowed to approach the clerk as often as he wanted to attempt speech. Children such as Brody tend to be more defiant about speaking, so anxiety may not be a key factor. Still, initial attempts may be difficult, so patience is particularly virtuous here. Other children may need contingencies linked initially to mouthing or whispering words, which is fine as long as later expectations involve audible speech. Parent and other adult responses in these situations are very important. Parents should adopt a neutral tone and matter-of-fact attitude without significant emotional content. Some physical distance, such as standing a few feet away, may be important as well. Some encouragement is acceptable, such as saying “You can do it, go ahead,” but parents should confidently convey an attitude that the child needs to finish his speaking assignment independently. Parents should also be encouraged to let the preassigned contingencies speak for them. They need not remind a child in the store about what will happen if he does not speak, but simply administer consequences later. Immediate consequences, such as praising a child for speech or gently admonishing him for failure to speak (e.g., “You’ll need to do better next time”), are often helpful as well. Brody initially refused to speak, but his parents were able to gently admonish him (they shook their head) and issue the early bedtime that night. Brody was reminded at that time why he was going to bed early and encouraged to try harder next time. I recommend that the child engage in the same situation as soon as possible, such as the next day. Most children with selective mutism that I work with eventually yield to ongoing requirements for at least minimal speech, as Brody eventually did. Once a child has successfully completed his first speaking requirement, then expectations for speech are raised. Brody, for example, was then expected to say two words to the person bagging groceries for his mother (“Thank you”). I have found that subsequent requirements for speaking are successfully met a little more quickly with each step, but consequences sometimes need to be changed to fit the situation. Parents

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may need to increase the power of their rewards and disincentives as a child is expected to speak more frequently, speak more audibly, and speak in a wider array of situations and people. Contingency management steps could follow the hierarchies outlined in Chapters 3 and 4. I also encourage parents to adopt routines that make it likely a child will encounter others and speak to others appropriately. Examples include accepting a telephone call from you or other family members, introducing oneself to another child at a park, or taking a child to recreational activities that require some social interaction. Other situations just naturally “pop up” during the day that could be used to help a child speak more frequently and audibly. Parents may bump into someone they know at a supermarket, for example, and ask their child to say hello. Or the telephone could ring and parents may ask the child to answer. These represent impromptu tasks that were not previously planned but provide opportunities for rewards. A child need not be punished for failing to speak in these situations, but could be given substantial rewards for “going the extra mile.” Recall from Chapter 4 that settings such as ice cream parlors could be used to take advantage of natural reinforcers. In this situation, a child is asked to order ice cream with family members. All those that audibly ask for ice cream receive the dessert and those that fail to speak receive no ice cream. Again, multiple attempts to speak should be allowed and parents should be reasonably sure the child is capable of the necessary communication. Contingency management in public (nonschool) situations can follow the same step-by-step process discussed in Chapters 3 and 4 for exposure-based practice. Here, the focus is on administering rewards and disincentives for speaking and failure to speak, respectively. Contingency management in community situations often precedes school-based intervention, but I also recommend that a child continue to practice speaking in community situations even as school-based tasks are set. This is especially important because a child’s behavior in school will be partly consequated at home.

Contingency Management for Defiant Behaviors and Selective Mutism: Teachers

Contingency management for selective mutism at school must involve close cooperation and communication among you, parents, teachers,

Contingency Management

and relevant others. I strongly recommend a contingency management program that involves all of the following components: • Specific daily expectations for speech in the classroom. • Specific rewards and disincentives for meeting or failing to meet these expectations. • A daily report card sent home to parents who can also provide consequences at home. • Ongoing teacher prompts to the child to communicate, including calling on the child. • Creating a milieu at school involving others who constantly encourage the child to speak. • Managing disruptive behaviors in the classroom, especially misbehaviors in response to requests to speak.

Specific daily expectations for speech in the classroom can mirror the gradual process we have covered in Chapters 3 and 4 and the beginning of this chapter. Brody, for example, might be expected to audibly state one word to his teacher during the course of a school day. Try to give the child great leeway as to when, where, and how this occurs (we will shape this more as time goes on). Brody can choose what word he wants to say, choose when he wants to say the word to the teacher, and choose a setting such as recess when no one is around. His success in doing so should be met with an immediate reward from the teacher, such as praise and extra computer time in the classroom, as well as a later reward at night from his parents (e.g., later bedtime). The opposite holds true as well, of course—Brody’s failure to meet the expectation should be met with an immediate (e.g., loss of recess) and later (e.g., earlier bedtime) disincentive. The close connection between school- and home-based consequences strengthens the contingency management process, conveys to a child the seriousness of the task, and helps teachers and parents form a united front. This connection should be solidified by a report card sent home by the teacher to the parents each day. A sample is provided in Figure 5.2. I recommend asking the teacher to indicate whether the child successfully fulfilled his speaking obligation for that day, rate a child’s level of anxiety and disruptive behavior on a 0-10 scale, and stipulate any disruptive behaviors or other relevant comments for parents. You can arrange appropriate responses to each item with parents, with a particular focus on whether the child successfully completed his speaking task.

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helping children with selective mutism and their parents Daily Report Card Date: __________ Speaking task for the day: _______________________________________________ The child successfully completed his or her speaking task today (circle one): YES NO Level of distress shown by the child today (use 0–10 scale): _____ X--------X---------X--------X---------X---------X---------X---------X---------X---------X--------X 0

1

None

2

3

A little

4

5

Some

6

7

Stronger

8

9

A lot

10 The worst

Level of disruptive behavior shown by the child today (use 0–10 scale): _____ X--------X---------X--------X---------X---------X---------X---------X---------X---------X--------X 0 None

1

2 A little

3

4 Some

5

6 Stronger

7

8 A lot

9

10 The worst

Behavior problems in school today ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Homework today or other comments ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Figure 5.2. Sample Daily Report Card.

Teachers should also be asked to modify instructional methods they may have employed to compensate for a child’s lack of audible speech. Some teachers eventually call on a child less in class, allow a child to avoid group projects, ask a child to sit in an isolated section of the classroom to work, and give incomplete grades for reading and other tasks that require verbalizations. These practices should change, but in a gradual fashion as a child speaks more. A child who is just speaking her

Contingency Management

first word to the teacher, for example, need not be required to read before the class. However, she could be reintegrated with peers, asked to participate in group projects even in a nonverbal fashion, and called on in class more to do things such as write on the blackboard. Reducing isolation is helpful to facilitate increased speech later on. Teachers will be asked to help extinguish compensatory behaviors as well (see later section). As a child successfully speaks more in class, others can join the process to encourage more spontaneous speech. Peers and classmates could be asked to praise a child’s speech, prompt speech throughout the day, and refrain from informing others that a child “does not speak.” A classmate could initiate a conversation at lunchtime, for example. The idea is to take a basic and natural life scene and shape it into a learning and rewarding situation for the child with selective mutism. In addition, specialized teachers (e.g., physical education, art, music), office staff, and other adults at school could do the same to create a general milieu where the default expectation for a child is audible speech. A teacher could pull a child aside and ask how his day is going, for example. You will have to take care not to overwhelm a child with this approach. Instead, bring others into the process only when you see the child is more willing to speak to the teacher and a few classmates. Teacher-based contingency management could apply as well to disruptive behavior a child may show in the classroom following requests to speak. Recall that Brody was somewhat disruptive in class when asked to speak, sometimes throwing something, stomping his foot, or walking out of the classroom. Specific consequences must be provided for such behavior, above and beyond those established for failure to speak when asked. Consequences for disruptive behavior should be particularly strong and set apart from those used for speaking. In this way, the child understands that his misbehavior reached a specific, unacceptable level that triggers a harsh response. You may find that establishing a 504 plan is useful for children with selective mutism, particularly if disruptive behavior accompanies their failure to speak. A 504 plan would allow you to implement special circumstances to help address the child’s behavior, including those discussed in this book as well as tactics such as modifying the workload, having a child sit near the teacher, and medication (see Chapter 7).

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A 504 plan might also assist with relapse prevention (see Chapter 7) because ongoing strategies must be practiced to ensure that a child continues speaking frequently and audibly at school. Contingency management in later stages could be extended as well to other disruptive behaviors that a child may show. Some children with selective mutism and defiance about speaking also refuse to complete homework or chores or even come to school (especially once expectations for speech are implemented). Some of Brody’s associated behaviors—such as disruptive classroom behavior or public tantrums— could be linked to specific contingencies. Associated behavior problems are thus reduced and parents can extend their contingency management practice so that the practice becomes a regular family style. Extending the contingency management process will help reduce chances of relapse toward mutism as well (see also Chapter 7). Contingency management often demands a broad approach so that rewards and disincentives are administered by multiple adults (parents and teachers) for various levels of misbehavior.

Extinguishing Compensatory Behaviors

As mentioned earlier, a key aspect of contingency management for selective mutism is to extinguish compensatory behaviors such as Brody’s pointing, gesturing, and writing words in the air. Compensatory behaviors are generally allowed at the beginning of intervention to ensure a child understands the expectations for speaking and the resulting consequences. A child may be allowed to nod or shake her head, for example, when asked if she understands what must be done and said in a given situation. As your intervention matures, however, a child should be expected to “use words” to express simple responses such as yes or no and later to converse more broadly. Recall that Brody was initially expected to say “please” to the person providing juice in the supermarket. One likely manipulation of this situation on the child’s part will be to convey information without speaking. Brody may try to point to the juice, smile, or otherwise charm his way into the treat using nonverbal means. This often works for young children. In this situation, Brody’s parents should tell their son ahead of time that such behaviors are not allowed and that he must “use

Contingency Management

his words.” In addition, try to convey to clerks and others that the child is learning to use his words and should not receive the treat unless he speaks clearly. Most people graciously comply and even encourage the child to speak. Extinction of compensatory behavior should occur on a daily basis and become a regular parental response. Encourage parents to tell a child to use his words, ignore nonverbal expressions such as pointing, “play dumb” by claiming they do not know what the child wants without speaking, or gently admonish the child. I recommend simply ignoring compensatory behaviors. As your intervention progresses, teachers and other school officials should adopt this practice as well. Doing so may create some initial awkwardness and hardship such as a failed classroom reading assignment, but ongoing practice should eventually extinguish most of the nonverbal behaviors. You may find it necessary as well to work closely with a child’s peers and classmates at school. Ask them to encourage the child to use his words, give the child much praise when he does speak, and stop telling other people that the child does not speak. Educate children about the need to help the child speak more frequently and audibly and to continue to ask him to play, converse, and participate in class or group projects. The idea here is to create a general milieu at school that always works toward encouraging active speech and discouraging compensatory behavior.

Prodding Exposure-Based Practice

Chapters 3 and 4 discussed exposure-based practice and mentioned that rewards and disincentives could be applied to facilitate the process. Children must always be rewarded for engaging in a successful exposure session and should be rewarded more if they happen to speak more than what was originally required. I encourage you to model this process for parents as you engage in various sessions with a child. A child may be rewarded with simple things such as stickers but also more natural stimuli such as praise and smiles. Parents should also help the exposure process by providing disincentives if the child refuses to engage with you verbally or nonverbally as required. Compensatory behaviors should be ignored as well as your intervention progresses.

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helping children with selective mutism and their parents Negative Reinforcement/Escape

Another behavioral technique for cases of selective mutism that involve oppositional tendencies is negative reinforcement/escape. Recall that negative reinforcement refers to rewarding a behavior by removing aversive consequences. With respect to selective mutism, a child is required to sit in a low-frequency speaking situation (such as your office) for an extended period of time until he speaks one word, and is then allowed to leave. Speaking thus allows the child the opportunity to escape a boring and potentially stressful situation (negative reinforcement). This process can last several hours, however, and there is no guarantee the child will speak. A twist on negative reinforcement/escape is to require a child to say one word in a new situation and, if she fails to do so, send her to her bedroom for an extended period of time until she complies. Negative reinforcement/escape is not a well-tested approach and can obviously be burdensome and ineffective. The greatest risk of the approach is that a child will successfully “wait out” the process and exit without ever having spoken. In this situation, the child is actually reinforced for not speaking. This would complicate future attempts at this or other intervention procedures as well because the child was able to force adult acquiescence to a rather lengthy and arduous attempt to get her to speak. Some children we have addressed in my clinic are quite intransigent and would not have much difficulty waiting out a 4-hour period of time, for example. You may wish to use this procedure only if you are completely confident it would work. Otherwise I would recommend the general contingency management procedures discussed earlier. Other Contingency Management-Related Techniques

During the course of contingency management you may wish to help parents address their children more effectively and reduce chaos. Two general strategies may be most beneficial. One strategy is to help parents restructure the way they issue commands to a child, whether it be to speak, complete chores, do something to get ready for school, or finish some other task. Some parents fall into the habit of bribing, negotiating, berating, lecturing, criticizing, and interrupting to get a child to comply with their requests. Other parents use sarcasm or phrase

Contingency Management

commands in the form of a question such as “Will you please put your jacket on?” I recommend that parents replace these habits with the following practices for issuing commands: • Tell your child exactly what you want him or her to do (e.g., “Pick up all clothes from the floor” instead of “Clean your room”). • Give short, direct commands. • Make direct eye contact when speaking to your child or giving him a command. • Be sure your child can actually physically do what you are asking him to do. • Do a task with your child (e.g., clean the bedroom with him). • Reward good listening and discourage poor listening.

A second general parenting strategy that may be helpful is to structure the morning routine, especially on school days. Some families are quite chaotic and could benefit from this, and parents of children with selective mutism may find such structure consistent with what you asked them to do earlier (i.e., establish specific situations and consequences for speaking). Toward this end, work with parents to establish a morning routine that begins with the child rising about 90-120 minutes prior to the start of school. Specific timelines should be given for all morning preparation behaviors such as dressing, eating breakfast, and brushing teeth. Provide extra time for each task—if a child should be able to eat breakfast in 15 minutes, for example, allow 20 minutes. Specific rewards and disincentives, which may parallel those discussed earlier regarding speech, may be applied for compliance or noncompliance to the morning routine. The goal of these command and routine strategies is to provide parents with skills they can use to respond appropriately to their child’s behavior and manage misbehavior. Families that communicate well and solve problems will be better equipped to address a child with selective mutism or reluctance to speak. Communication and problemsolving skills will go a long way toward preventing relapse as well.

Final Comments and What Is Next

Contingency management is a key aspect of addressing youths with selective mutism with oppositional characteristics and is a good

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supplement to exposure-based practice. Indeed, a combination of contingency management and exposure-based practice is a good intervention strategy for most youths with selective mutism. Other children of this population, however, have great difficulty speaking, which may be due to communication deficits or developmental delay in addition to selective mutism. This latter population is discussed in greater detail in the next chapter.

6 Strategies for Children with Communication Problems

Mark is a 6-year-old boy who has great difficulty speaking to others. His school psychologist believes Mark has selective mutism but the problem seems associated with communication deficits as well. For example, people other than Mark’s parents have great difficulty understanding what Mark says. As a result, Mark often whispers to his parents or communicates nonverbally by pointing. Mark’s parents have adopted the habit of translating information conveyed by their son. Mark was fairly reserved and quiet during kindergarten and did not play much with others. His parents and the school psychologist became more alarmed about Mark’s ability and his unwillingness to speak to others at the end of kindergarten when reading difficulties surfaced.

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ecall from earlier chapters that some children with selective mutism, such as Mark, display communication problems in addition to failure to speak. Some children seem quite hesitant about speaking in part because they are not fluent, have difficulty forming words or sentences, or cannot understand what others have said to them, among other communication problems. Specific language impairment or other developmental delay may be present. These children may also show some anxiety about trying to speak to others and withdraw from social interactions. Some oppositional behavior may be present as well, but many children with communication problems and selective mutism tend to avoid others and avoid situations in which speaking may be expected. A key aspect of intervention for children such as Mark is to address possible underlying speech or language deficits in conjunction with techniques described in this book for selective mutism or reluctance 113

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to speak. This chapter introduces the concept of specific language impairment and communication disorders prior to a discussion of comorbidity with selective mutism. The chapter then outlines typical intervention procedures for specific language impairment and communication disorders prior to a discussion of how these interventions can intersect with techniques to address selective mutism or reluctance to speak. A complete description of specific language impairment and communication disorders is outside the scope of this book, so the reader is referred to the references provided in this chapter for additional information. In addition, I strongly recommend consulting or working with a speech pathologist who can coordinate necessary language programs with your intervention for selective mutism. Children with communication disorders and selective mutism will benefit most from a multidisciplinary approach that includes parents and various school-based specialists.

Specific Language Impairment and Communication Disorders

Specific language impairment refers to problems in understanding or producing language, especially in comparison to normal nonverbal ability. This is sometimes defined as a low score on a standardized language measure without additional impairment such as deafness or low intellectual ability. Problems of vocabulary, grammar, comprehension, word reading, verbal working memory, and phonology are common. Specific language impairment occurs in about 3–7% of children and tends to affect more boys than girls. The long-term outcome for many of these children is good because many early language impairments resolve with age, but associated reading difficulties and motor coordination problems may be present (Bishop & Snowling, 2004; Gathercole & Alloway, 2006; Hulme & Snowling, 2009). Specific language impairment overlaps to a degree with various communication disorders outlined by the Diagnostic and Statistical Manual for Mental Disorders (4th ed., text revision). These disorders include expressive language disorder, mixed receptive-expressive language disorder, phonological disorder, stuttering, and communication disorder not otherwise specified. The sections that follow discuss each of these disorders in turn.

Strategies for Children with Communication Problems

Expressive language disorder refers to a situation in which a child’s scores on a standardized measure of expressive (verbal or sign) language are substantially below scores on standardized measures of nonverbal intellectual ability and receptive language (American Psychiatric Association [APA], 2000, p. 58). These children may demonstrate limited vocabulary, omit sentence structures, and have trouble recalling words, producing lengthy or complex sentences, using correct tense, or demonstrating fluency. The problem must interfere with social communication or academic or occupational achievement, criteria for a mixed receptive-expressive language or pervasive developmental disorder must not be met, and the language problems must be in excess of mental retardation if that disorder is present. Expressive language impairment may occur after some period of normal development or may be more lifelong in nature. Mixed receptive-expressive language disorder refers to a situation in which a child’s scores on standardized measures of expressive and receptive language are substantially below scores on a standardized measure of nonverbal intellectual ability (APA, 2000, p. 62). These children may demonstrate features similar to expressive language disorder in addition to severe comprehension deficits. Comprehension deficits may come in the form of confusion when spoken to, difficulty understanding words or sentences, trouble with auditory processing, inattentiveness, and withdrawal. The problem must interfere with social communication or academic or occupational achievement, criteria for a pervasive developmental disorder must not be met, and the language problems must be in excess of mental retardation if that disorder is present. Mixed receptive-expressive language impairment may occur after some period of normal development or may be more lifelong in nature. Phonological disorder refers to a situation in which a child fails to use developmentally expected speech sounds appropriate for his age and dialect (APA, 2000, p. 65). Children with phonological disorder often display errors in sound production, use, or organization, or omit sounds such as final consonants in a word. The child may lisp, form words poorly, show unintelligible speech, mix sounds, or otherwise demonstrate inferior articulation. The problem must interfere with social communication or academic or occupational achievement and the language problems must be in excess of mental retardation if that disorder is present.

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Stuttering refers to a situation in which a child has problems of normal fluency and time patterning of speech inappropriate for her age (APA, 2000, p. 67). The child may frequently repeat or prolong sounds or monosyllablic words, use many interjections or broken words, pause often in speech, avoid certain difficult words, and show great physical tension when speaking. The problem must interfere with social communication or academic or occupational achievement and the language problems must be in excess of speech-motor or sensory deficits if present. Finally, communication disorder not otherwise specified refers to significant problems in communication that do not fit the criteria for the disorders just described.

Communication Disorders and Selective Mutism

Several researchers have noted a connection between communication disorders and selective mutism. One research group examined 130 children with selective mutism and found that 43.1% displayed anxiety and communication problems, especially on measures of expressive and receptive communication. The degree of selective mutism in this group was also more severe than other groups (i.e., purely anxious or oppositional). However, expressive and receptive communication deficits were not strong enough to warrant a diagnosis of mixed receptive-expressive language disorder. This suggests that many children with selective mutism also have low-level aspects of communication problems (Cohan et al., 2008). Kristensen (2000) estimated that 30–65% of children with selective mutism have a language disorder or language delay. Other researchers have also noted substantial overlap between selective mutism and communication problems such as poor articulation, expressive language disorder or phonological delay, stuttering, and auditory verbal-memory problems. Others have noted developmental disorders such as Asperger’s disorder or other developmental delays in youths with selective mutism as well (Kristensen & Oerbeck, 2006; Remschmidt et al., 2001; Steinhausen & Juzi, 1996). Many children with selective mutism also have academic or reading problems or receive special services in schools (Bergman, Piacentini, & McCracken, 2002). As mentioned in Chapter 2, evaluating a child with possible selective mutism should include a speech and language assessment.

Strategies for Children with Communication Problems

Interventions for Communication Disorders

Various interventions have been designed to address communication disorders and these interventions have good efficacy with respect to expressive syntax, phonology, and vocabulary as well as receptive syntax and phonology (Law, Garrett, & Nye, 2004). The next sections provide a general overview of common language interventions for preschoolers and school-aged children. The descriptions are necessarily brief and so I encourage you to consult with a speech and language pathologist and the references provided here for greater detail. These sections precede a discussion of melding language training with techniques for addressing selective mutism or reluctance to speak. One general approach to language intervention for young children involves teaching adults such as parents and teachers to appropriately respond to a child’s attempts to communicate and strengthen her skills. Parents and teachers may be instructed to model, modify, or expand a young child’s attempts to communicate. When a child elects to communicate, parents and teachers could smile, praise the speaking behavior, model the correct way of producing speech, modify the child’s syntax or semantic information, and expand on the child’s idea. A child may say “coo-ee ee” (“cookie eat”) to a parent, for example, who could model proper pronunciation (“COOK-EEE”), modify syntax (“eat a cookie”), and expand the child’s statement (“You want to eat a cookie”) (Warren & Yoder, 2004). Another general approach to enhance communication ability among young children is to directly teach language. This approach is adult-initiated and involves direct prompts for speech, reinforcement, frequent and massed trials, and specific goals of intervention (e.g., saying a word correctly). A teacher may, for example, hold a small cookie near her eye, issue a command to the child to say “cookie,” and reward the child for doing so correctly. Direct teaching of language via applied behavior analysis involves various stages of intervention. The process typically focuses first on nonverbal requests as well as motor imitation and social play. Receptive language in the form of applying labels to items and actions is next. Expressive language is then emphasized as children categorize objects, form words and short sentences, and engage in more social speech such as answering questions from others. Academic communications such as counting or reading and self-help communication such as asking to use the restroom represent

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higher-end tasks. Although effective, direct teaching requires good child attention and generalization of language to other, more natural settings. Effective language training for very young children often involves a combination of child- and adult-initiated methods (Sallows, 2005; Warren & Yoder, 2004). A downside to teaching communication skills is that the approach depends heavily on a child who initiates or copies speech. A relatively quiet child will thus receive little adult feedback. To address this, parents and teachers may establish indirect and direct prompts for speech. Indirect prompts involve modifying the child’s environment to facilitate the likelihood of speech. For example, a parent could deliberately leave a cookie on the counter for a child to see, provide pictures to a child who offers them for items he wants, or sing songs or use puppets with the child. Or a teacher could place several enticing play options before a child. Direct prompts involve specific solicitations of speech, perhaps via open-ended questions (e.g., what activity should we do today?) (Gallagher & Chiat, 2009; Webb, Baker, & Bondy, 2005). A related approach to direct teaching is structured teaching (the TEACCH model) designed primarily for children with autism. This approach emphasizes helping a child understand how the world is organized and predictable. To do so, children engage in a planned and routine sequence of school-based learning activities, including speech therapy. Visual and spatial stimuli are also established to help children understand where they are supposed to be, what they are supposed to do (and for how long), when the task is complete, and what will happen next. A key component of this approach is an emphasis on spontaneous communication in addition to formal training for receptive and expressive language. A child may learn, for example, to use a meaningful word such as “restroom” in a real-life situation. Such an approach will hopefully increase generalization of speech (Mesibov & Shea, 2005). Another general model of language intervention emphasizes a child’s affects and relationships with others. This model focuses on an intensive, home-based program of 20-30-minute daily sessions involving spontaneous interactions between a parent and child and sensorimotor and spatial activities as well as comprehensive speech and occupational therapy and special education if necessary. Intervention is geared toward a child’s affect, so a reserved child may receive more active encouragement from others during play. Intervention is also tailored to a child’s developmental level with respect to sophistication of

Strategies for Children with Communication Problems

communication. Older children, for example, are better able to engage in reciprocal interchanges than younger children who are more responsive to communications initiated by others (Greenspan, 2005). Other researchers believe that language problems largely result from auditory processing deficits that lead to great difficulty recognizing speech and its nuances, expressing thoughts clearly, and reading. A language intervention based on this premise emphasizes phonemic awareness in spoken words, logical thinking about how a sentence is formed and expressed, verbal working memory to retain and manipulate information about speech and other tasks, and discriminating acoustic signals such as rapid and successive sounds. Computer-based exercises are used so a child can practice acoustic reception as well as syntactic and semantic skills. Phonics training, for example, helps children identify specific sounds within words and distinguish words that differ by only a first or last consonant. Environmental distractions are also kept to a minimum (Madell, 2005; Miller, Calhoun, Agocs, DeLey, & Tallal, 2005). The Lindamood–Bell program of language intervention is also quite popular. This program is based on the idea that phonemic awareness and symbol imagery (mental images of letters that form phonemes) are critical for good communication and reading. Language training focuses on asking a student questions about consonants and vowels and articulation, labeling phonemes, and identifying and sequencing sounds within syllables. Pictures, creative labels, and blocks are often used to facilitate this process and enhance self-correction of mistakes. Some children may require imagery or language comprehension training prior to this process (Bell, 2005; Lindamood & Lindamood, 2005). The next section discusses ideas for how interventions for communication disorders and selective mutism might be integrated.

Integrating Interventions for Communication Disorders and Selective Mutism

A child with selective mutism and some aspect of a communication disorder will likely benefit from multiple techniques to address both problems simultaneously. Keep in mind however, that some children require extensive language or other interventions prior to any attempt to remediate selective mutism. If the child you are addressing has severe

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language deficits or significant developmental delay, then intense and basic language training or self-care skills training may need to be conducted first. Coordinating your intervention with developmental specialists will obviously be necessary in these cases. In addition, children with substantial communication problems may require a lengthy timeline with respect to intervention for selective mutism or reluctance to speak. Other children display moderate levels of communication problems or developmental delay. A common associated condition with selective mutism, for example, is Asperger’s syndrome. Children with Asperger’s syndrome typically have severe social skills deficits, eccentric or repetitive or ritualistic behaviors, coordination problems, and difficulty understanding language in context. The latter commonly involves poor eye contact, little facial expression, and trouble understanding body language and subtle communication cues provided by others. As such, some children with Asperger’s syndrome withdraw from others and may rarely speak, which could qualify them for a diagnosis of selective mutism. Children with moderate levels of communication problems or developmental delay may benefit from a combination of language and social skills training with the techniques described in this book for selective mutism. The following sections outline suggestions for such a combined approach. Exposure-Based Practice

Exposure-based practice is a key aspect of treatment for selective mutism and reluctance to speak and was given considerable attention earlier in this book (Chapters 3 and 4). Several aspects of exposure-based practice are compatible with a language intervention program, especially one based on principles of applied behavior analysis. Recall that principles of applied behavior analysis for language intervention include direct prompts for speech, reinforcement, frequent and massed trials, and specific goals. Each of these principles applies as well to exposure-based practice: adults prompt speech from a child in various situations, reward a child for meeting goals associated with frequent and audible speech, conduct regular exposure sessions, and have a clear end-state goal such as reading aloud to classmates or conversing with new friends. Exposure-based practice and applied behavior analysis for language intervention are also compatible in that both approaches rely on a gradual stage model. That is, each approach emphasizes subdividing the

Strategies for Children with Communication Problems

language and speaking process toward an end goal such as good articulation or frequent and audible speech. Doing so allows a child to systematically progress in small steps that are manageable and that increase the likelihood for success. Recall, for example, the discussion of hierarchy development and successive steps from Chapters 3 and 4 for exposurebased practice. How specifically might exposure-based practice for selective mutism meld with an applied behavior analysis program for language development? A traditional applied behavior analysis program for language development progresses through multiple stages such as matching, motor imitation, play, receptive language, verbal imitation, expressive language, categorization, early sentences, social speech, early academics, and self-help (Sallows, 2005). Aspects of exposure-based practice can be integrated into each of these stages. Matching refers to increasing basic skills of paying attention and complying with instructions from an adult such as a parent or teacher. Imitation refers to asking a child to copy a simple act during play, which also requires attention and compliance. Matching and imitation are similar to what I recommended during the early home visit section of exposure-based practice (Chapter 3). Your initial exposure-based interactions with a child are designed to build rapport. A specific focus on interactive abilities such as attention, compliance, and physical imitation may indeed build rapport but can also facilitate the next stages of language development and the reduction of selective mutism. The play stage of applied behavior analysis for language development involves asking a child to imitate an action that leads to a vocalization or rudimentary verbalization. Examples include humming or singing a part of a favorite song, labeling a desired object, or greeting a child by saying “hi” and hoping for a response (Sallows, 2005). The play stage dovetails nicely with initial forays of exposure-based practice to reduce a child’s anxiety to the point that he will initiate vocalizations or one or two words with you. We discussed how these early vocalizations or verbalizations can be whispered or barely audible to begin but must later progress to full-volume speech. You can see that the process of developing language as well as audible speech can be a painstaking one at this point. Shaping can begin at this stage as well. A child who vocalizes “mmm,” for example, can be asked to add an “ah” sound to form the word “Ma.” Or a child could be asked to repeat a certain syllable or

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phoneme several times (e.g., “ah-ah-ah” or “ma-ma-ma”). The instructor can also present the phoneme string so that the child can imitate it and immediately receive a reward. More phoneme strings can be added over time and can eventually shaped into specific words. Ideally, these specific words are labels the child can use to request and receive something desirable such as a toy or cookie––the words should have as much communicative value and function as possible. Others such as parents should be asked to encourage and reward these phoneme strings and labels as well during the week. Receptive language is also a key target of applied behavior analysis and involves asking a child to listen and comply with various instructions such as “sit,” “stand,” or “pick up the toy.” Physical prompts may also be used by instructors to enhance this process; they may, for example, sit on the floor as they say “sit.” Developing receptive language in this manner can dovetail nicely with teaching a child to use relaxation and breathing techniques (Chapter 3) to quell physical symptoms of anxiety. These exercises need no explicit verbalization from the child but do require attention, compliance, imitation, and receptive ability. Developing receptive language ability and anxiety management skills may thus be conducted simultaneously. Direct physical prompts are often necessary to prod speech in young children, but as mentioned earlier, researchers also recommend indirect prompts for language development. Indirect prompts involve modifying a child’s environment to facilitate the likelihood of speech. Consider the earlier example of a parent who leaves a cookie on the counter to prompt speech from her youngster. Use of indirect prompts parallels the discussion of impromptu exposures in Chapters 3 and 4. Impromptu exposures involve taking advantage of naturally occurring situations to prompt a child to speak. Examples include asking a child to answer the telephone when it rings or say hello to someone who greets her at church. The idea here for both language development and reduction of selective mutism is to always be looking for opportunities to increase the likelihood of well-articulated, fluent, frequent, and audible speech. Parents and teachers who adopt this default pattern of always expecting more and better speech will greatly enhance the chances for intervention success and help prevent relapse. As a child’s verbalizations and receptive ability increase in scope and proficiency, he may expand his vocabulary and begin to express more abstract concepts. Children at this stage can be asked to provide

Strategies for Children with Communication Problems

more information about something they want, especially with respect to color, size, and class (Sallows, 2005). Providing more information in this way dovetails nicely with the hierarchical system in exposure-based practice that involves moving from single words to short sentences. A child who wishes a cookie, for example, may be required to tell you which kind of cookie he wants from a choice selection (e.g., chocolate chip, oatmeal, or sugar). Exposure-based practice at this point would discourage the use of pointing and the simple expression of the word “cookie” in favor of a more descriptive response such as “sugar cookie” or, better yet, a longer phrase such as “I want a sugar cookie.” These early conversations should be rewarded not only for their increased complexity (language development) but also for their frequency and audibility (reduction of selective mutism). These early conversations can then be extended to more social types of interactions. As mentioned in Chapter 3 for example, children could be encouraged to discuss things most enjoyable to them such as their pets, family members, or toys. Such a practice increases generalization of speech to social situations (language development) and increases a child’s willingness to discuss multiple topics with you and to lower his anxiety about speaking (reduction of selective mutism). Later stages of language development from an applied behavior analysis perspective involve greater generalization to other children, academic settings, and self-care tasks. These stages match well the hierarchical process for selective mutism when exposures are conducted eventually in community and school settings. Children are increasingly but gradually expected to converse with a greater number of peers, verbally participate in class and group projects, and issue requests for help such as asking a teacher to use the restroom. Stimulus fading can be especially useful in this regard. Systematically adding more stimuli to a speaking situation, such as the number of classmates, will serve to generalize language development and reduce selective mutism. Consistent feedback to a child about his use of language as well as his frequency and audibility of speech must continue as well. Language development as well as relapse prevention for selective mutism must be an ongoing process. Self-Modeling

Recall from earlier chapters that self-modeling involves audiotaping or videotaping a child as she speaks clearly in a comfortable situation

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such as the home and then replaying the recording in a low-frequency speaking situation such as your office at school. The child is then praised or given tangible rewards for the clarity, volume, and beauty of her voice. Self-modeling can be used in conjunction with various language intervention programs, especially those that help increase articulation ability. As mentioned, children sometimes have difficulty recognizing speech and its nuances, expressing thoughts clearly, and reading. Phonemic awareness––or the ability to hear, identify, or manipulate phonemes––is a key skill that needs to be developed for these children. Children are thus taught to blend and sequence various phonemes and distinguish words that differ only slightly (e.g., “set” and “sit”). Emphasis is also placed on learning and articulating vowels and consonants and discriminating continuous sounds such as “m” and “s” from stop sounds such as “t” and “k.” Various teaching programs have been developed to increase phonemic awareness. Self-modeling may be useful during this process because it gives you a mechanism for providing feedback to a child not only about the qualities of her voice but also about the competence of her speech. You may notice over time and during extended self-modeling sessions that a child becomes better at articulating certain words, and this should be identified and praised. Self-modeling also allows you to provide feedback about specific aspects of a child’s speech and affords an opportunity to ask the child to work on the clarity of one or two words in your office. As you watch a child say a particular word, for example, you could “play dumb” and ask the child to repeat the word for you (I recommend blaming the sound quality of the camera in this regard). This helps build language and reduce selective mutism at the same time. Self-modeling also provides a child an opportunity to correct mistakes made during the videotaped speaking session if she desires. Self-modeling may be useful as well to help a child reduce stuttering. Interventions for stuttering often involve protracted syllableby-syllable speaking, improving airflow, slowing the rate of speech, and other methods to increase fluency. Self-modeling provides a mechanism by which a child can practice fluent speech and receive feedback and appropriate consequences for effort and success in doing so. Interventions for stuttering also involve anxiety management, which matches nicely with exposure-based practice and relaxation and breathing training.

Strategies for Children with Communication Problems

Contingency Management

Contingency management is important to language development and reduction of selective mutism. Children with language problems can be reinforced for greater articulation, fluency, comprehension, phonemic awareness, and practice and effort, among other behaviors. Children with selective mutism can be reinforced for more frequent and audible speech, initiating conversations with others, and practice and effort, among other behaviors. Many children with a communication disorders and selective mutism will respond favorably to a specific type of reward for completing language tasks and completing strategies to reduce failure to speak. Other children, however, demand a more nuanced approach. A child with Asperger’s syndrome, for example, may respond well to praise from her mother when practicing fluency and eye contact but may require more powerful tangible rewards to boost speech with classmates. Social Skills Training

Many children with communication disorders, such as children with selective mutism or reluctance to speak, could also benefit from social skills training (see Chapter 4). Social skills training may be particularly useful for very young children or older children with Asperger’s disorder and communication disorders that has led to restricted social interactions. As with children with selective mutism, social skills training for youths with communication disorders or developmental delay can follow a stage model that gradually addresses smaller skills such as eye contact, larger skills such as responding to requests from others, and broader skills such as initiating and maintaining conversations. Cognitive Therapy

As mentioned in Chapter 4, cognitive therapy may be useful when a child with selective mutism begins to speak and can express concerns about how others will react to his or her speech. General principles of cognitive therapy can also apply to some circumscribed cases of communication disorder. Some children with communication disorder, particularly those with stuttering, also have substantial concern about how others respond to them as they speak. These cases may benefit

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from some discussion about the child’s specific anxieties and the (hopefully low) probability of negative events occurring after speech (see specific questions and suggestions in Chapter 4). Keep in mind, however, that you may have to address actual instances of peer ridicule or alienation.

Final Comments and What Is Next

Strategies to address communication problems and selective mutism in a given child can be administered together. General ideas were presented in this chapter, but I recognize that a child with both kinds of problems will require a highly individualized and nuanced approach. As mentioned, a multidisciplinary approach to these children is strongly recommended. The next and final chapter addresses suggestions for relapse prevention as well as associated intervention techniques for selective mutism and a discussion of special issues that sometimes arise in this population.

7 Relapse Prevention, Other Interventions, and Special Issues

Carson is an 8-year-old girl who was diagnosed with selective mutism at the beginning of third grade. She did not speak to others at school and seemed particularly anxious about being around her classmates and peers. Carson was more comfortable addressing her teacher and other adults at her school. The school psychologist and counselor at Carson’s school worked with her throughout the school year to develop greater ease about speaking in different situations, enhance her social skills, and teach her some anxiety management techniques. With parental support and help at home, Carson was able to gradually speak more to others at school and play with friends at recess. Her ability to speak before others had reached a point at which she could read a story aloud in class. Carson had made several friends and was able to participate verbally in group projects.

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hildren such as Carson make the months of intervention seem worth all the effort. Intervention for children with selective mutism or reluctance to speak can be a grinding, slow, and methodical process. As such, we certainly want to maintain the gains we have made! Many children with selective mutism, especially those of the severe type, remain relatively shy in their demeanor, which is fine. The danger, however, is that these children may be prone to regress to old habits of relying on compensatory behavior, initiating conversation and play less often, and withdrawing from social and verbal activities. Parents and even teachers can also regress to old habits of rewarding inappropriate compensatory and other behaviors and neglecting the ongoing development of robust speech and social skills. The initial part of this 127

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chapter addresses relapse prevention, or methods you should consider to ensure that a child’s speaking and social behavior remain healthy. This chapter also contains a summary of intervention techniques that could be used in conjunction with the behavioral strategies emphasized in this book. These include group and family therapy, medication, and an Internet-based intervention. In addition, a separate section addresses special issues that often arise with this population as well as suggestions for handling them. These issues include bilingualism, difficult parents, comorbidity, and mental retardation or other developmental delay.

Relapse Prevention

We want to maintain gains for children such as Carson, so active strategies to prevent relapse must be implemented. A first step when considering whether a child is regressing in her behavior is to determine whether such regression is a slip or an actual instance of relapse. A slip represents some minor backsliding toward failure or refusal to speak, such as declining to answer a teacher’s question on a particular day, withdrawing from peers during lunch, or trying to communicate by pointing instead of using words. Slips occur frequently, especially after breaks from school, and should not be made too much of unless the problem worsens. Slips can usually be addressed quickly by practicing anew the strategies used to help a child speak more frequently and audibly (see Chapters 3–6). Parents, teachers, and others sometimes become discouraged when slips happen, thinking they are back to “square one.” Everyone should remember, however, that a child with selective mutism or reluctance to speak is likely to be a shy child by nature and that this nature will not dramatically change. The occurrence of slips means that parents, teachers, and others must intensify intervention efforts and communicate well with each other. Use of ongoing scheduled and spontaneous exposures, including calling on a child in class and providing feedback about her withdrawn behavior, is important. Parents and teachers should continue the daily report card system (Chapter 5), maintain and modify contingencies for speaking and failure to speak, and have the child practice anxiety management techniques, social skills, and other relevant aspects of the intervention.

Relapse Prevention, Other Interventions, and Special Issues

Slips can accumulate or intensify, however, and possibly lead to relapse. Relapse represents more intense backsliding toward the original problem. If Carson failed to speak one day at school, then this would be a slip. This slip could be addressed by prompting Carson to read a passage to her class or encouraging her to approach someone to play with at recess. If Carson did not respond to these prompts or other techniques and her situation deteriorated over a period of a month or so, then this may be a moderate relapse. Relapses can be moderate or severe, but in either case it is a situation we want to actively prevent. The following sections present suggestions for doing so.

Reminders following Intervention

When a child has begun speaking more frequently and audibly in various situations, parents and school officials can certainly feel good about the successful work they have accomplished. The temptation at this point, however, is to assume that the child will naturally continue to speak well on her own with little help from others – this is a big mistake. Relapse prevention must begin the moment you successfully complete the last stage of your intervention. I recommend that you, parents, and relevant teachers construct a list of reminders or techniques that were most useful for helping the child speak more frequently and audibly in different situations. Often this means focusing on two to four techniques or ideas that were particularly salient for that child. Examples include ongoing exposures in various community and school situations, practicing anxiety management techniques, administering potent rewards and disincentives, and continuing a child’s speech and language development program. Parents, teachers, the child, and relevant others should keep this list of reminders and refer to it when a slip occurs. I also strongly recommend that a child’s anxiety level and number of words spoken per day continue to be monitored and recorded daily for at least several months after the formal end of intervention. Note the forms introduced in Chapter 2. The idea here is that a child should know that her willingness to speak in public situations is constantly monitored and addressed. Ongoing monitoring will also provide useful information about whether a child is regressing to old habits of nonspeaking behavior.

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Many parents and teachers continue to practice techniques to prod frequent and audible speech for a child, but others do not. Some parents and teachers naturally relax once a child has shown that she can speak in different and previously difficult situations. Parents and teachers become preoccupied with many other distractions and may thus become less focused on the intense intervention techniques needed to address selective mutism. Adults may tend to take for granted a child’s willingness to speak. Parents and teachers must understand that continued practice and constant vigilance from the end of intervention are the best ways to prevent future problems. Parents should continue practicing techniques useful for encouraging speech, such as natural exposures and contingency management. Similarly, teachers should continue to monitor a child’s anxiety and level of speech each day and implement activities that must include the child’s verbal input. Peers can also be encouraged to continue to initiate conversations with and extend play invitations to the child. You, the parents, and the teachers should remain in close contact with one another for at least several months following the formal end of intervention. Close communication can come in the form of daily report cards, monthly scheduled meetings, or regular email or telephone contact. These communications should focus on the remaining areas of difficulty for a child, new situations or obstacles that must be addressed, and how existing practices such as the use and type of contingencies may need to be tweaked. Problems related to a child’s extended period of selective mutism could also be addressed. Examples include finishing extensive make-up work, integrating a child into previously avoided extracurricular activities, and helping the child build new friendships. Exploring and Addressing New Obstacles to Frequent, Audible Speech

A child’s slip or relapse could be due to recent life changes instead of failure to practice techniques. Slips or relapses could follow important family changes, academic problems, peer conflicts, or other new difficulties. Having regular conversations with a child to explore and resolve new obstacles to speaking in various situations is recommended. If the

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child has another mental disorder that seems to interfere with proper communication, then school-based academic intervention or referral to a mental health professional outside the school setting (see Chapter 1) may be necessary. Slips or relapses with respect to selective mutism could also occur because a child is inadvertently receiving some new reinforcement for not speaking. In this case, you and the parents will need to locate the source of the new reward and resolve the issue. Carson, for example, may find that someone at her school who is unfamiliar with her history allows her to communicate using compensatory behavior. Or parents may respond to a child’s temporary spike in anxiety by allowing him to skip a social event. Peers are also notorious for “helping” a child with prior selective mutism navigate a social situation by speaking for her. Rewards for failure to speak must be removed. Beginning of a New School Year

A child who previously had selective mutism or reluctance to speak will often have great trouble resuming a regular pattern of speaking and social behavior following an extended break from school, such as summer. This may be especially true if a child is entering a particular school for the first time and does not know many people. To help prevent a relapse at this point of the school year, try the following: • Be sure the parents and the child attend all scheduled orientation sessions held at the beginning of the school year. • Conduct a private tour of the school with the parents and child, emphasizing areas of socializing that might pose particular difficulty for the child: classrooms, the cafeteria, art and music centers, the gymnasium, and the playground. Discuss potential obstacles to good speech. • Be sure the child knows where to go—such as a counselor’s office— if she has conflicts with others at school, needs to discuss areas of difficulty surrounding speaking, or has other adjustment problems or sources of anxiety. • Educate relevant school personnel about the child’s history of selective mutism, strategies that resolved the issue, and important reminders for preventing a relapse. • If relevant and appropriate, establish a 504 plan so teachers can better monitor a child’s speech throughout the day or modify

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academic practices so the child’s speech continues to be practiced and rewarded. • Establish regular lines of communication among parents, teachers, and school personnel responsible for addressing the child’s selective mutism. • Involve the child in extracurricular activities of his choosing to boost speech and friendship development. Booster Sessions

Another relapse prevention method is booster sessions, or special meetings between you, the parents, and a child who has overcome selective mutism. The purpose of booster sessions is to review techniques from your intervention and discuss upcoming issues that may interfere with proper speaking. Booster sessions are often held during “high-risk” times such as immediately before a new school year or during class projects that demand significant verbal input. Carson’s school-based social worker may wish to meet with Carson and her parents before the start of fourth grade to boost skills needed to speak frequently and audibly to others. Booster sessions are especially important when children move from elementary to middle school and from middle school to high school. Reminders of a Child’s Success

A relapse prevention method that can be fun is to have a child develop an art project that represents her gains during your intervention. Carson, for example, could collect photographs of herself engaging in difficult tasks such as reading aloud before her class, playing with peers on the playground, greeting someone at the door, and chatting with classmates at lunch. These photographs could be arranged in a mosaic or other project to illustrate her accomplishments and serve as a reminder of what to do in the future when she is having trouble speaking. Videotapes, drawings, journals, storybooks, posters, and other creative methods of illustrating a child’s successes in speaking could also be used in this regard. Structured Activities during a Break

Children with a history of selective mutism can benefit from continued involvement in certain activities during breaks from school. Youths with

Relapse Prevention, Other Interventions, and Special Issues

a history of shyness and failure to speak to others, for example, could participate in social groups, clubs, teams, or other organized activities during school breaks. They could also be expected to maintain contact with former classmates and current friends to arrange mutual play times, a fun night out, or sleepovers. The idea is to continually place a child in situations where she must practice her ability to manage anxiety, speak clearly, and converse with others. Parents should continue to administer proper consequences for speaking and failure to speak during breaks as well. Maintaining the Right Attitude

An important part of relapse prevention is the attitude of the parents concerning a child’s speech. This means two things. First, parents should not allow backsliding. Once a child demonstrates that he can speak frequently and audibly to others in a given situation, he should continue to do so. If Carson could greet people in the supermarket during intervention, for example, then there are few reasons why she should suddenly stop doing so. Second, parents must maintain an attitude that proper speech will always be encouraged. The default option must always be to expect a child to attend social events and speak clearly to others, even if minor problems are present. Efforts on your part to help parents maintain a proper attitude about school attendance will serve to prevent relapse. Relapse prevention is an essential aspect of intervention for children with selective mutism, especially because many of these children continue to be shy and reserved in their behavior. The remainder of this chapter covers other interventions for selective mutism and discusses special issues inherent to this population. You may find that special strategies are sometimes needed to successfully address certain cases and prevent relapse.

Other Interventions for Selective Mutism

The behavioral approaches described in this book are the primary interventions utilized for children with selective mutism or reluctance to speak. Other interventions have, however, been discussed in the research literature and are summarized here. In some cases of selective mutism,

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a combination of behavioral approaches with these interventions may be helpful. In other cases, intricate behavioral strategies cannot be implemented although other approaches can still be beneficial. Group Intervention

Group intervention for selective mutism or reluctance to speak involves addressing two or more children together at the same time. Several advantages exist for group intervention. First, the strategy is costeffective because you can implement exposure-based practice, contingency management, social skills and language training, and other relevant techniques to multiple children at one time. Second, group intervention allows extensive modeling of appropriate speaking and social behavior. Children in the group can watch each other speak to a teacher, increase voice volume, and interact with peers on the playground. Third, group intervention allows children with selective mutism to practice skills on each other in a safe and nonstressful environment. Children in a group can practice introducing themselves to one another, prompt additional vocal speech from each other, maintain eye contact with each other, and converse, for example. Finally, group intervention often facilitates building friendships and social support, which may lower the risk of future relapse. Group intervention can be effective, but several caveats must be recognized. First, not all children will advance at the same pace during your intervention. Some children will move quickly during your intervention and others will require more time. Be sure no child feels compelled to do something she is not ready to do just because another group member has already reached a certain level. Second, form a group based on similarities in child age, cognitive functioning, and speech level. Do not mix children of different ages, developmental ability, or degree of selective mutism. Children tend to model positive effects from peers who are closer to them personally with respect to these characteristics. Third, consider whether children with selective mutism in your proposed group primarily have issues related to anxiety, oppositional behavior, or communication problems. I recommend maintaining homogeneous groups so that these characteristics are largely separate. Keep children whose selective mutism relates primarily to social anxiety

Relapse Prevention, Other Interventions, and Special Issues

separate from those who are clearly more oppositional, for example. Of course, some overlap in characteristics will occur and this is acceptable. Recall that many children with selective mutism share characteristics of anxiety and oppositional behavior. Finally, you may find that not enough children are available at your school to form a group, so the procedures discussed in this book would obviously have to be applied to individuals. Family Therapy

Family therapy regarding this population refers to educating family members about selective mutism, exploring family patterns of communication, addressing enmeshed or overcontrolling parent–child relationships, and reducing family member pressure on a child to speak. As mentioned in Chapter 1, you may not have the time or resources to conduct formal family therapy for a particular case of selective mutism, but addressing family dynamics to some extent in many of these cases is crucial for success. Several researchers have noted that parents of children with selective mutism tend to be meek, shy, or verbally reserved themselves. You may find as you address a particular case that parents will also need to be encouraged to engage in more social, verbal, and otherwise interactive behavior. These parents may also need more information concerning the long-term negative consequences of selective mutism and why early intervention is important. Some parents and children have a deeply enmeshed relationship, meaning the parents are overinvolved in many aspects of the child’s life. During the course of the intervention you may find that parents need instruction about how to permit a child to speak and engage in exposures independently. Some parents prefer to “rescue” their child from anxiety-provoking situations, but this does not allow the child to practice skills necessary to manage anxiety and build social and verbal skills. Other parents tend to be more controlling or domineering in their approach toward their child and may insist that the child speak when he is not ready to do so. These cases demand a more measured approach in which a child gradually speaks in increasingly difficult situations. Parents should be encouraged to support this gradual approach, eliminate belligerence when addressing the child, and refrain from

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harsh punishments. Addressing these dynamics can often be done in the context of contingency management practices, especially as you work with parents to implement moderate rewards and disincentives, restructure commands, and develop effective morning and other routines. Pharmacological Intervention

Pharmacological intervention or medication for selective mutism has been evaluated by some researchers but supporting data remain preliminary. The predominant medication for selective mutism has been antidepressants, particularly phenelzine, fluoxetine, sertraline, fluvoxamine, citalopram, and paroxetine. Other medications, such as anxiolytics and neuroleptics, have been less commonly used. Most studies reveal a moderate effect for reducing selective mutism, although side effects and adverse food and drug interactions are of substantial concern in young children with the disorder. Medication for selective mutism may decrease physical arousal but does not necessarily enhance social or related skills necessary for full symptom improvement. Medication in conjunction with behavioral techniques may be most applicable to severe cases of selective mutism. Medication is likely a good choice if a child has very severe anxiety symptoms that clearly interfere with your ability to implement techniques such as exposure-based practice. You may find that a referral to a pediatrician or psychiatrist may be necessary in these cases (see the referral box in Chapter 1). Internet Intervention

Some researchers (Fung, Manassis, Kenny, & Fiksenbaum, 2002) reported an innovative use of an Internet-based program for a 7-yearold child with selective mutism. The researchers emphasized education about selective mutism, recognizing symptoms of anxiety, using specific social skills, and practicing anxiety management techniques over weekly sessions. Homework assignments, such as situations where speech could be practiced, were provided via email. This approach is preliminary but may be useful if family members are unwilling or unable to meet or if you do not have direct access to the child with selective mutism.

Relapse Prevention, Other Interventions, and Special Issues

Special Issues Regarding Intervention for Selective Mutism

As you address children with selective mutism and reluctance to speak you will find that special issues often arise. This section covers many of the special issues I have faced in my clinic and some of the strategies that I and other researchers have used to overcome them and maximize therapeutic effectiveness. Bilingualism

A particularly difficult issue that arises with some cases of selective mutism is family bilingualism and a tendency to predominantly speak a non-English language in the home. I have encountered many cases of selective mutism where a child will not speak at school in part because his proficiency with the English language may be limited. Recall that the diagnostic criteria for selective mutism rules out children who lack knowledge of, or comfort with, the spoken language required in the social situation. A child who recently moved to the United States from South Korea and was placed in an elementary school where everyone spoke English would naturally be unable to communicate and therefore would not receive a diagnosis of selective mutism. The problem that arises is that gray areas exist regarding this diagnostic criterion. A typical example is a child who can speak English but not particularly well because his parents primarily or exclusively speak a non-English language such as Spanish at home. The child may not have a communication disorder and may even be willing to speak more but naturally feels uncomfortable or unsure of himself at school. The child may fear social rejection or have trouble understanding what the teacher is saying. Some of these kids remain shy and fail to speak even when addressed in their parents’ primary language, however. Several suggestions can be made regarding this situation. First, I do encourage parents to speak English in the home to a greater extent. I do not advocate a wholesale adjustment of a family’s value system, but do try to convey to parents that a child’s better proficiency at English will enhance his ability to speak clearly to others at school and participate more meaningfully in academic endeavors. Sometimes this means that parents need to learn English themselves, bring someone into the family unit who can converse with the child in English more, or practice English for a set period of time per day. Most parents I have

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encountered are receptive to these ideas and understand the rationale for them. Second, the techniques discussed in this book can still apply to a child in a bilingual type of situation. You may need to enlist the help of a translator or a cotherapist who speaks the parents’ language, but do not allow the child or a sibling to translate your statements to the parents. Collaboration with multilingual school personnel may be especially useful in these cases. Third, I have found that extensive self-modeling (see Chapter 4) is useful not only to address selective mutism but also to show parents how you and others will positively respond to the child’s use of clear, audible English. You may even wish to extend this process by showing the parents a videotape of their child speaking English to others at school. Fourth, I recommend extensive home visits with parents who speak little English and who may have withdrawn themselves from many aspects of their child’s education. Many parents in this situation avoid parent–teacher conferences, participation in orientation and other sessions at school, and discussions about intervening in a child’s speaking problem. Home visits allow you to establish rapport, convey the importance of addressing selective mutism, observe family customs and values, and conduct home-based exposures. Consider closely any cultural factors that may impinge on your intervention, such as a parent’s belief that a child should obey directives without the use of rewards. Finally, you will need to address negative, prejudiced, or otherwise biased views of the child and his language and cultural values at school (Toppelberg, Tabors, Coggins, Lum, & Burger, 2005). Teachers and other school personnel sometimes ignore or become intolerant of children who struggle with English. Peers can obviously be harsh as well. A child faced with a stressful and threatening learning environment will likely not speak frequently even with extensive intervention. Some cases of selective mutism thus demand a systemic approach to reduce ostracizing behaviors within a classroom or school. Difficult Parents

Do you ever have to face difficult parents? Of course you do! Some parents can obviously be quite challenging to work with and seem to defy many of your suggestions regarding a particular problem. These parents may be hostile, skeptical, suspicious, evasive, and pessimistic

Relapse Prevention, Other Interventions, and Special Issues

about change. You will find some belligerent or combative parents of children with selective mutism, but this is unusual unless the child is older or has many comorbid problems such as attention deficit/hyperactivity disorder or aggression. If you do encounter antagonistic or argumentative parents, I generally recommend the following: • Increase collaborative contact with parents via telephone calls or email or other daily correspondence. • Meet parents at school or in the home to explain the child’s speaking problem and discuss means to address the problem. Invite other professionals working with the family (e.g., pediatrician, psychiatrist, therapist) to attend the meetings if possible. • Provide parents with options, such as developing a 504 plan or conducting in-school exposures, that can accommodate a child’s needs and allow for effective intervention. • Explore potential obstacles to your proposed intervention and suggestions to overcome them. • Explore the need for a referral to other professionals for extensive parent or family problems that may interfere with the intervention. • Outline how a preliminary intervention on your part with the child has already led to some success regarding frequent and audible speech, if applicable.

When working with parents of children with selective mutism, I find that problems other than belligerence are more common. First, many parents in this population are a bit shy, meek, or reserved themselves. As such, they may be slow to recognize that their child has selective mutism, have trouble grasping the concept of selective mutism, and fail to understand that the disorder has led to other social and academic problems. As mentioned in Chapter 1, many parents believe their child is simply shy and will eventually “grow out of ” whatever problems he currently faces at school. I strongly recommend giving the parents as much detail as possible regarding how far afield their child is vis-à-vis nonverbal behavior. Discuss with them teacher reports, academic records, and other data that support your claim. One of the best pieces of evidence for parents involves a personal but surreptitious observation of their child in the classroom. Parents can be shown, for example, that their child speaks far less than classmates (or not at all), withdraws from group activities, and appears sad or anxious. I also recommend helping parents understand

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the difference between common shyness and selective mutism. People who are shy still interact with others and enjoy academic success, but children with selective mutism rarely if ever speak, which may lead to substantial social and academic problems. Encourage reluctant parents to allow you to begin a limited intervention plan such as some home-based exposures or some self-modeling at school. Involve parents as much as possible in these endeavors and show them incremental progress. For example, parents may see that even a few exposures led to a nice conversation between you and their child or that a school-based exposure with the teacher led to their child’s ability to ask to use the restroom. Outline for parents how extended intervention can lead to other, specific advances in their child’s frequent and audible speech. A common second problem is intervention noncompliance, meaning that some parents are not very good at implementing recommendations to increase a child’s exposure to speaking situations, administer appropriate consequences, develop a child’s social skills, or extend a school-based language program at home. Some parents are confused about doing these things and others parents lack the energy, motivation, or wherewithal to do so. Whatever the reason, treatment noncompliance will be highly damaging to your attempts to fully address selective mutism. Intervention noncompliance may be addressed in several ways. First, discover the exact reason why parents are having trouble following through with your recommendations. Parents often have good intentions but simply lack the energy, time, or skills to implement a complicated intervention. I commonly ask parents, after they have agreed to a wonderful intervention plan, what could possibly go wrong. I am always surprised by the number of potential problems they raise, but all potential problems must be addressed before the intervention begins. Parents may say, for example, that they simply have too hard a time denying their child ice cream if he does not speak clearly to a clerk or are not structured enough to schedule formal exposures. In other cases, peer conflict needs to be resolved or reluctant teachers need to agree to participate more fully in the intervention process before you can begin. You may find it necessary to simplify your intervention to fit the family’s ability. This may mean adopting a slower pace to intervention, giving parents and their child fewer therapeutic homework assignments during the week, or emphasizing areas in which the parents and

Relapse Prevention, Other Interventions, and Special Issues

child excel. Regarding the latter, you may find that parents and children have no trouble practicing anxiety management techniques or conducting spontaneous exposures in community settings. Emphasizing what the parents and child can do will, at a minimum, help produce some gains in speaking and perhaps prevent the problem from getting worse. Be aware as well that many children increase the severity of misbehavior after parents and school personnel begin to implement an intervention. Increased misbehavior is often designed to force parents to acquiesce to the status quo. This misbehavior may come in the form of tantrums, increased compensatory behavior, crying, or greater withdrawal. Parents should be made aware of this possibility, instructed to extinguish the misbehavior via consequences (Chapter 5), and maintain the components of intervention such as exposures. Comorbid Psychiatric Disorders

As mentioned in Chapter 1, certain mental disorders or other problems are sometimes comorbid with selective mutism. Common examples include anxiety disorder, depression, or trauma-related experiences, but other problems could be involved as well. Many of the techniques described in this book—especially exposure-based practices—are also useful for children with considerable levels of general, separation, and social anxiety. If a child with selective mutism appears anxious in different situations, then relaxation and breathing training, exposure-based practice, and cognitive therapy may be used. As with areas of speaking, hierarchies can be developed (Chapter 3) regarding anxiety-provoking situations that the child can eventually master. Sadness and depression are sometimes a part of selective mutism as well, especially if a child seems socially alienated. In many cases, the sadness will dissipate as a child becomes more comfortable speaking to others. If a child with selective mutism does seem particularly sad, then emphasize social skills training, participation in extracurricular activities, and friendship development in addition to techniques to increase audible speech. In other cases, however, especially with adolescents, comorbid depression is not completely related to selective mutism and may be severe. A referral to a child psychologist or psychiatrist is thus recommended (Chapter 1). Finally, failure to speak may occasionally be related to a traumatic experience the child encountered. Examples include personal or family

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member illness, accidents, maltreatment, or peer victimization. Failure or refusal to speak can actually be adaptive for some children who try to avoid abuse. These cases demand a much more sensitive approach that usually requires helping a child address the traumatic incident before proceeding to techniques for selective mutism. In other cases, treatment for selective mutism can perhaps lead to the child’s ability to discuss the traumatic event. If a child shows symptoms of posttraumatic stress disorder, however, then I recommend referral to a child psychologist or psychiatrist. Mental Retardation and Other Developmental Delay

Another special issue that can arise with cases of selective mutism is mental retardation or other severe developmental delay. Some of the recommendations made in Chapter 6 are also useful for addressing children with selective mutism and developmental delay. In other cases, the developmental delay is severe (e.g., autism) and so language training tailored for that problem is necessary. If you wish to treat a child with selective mutism with severe cognitive limitations, you should adopt a slower pace of intervention, eschewing cognitive techniques and emphasizing behavioral ones (e.g., exposure-based practice, shaping, contingency management), and integrating your approach into other programs designed to boost adaptive and social skills.

Final Comments

I hope you find this book helpful in addressing children with selective mutism or reluctance to speak. I and my graduate students have treated many of these children for years and so I know how time-consuming, intense, and personally frustrating many of these cases can be. Please remember that the work you do with these children is extremely important! You may find little reward or praise from others when a child successfully speaks for the first time and on a regular basis, but be assured that you have made a gigantic difference in that child’s life. You have opened the door for that child to achieve greater social and academic progress than she could have achieved by failing to speak to others. Keep up the great work!

Appendix

Publishing Companies and Information Regarding Measures Described in Chapter 2

Multi-Health Systems (North Tonawanda, NY, www.mhs.com). Pearson/PsychCorp (San Antonio, TX, www.pearsonassessments.com, www.psychcorp.com). Pro-Ed (Austin, TX, proedinc.com). Western Psychological Services (Los Angeles, CA, wpspublish.com). Child Behavior Checklist and Teacher’s Report Form (Achenbach System of Empirically Based Assessment, www.aseba.org). Children’s Depression Inventory (Multi-Health Systems, www.mhs.com). Child Symptom Inventory-4 (Western Psychological Services, www.wpspublish.com). Conners Rating Scales (Multi-Health Systems, www.mhs.com). Multidimensional Anxiety Scale for Children (Multi-Health Systems, www. mhs.com). Screen for Child Anxiety-Related Disorders (from author Boris Birmaher, Department of Psychiatry, Western Psychiatric Institute and Clinic, Pittsburg, PA). Social Anxiety Scale for Children-Revised and Social Anxiety Scale for Adolescents (from author Annette La Greca: Social anxiety scales for children and adolescents: Manual and instructions for the SASC, SASC-R, and SAS-A [adolescents], and parent versions of the scales. Department of Psychology, University of Miami, Miami, FL). Social Phobia and Anxiety Inventory for Children (Multi-Health Systems, www.mhs.com). Additional Readings and Resources

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington. DC: Author. 143

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Appendix

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Appendix

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