®  

SM  101    

Steven  Kurtz,  PhD,  ABPP  Director,  Selec9ve  Mu9sm  Program  

 October  16,  2013  

Current  Conceptualiza9on  of  SM  •  Anxiety  disorder  

•  Nega0vely  reinforced  avoidance:  escape  paradigm  •  Distress  intolerance  •  Intermi:ent  enabling  strong  maintaining  variable  

•  Dis0nguishable  from  social  phobia  •  SM  as  (mal)adapted  solu0on  •  Unsupported  hypotheses  

•  Trauma  •  Willful  •  Normal  developmental  phase*  

•  Spontaneous  remission  rates  unknown  

Current  Conceptualiza9on  of  SM  

Nature  -­‐  Nurture  

The  Nature  Part  

v Pre-­‐disposi9on  to  be  behaviorally  inhibited  

v Detectable  incredibly  early  in  life  

v Incredibly  stable  paLern  of  response  

Child is prompted to

talk or engage

Child gets (too)

anxious

Child avoids

Adult rescues*

Child’s and adult’s anxiety are lowered*

Negative reinforcement

Behavioral Conceptualization�

2  unanswered  ques9ons  per  minute  =  20  unanswered  ques9ons  per  10  minutes  =  720  unanswered  ques9ons  per  day  =  130,120  unanswered  ques9ons  per  school    year!!!  •   Let’s  say  it  was  especially  high  and  it’s  only    100,000  per  year    •   Prac%ce  anything  100,000  %mes  and  see  if    you  get  “good”  at  it  !!!  • overlearning  

 

Let’s  Do  the  Math  

Rigid  Rules  of  the  Game  for  the  Child  with  SM  

•  Kids  with  SM  divide  the  universe  into  those  they  talk  with  and  those  they  don’t  

•  Boundaries  are  not  fluid  •  Old  people  and  old  situa9ons  are  contaminated  •   New  people  and    new  situa9on  are  not  associated  with  any  history  of  not  talking    

•  That  is  why  don’t  we  ask  any  ques9ons  at  all  when  first  we  meet  the  child  with  SM?  

•  We  protect  the  tabula  rasa  

Contaminated  

Places  

Ac9vi9es  People  

What  is  treatment?  v Treatment  is  providing  opportuni9es  to  prac9ce  being  brave  

v Within  a  trus9ng,  fun  rela9onship  v In  graduated  steps  v Systema9cally  increasing  difficulty  v Decreasing  avoidance  and  enabling  v Increasing  distress  tolerance  for  both  v Not  targe9ng  anxiety  per  se  

v Anxiety  ex%nguishes  with  habitua%on  

Treatment  is…  v   dose  dependent  v   varies  a  lot  across  children  v   typically  lasts  once  aLained  v   fun  &  exhaus9ng  at  the  same  9me  v   transparent  v   developmentally  sensi9ve  v   o_en  requires  adjunc9ve            medica9on  

CDI  (Child  Directed  Interac9ons)  -­‐  or  -­‐  

VDI  (Verbal  Directed  Interac9ons)  

Driving  in  2  gears:  

What  is  enabling?  Accommoda9ng?  •  Define  enabling?  •  Define  accommoda9ng?  •  How  are  they  different?  •  Parent-­‐child  enabling?  •  Peer  enabling?  •  Teacher/coach/tutor  enabling?  •  So  what’s  a  ______  to  do?  

CDI  (Child  Directed  Interac9ons  

When  your  child/student  is  NOT  yet  ready  to  be  prompted  

VDI  (Verbal  Directed  Interac9ons)  

When  your  child/student  IS  ready  to  be  prompted  

Do’s  Labeled  Praise  for  talking   Mind  read  

Reflect  verbaliza<ons   Yes/No  Ques<ons  

Play-­‐by-­‐Play  Announcer  (Behavioral  Descrip<ons)   Direct  commands  to  talk*  

Wait  5”  *   Indirect  Commands  to  talk  

Forced  Choice/Open  Ended  Q’s*   Nega<ve  Talk  

Do’s  &  Don’ts  Don’ts  

*  Never  in  CDI,  only  in  VDI  

We  always  use    v Brave  Talking  points    

v To  shape  progressively  more  talking  

v Trade  points  for  Prizes  or  Privileges  v Note  that  no  child  ever  becomes      addicted  to  prizes  v No  child  ever  becomes  extor9onist    about  prizes  

Typical  Reinforcement  Paradigm  

Trade points for prizes (determined ahead of time)�

Check mark or sticker (Immediately) �

Labeled Praise (with or without a Reflection) �

Brave Talking �

Valid prompts*: (Forced Choice or Open Ended + wait 5”)�

Small  bag  to  hold  everything  White  Board/Dry  Erase  to  write  prompts  on  

Prompts  for  the  child  Prompts  for  the  adults/other  

Point  tracker  Paper  with  s9ckers  Paper  with  stamps  Paper  with  just  checkmarks  

3-­‐5  Games  Spot  It!  Drawing  Travel  Bingo,  Travel  Guess  Who?,  etc  UNO,  GoFish,  etc  

Prize    Picture  of  prize  they  are  working  towards    

Puzzle  pieces  op9on  The  actual  prize  

Brave  Prac9ce  Kit  

•  Go  Fish  •  BaLleship  •  Surveys  of  “Favorites”  •  Hangman  •   Spot  It!  •  Tell  Tale  

Games  for  Elici9ng  Talk    when  child  is  ready  !  

•  Small,  incremental  steps  •  Systema9c  •  Involve  child  to  the  extent  possible  •  Ready  to  find  and  “9trate”  half-­‐steps  as  needed  if  child  is  struggling  with  given  step  

Goal  Senng  

Fading  one  change  at  a  9me  

�• Child  and  parent*  in  classroom  (1:1)  • Fade  teacher  in  (1:2)  • Fade  peer  in  (1:3)  • Fade  parent  out  (1:2)  • Fade  child  #2  in  (1:2+1)  • Fade  into  rou9ne  ac9vi9es  • CHANGE  1  VARIABLE  AT  A  TIME  

*  This  might  be  therapist  rather  than  parent  who  accompanies  to  classroom  at  first  

Goals of individuals to

speak to color-coded by setting

Collabora9ve  Goal  Senng  

Hierarchy  of  goals  for  1st  grader    

With  only  Mom,  mimic  silly  sound  

With  only  Mom,  answer  ques9ons:  forced  choice,  math  

With  only  Mom,  mimic  long  words  

At  school,  Mom  and  W.  only  in  a  non-­‐classroom  

Begin  to  fade  Mom  out  

Add  Dad  to  “talking  circle”  

Add  Dr.  Kurtz  to  “talking  circle”  

With  only  Mom  in  room,  mimic  face  

With  only  Mom,  mimic  short  words  

start  

Fade  therapist  into  the  room  again  

Fade  Mom  out  of  the  room,  leaving  student  +  friends  +                        therapist  

Fade  2nd  friend  into  this  same  room  

Fade  in  1st  teacher,  then  second,  then  both,  in  addi9on  to  peers  

Fade  therapist  in  again,  followed  by  1  peer,  then  2,  then  3  

Fade  student  and  Mom  into  classroom;  peers  not  present  

Fade  teacher  in  to  this  non-­‐classroom  with  friends  

At  school,  Mom  and  W.  only  in  a  non-­‐classroom  

 

Fade  1st  friend  into  this  non-­‐classroom  

Hierarchy  for  1st  grader  -­‐  con9nued    

Generaliza9on    Change  only  1  variable  at  a  9me  

v  The  person  v  The  place    v  The  ac9vity  

 

Upcoming  Events  

Building  Brave  Muscles:  The  Specific  Behavioral  Skills  that  Target  Increasing  Bravery  

Wednesday,  November  13,  2013  |  6:15  –  7:30  PM    Join  Laura  Kirmayer,  MSW  for  a  review  of  behavioral  skills  that  are  crucial  to  

effec9ve  selec9ve  mu9sm  treatment.    

Register  at  www.childmind.org/events!