Behavioral Techniques in the Treatment of Selective Mutism
Aimee Kotrba, Ph.D.
Can you identify the child with selective mutism?
DSM-IV Criteria
Consistent, ongoing failure to speak in specific social situations
Interferes with education or social communication Not due to lack of language skills Other disorders (e.g., stuttering, PDD) have been
ruled out A relatively rare childhood disorder, affecting
approximately 1% of children in elementary school settings
Assessment of Selective Mutism History Behavioral observations Cognitive functioning Language functioning
Psychological Treatment of Selective Mutism Education Medication Desensitization Hierarchical exposure Relaxation techniques Shaping speech Generalization
Psycho-education of Child Bibliotherapy Cat’s Got Your Tongue: A Story for
Children Afraid to Speak Written by Charles Schaefer Published by Magination Press in 1992
Treatment is explained in age-appropriate language to child
Child is assured that the therapist will practice with them in becoming braver and stronger.
Psycho-education of Parents Selective mutism is conceptualized as a
social anxiety disorder Behavioral techniques are explained Describe ways parents could prevent
inadvertently reinforcing mutism Pediatrician discusses role of medication
Anti-depressants have been found to produce beneficial effects for children with selective mutism.
However, research demonstrates that the most effective treatment is cognitive-behavioral therapy.
Treatment Package
Behavior modification
&Contingency management
Relaxation techniques/Post. self talk
Consultation with
Teachers and other
professionals
RegularBehavioral contracting
Self modeling(via video editing)
Graduated exposure
to fear
Development of Fear hierarchy
Treatment package
components
Individual work with child
Work with parent present
Training parents
Collaboration with otherprofessionals
Implementation Flowchart
Fear Hierarchies
Maintain eye contact for 5 second count
Imitate simple body movements
Imitate sounds made with instruments
Imitate sounds made with the mouth
Imitate words, then phrases
Answering questions with head nod
Answering yes/no questions (audible)
Answer novel “Wh” questions
Ask spontaneous questions
Expanding stimulus & response classes
•Expand hierarchy to include other adults and children
•Increase volume requirements for speech
•Decrease latencies to responding
•Utilizing shaping and fading principles
Example Fear Hierarchy
Self Modeling
Case Example 1Alone with Mother
6 year old (Annie) diagnosed with selective mutism
2nd session of treatment
Early treatment on her fear hierarchy
Escape Contingency
Required to nod head Yes or No as a response to the question posed by the therapist
Posture, facial expression, and demeanor changes when therapist enters the room
Relaxation Techniques Deep breathing exercises Positive self-statements Visualization
Shaping Techniques One word spoken simultaneously with
therapist One word spoken alone Repeated a short sentence Answered questions Gradually increased voice volume
Generalizing Behavior to School Teachers are given information concerning
the present step on the heirarchy. Importance of practicing heirarchy in the
school setting Steps are only added when they were
“cleanly” demonstrated in the therapy session
Generalizing Behavior to Public Gradually increasing proximity to peers Working with peer dyad in the clinical
setting Parents asked child questions in public Parents arranged play dates
Post treatment with Therapist
Hierarchical steps have been accomplished with the therapist
Future goals will include expanding the response class to include additional adults and children in a variety of settings
Termination Achieving spontaneous speech across
multiple settings Booster sessions will likely be necessary