Personalized Individual and Group Therapy for Multifaceted Selective Mutism

Abstract

Selective mutism refers to a persistent and debilitating condition in which a child fails or refuses to speak in public situations. Research on treatment for selective mutism has progressed in recent years toward a more personalized model based on clinical profiles unique to a given child. Such profiles may include aspects of anxiety, oppositional behaviors, and communication problems as well as operant factors that maintain selective mutism. The present case represents a 6-yearold child with selective mutism with a multifaceted clinical profile that included internalizing and externalizing behavior problems with multiple operant factors. Initial personalized individual therapy focused on anxiety and contingency management procedures to address school refusal behavior and to lay the groundwork for later treatment of selective mutism. Group therapy with parent and child components focused on these procedures in more detail in addition to social skills development. Each component included detailed hierarchies for increasing frequency and audibility of speech in a clinic setting as well as in community and school settings. Keywords selective mutism, personalized treatment 1 Theoretical and Research Basis for Treatment Selective mutism is a persistent and debilitating condition in which a child fails to speak in public situations where speaking is expected. Children with selective mutism often speak well in familiar situations such as home but less so if at all in public situations, especially school. Failure to speak must last at least 1 month. Selective mutism does not generally apply to youths with a communication disorder or to youths who lack comfort or knowledge with the primary language spoken in public situations (American Psychiatric Association [APA], 2013). Selective mutism affects 0.2% to 2.0% of children and commonly begins during preschool years. Selective mutism may have a chronic course for some children because treatment is often delayed. As such, selective mutism has been linked to peer rejection and inadequate academic, language, and social skills (Viana, Beidel, & Rabian, 2009).

Be Your Own Superhero: A Case of a Young Boy With Selective Mutism and Complex Comorbidities

“…Anxiety is recognized as one of the most common and extensively documented psychological complaints, affecting individuals across various developmental stages (Kessler et al, 2012). Relative to anxiety disorders in general, profiles of selective mutism (SM) in young children, however, have been shown to be more nuanced, underresearched, and less understood (Bergman, 2013; Keen, Fonseca, & Wintgens, 2008; Skedgell, Fornander, & Kearney, 2017). SM, which historically was thought to be associated with oppositionality and conceptualized as one “electing” not to speak, has been categorized more recently as anxiety-related.…”

“…Another case study demonstrated the treatment efficacy of building self-confidence while employing developmentally informed behavioral strategies, such as modeling, exposures through interactive games, positive reinforcement, and developmentally appropriate psychoeducation, for a 4-year-old female child with SM (Jacob et al, 2013). Given the complex nature of SM, several case studies highlighted the importance of treatments taking a personalized approach for each child (Ale et al, 2013; Conn & Coyne, 2014; Skedgell et al, 2017).…”

“…Despite high comorbidity between SM and social anxiety disorder (85.7%), difficulties relating to comorbid anxiety and potential speech or communication deficits were not addressed specifically in this treatment (Bergman et al, 2013). As such, a multimodal treatment may be most beneficial for young children with SM and other anxiety-related and/or speech or communication difficulties (Muris & Ollendick, 2015; Skedgell et al, 2017).…”

“…In fact, working on a child’s anxiety within the family context, especially with parents who themselves exhibited anxiety, led to more substantial and lasting effects (Creswell & Cartwright-Hatton, 2007). Also, research showed the benefit of multifaceted treatment (Cohan, Chavira, et al, 2006; Skedgell et al, 2017), and Bergman (2013) emphasized that individualizing treatment with creativity is crucial in IBTSM. The novelty of using IBTSM with an attachment focus for a young boy with SM who also had complex comorbidities and complicating factors made for a unique teaching case.…”

“…As such, drawing, interactive games (e.g., a feeling game, Simon Says, I Spy), and Jasper’s personal interests (e.g., dogs, superheroes) were incorporated into treatment, allowing for his engagement and enjoyment. Such activities have been used successfully in previous exposure-based cases (e.g., Hung et al, 2012; Skedgell et al, 2017).…”