Behavior Observations for Linking Assessment to Treatment for Selective Mutism
Shriver, Mark D., Segool, Natasha, Gortmaker, Valerie, Education & Treatment of Children
Selective mutism is a childhood disorder that most school psychologists and educational providers will come across at least once in their careers. Selective mutism is associated with significant impairment in educational settings where speaking is necessary for academic and social skill development. Effective treatments for selective mutism typically involve shaping or stimulus fading procedures. Choosing an effective treatment strategy for a child with selective mutism is dependent upon careful analysis of data gathered during the assessment process. This article focuses on behavior observations as a primary source of data for effective decision making regarding treatment for selective mutism. Previous literature on behavior observation and selective mutism is reviewed and guidelines are presented for decision making based on observational data. This article presents two case studies that illustrate the use of observational data for treatment decision making. In addition, the role of behavioral observations to inform selective mutism treatment decisions in practice and the need for future research on this topic are discussed.
Selective mutism is a disorder that is typically noticed during childhood and characterized by a child's almost complete lack of speaking in certain situations or settings but adequate speaking in other situations and settings, most often at home and/or with family members. The classroom is often the setting where a child's lack of speech becomes most noticeable and may be most problematic due to academic and social expectations in school. In mental health settings, the prevalence for selective mutism is reportedly low, with a prevalence of less than 1% (American Psychiatric Association, 2000; Elizur & Perednik, 2003). It is likely that the observed prevalence of selective mutism in schools may be higher, however, as the classroom is the setting in which impairment may be most likely observed (Bergman, Piacentini, & McKracken, 2002; Kumpulainen, Rasanen, Raaska, & Somppi, 1998). It seems likely that psychologists working in schools will come across at least one child with selective mutism sometime in their careers.
Although etiology is unclear contemporary research on selective mutism suggests that it is an anxiety-related disorder, or at least frequently co-occurs with anxiety (Black & Uhde, 1995; Vecchio & Kearney, 2005). Conceptualizing selective mutism as an anxiety disorder implies that there is an adverse physiological arousal of the autonomic nervous system in response to certain stimuli. For children with selective mutism, it may be that anxiety (i.e., the averse physiological response) occurs in the presence of people outside the family context. It is not clear what the controlling variable(s) is that elicits anxiety for children with selective mutism. For example, anxiety may be elicited by the mere presence of other people, or when the attention of others is directed toward the child (i.e., looking at the child, speaking to the child) or by the act of actually talking to others. It is more than likely that the functional variable(s) is different for each individual child. Although anxiety is a common construct invoked in mainstream psychology, behavioral conceptualizations of anxiety-related disorders are not yet well established empirically or theoretically since anxiety as a term encompasses such a broad array of responding (Dymond & Roche, 2009; Friman, Hayes, & Wilson, 1998). What is clear, however, is that over time a child learns alternative responses to speech (i.e., silence) in the presence of others and/or in the presence of particular situations and settings.
Treatment for selective mutism has typically focused on behavioral and pharmacological interventions. This article focuses primarily on behavioral interventions (see Carlson, Mitchell, & Segool, 2008 for a review of pharmacological treatments for selective mutism). …