Personalized Individual and Group Therapy for Multifaceted Selective Mutism

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).

The clinical conceptualization of selective mutism has been debated for decades. Selective mutism is currently listed as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013), and many researchers have noted a close connection of the problem to general and social anxiety (Facon, Sahiri, & Riviere, 2008; Vecchio & Kearney, 2005). Many children with selective mutism are characterized as overly shy, reticent, behaviorally inhibited, socially withdrawn, and dependent (Kristensen, 2000). Some children with selective mutism may fear negative consequences for speaking and some experience difficulties in theory of mind, and may thus have trouble accurately judging others’ intentions (Cohan, Price, & Stein, 2006; Popolo et al., 2014). Selective mutism is thus often conceptualized as an anxiety-based condition.

Other researchers have noted, however, that some children with selective mutism may have oppositional problems. As many as 29% of those with selective mutism have oppositional defiant disorder (Yeganeh, Beidel, & Turner, 2006). In addition, some children with selective mutism display tantrums, aggression, stubbornness, manipulativeness, negativity, and disobedience (Anstendig, 1999). Parents note as well that their children with selective mutism can be strong-willed, irritable, argumentative, demanding, and noncompliant (Ford, Sladeczek, Carlson, & Kratochwill, 1998). Refusal to speak may also be seen by others as noncompliance or an anxiety-based reaction (Keeton, 2013).

Clinical profiles of selective mutism also reveal a confluence of anxiety and oppositional behaviors in many of these children. Cohan and colleagues (2008) surveyed parent ratings of anxiety and externalizing behavior problems regarding children with symptoms of selective mutism. Latent profile analyses revealed anxious, anxious-mildly oppositional, and anxious-communication delayed groups. Diliberto and Kearney (2016) evaluated parent ratings of internalizing and externalizing behaviors regarding children formally diagnosed with selective mutism. Exploratory and then confirmatory factor analyses of 18 highly rated items revealed anxiety and oppositional behavior factors. The anxious behavior profile was linked to social anxiety disorder symptoms, social problems, and aggressive behaviors but not oppositional defiant disorder symptoms. The oppositional behavior profile was linked to aggressive behaviors, oppositional defiant disorder symptoms, social problems, and inversely to social anxiety disorder symptoms.

A functional model of selective mutism may be an important behavioral conceptualization that links these various findings. Such a model focuses on operant factors that maintain failure or refusal to speak, which can vary across children and settings (Ale, Mann, Menzel, Storch, & Lewin, 2013). Some maintaining variables of selective mutism involve negative reinforcement or termination of an aversive stimulus. A child may not speak to decrease anxiety in a given situation, to avoid having to display inefficient or underdeveloped speaking skills, or to avoid aversive directives from others. Conversely, some maintaining variables of selective mutism involve positive reinforcement. A child may not speak to increase social or sensory (physical) feedback or attention from others (Kearney & Spear, 2013). Some selective mutism may be due to a combination of these maintaining variables as well.

Varying clinical profiles and functions among children with selective mutism support the need for personalized, multifaceted, and nuanced interventions. Interventions to address anxiety-based or negative-reinforcement-based symptoms in this population often involve exposure-based practices. A child with selective mutism may practice speaking in increasingly difficult or anxiety-provoking situations that are often organized on a hierarchy. Hierarchy items generally entail speaking to a therapist in the child’s home, speaking to a therapist and others in a clinic setting, speaking to a therapist and others in community situations, and speaking to others at school. Hierarchies may also include steps such as mouthing words, whispering, barely audible speech, low-volume speech, and full-volume speech. Frequency and audibility of speech are thus emphasized at each step of a hierarchy (Kearney, 2010).

Exposure-based practices can include stimulus fading, shaping and prompting, and self-modeling whereby a child watches himself speak on videotape as others provide ample reinforcement for the clarity, volume, and beauty of the child’s voice. In addition, exposure-based practices can be linked to social skills training because many children with selective mutism have not spoken publicly for lengthy periods of time, and thus have underdeveloped social skills and few friends. Group therapy may be particularly useful for developing social skills for this population (Sharkey, McNicholas, Barry, Begley, & Ahern, 2008).

Interventions to address oppositional-based or positive-reinforcement-based symptoms in this population often involve parent-based contingency management practices. These practices can include reinforcement or response cost for successful or unsuccessful progress toward treatment goals. Contingency management targets may thus include replication of exposures completed during a therapy session, gradual increases in speech audibility and frequency during natural exposures such as greeting someone in a public place, reduction of compensatory behaviors such as pointing or gesturing, and practicing social skills. Contingency management, like exposure-based practices, may be conducted in individual as well as group therapy contexts for youths with selective mutism (Cohan, Chavira, & Stein, 2006). Such was the case for the child presented next.

2 Case Introduction

Carter was a 6-year-old European American male who was referred to a specialized, university-based outpatient therapy clinic for children with selective mutism and related conditions. Many of the questions posed to Carter were answered nonverbally, such as nodding or gesturing, or via inaudible or barely audible verbal responses. Carter was attending a new school and reported some distress while there because he was largely unfamiliar with the other students and teachers. He reportedly had few friends and indicated he had more difficulty making friends than other children his age. Carter stated that he preferred to be by himself but that he got along well with his parents and two brothers. He did not meet diagnostic criteria for separation anxiety disorder but did report difficulty being away from his parents in some public situations.

Carter reluctantly participated in session and made minimal eye contact. He sat on his mother’s lap during the informed consent process and, when asked to speak to the therapist, would hide his face in his mother’s chest. Carter became tearful and would not let go of his mother’s arm when she attempted to leave the room but agreed to talk to the therapist as long as the door was open and he was able to see his mother sitting outside. During the interview, Carter remained curled up in the chair and chewed on his finger. He hesitated to answer questions, and his verbal speech was often inaudible. However, the therapist engaged in play therapy with Carter after the interview to continue to build rapport.

Carter’s mother, Mrs. C., reported that her son had fewer friends than his peers. She said he had trouble making and keeping friends and felt this was due to his lack of verbal speech and social interaction with his peers. At school recess, for example, Carter would often play by himself or play the same game as his peers near them but without social engagement or interaction. As such, Carter preferred to be home with his brothers or be alone.

Consultation with Carter’s school counselor revealed behaviors that were consistent with selective mutism. These behaviors were most evident in the classroom and included minimal eye contact with his teacher, failure to respond to direct questions, and hiding behind objects when spoken to or otherwise addressed. The school counselor reported no externalizing behavior problems but rather a distinct lack of academic and social participation and engagement.

3 Presenting Complaints

Carter was referred to the clinic primarily for his difficulty entering school and also for a lack of speaking and participation at school and other public situations. Carter himself provided little information on his symptoms, but his parents reported that their son often worried about school, his academic performance, making friends, saying the wrong thing, health of family members, and the status of family relationships. Carter’s worries were most intense regarding school and were manifested in part by inability to sit still, difficulty paying attention, and trouble sleeping.

Diagnostic criteria for selective mutism were met. Mrs. C. reported that Carter refused to speak in school and other social situations when required to speak or asked simple questions. She reported that she and Carter’s father were often frustrated by their son’s lack of verbal speech because he was talkative at home. In public situations, Carter was reluctant to speak or refused to speak. As such, his mother often spoke for Carter, such as ordering for him in a restaurant or answering a question from someone that was directed to her son.

Carter did not meet criteria for attention-deficit/hyperactivity disorder but reportedly made many careless mistakes, was easily distracted and forgetful, had difficulty listening, lacked organization, and often lost items. In addition, he had difficulty staying seated and playing quietly, was restless and unable to finish tasks, talked a lot at home, interrupted others, and had trouble waiting his turn. These behaviors were primarily manifested at home, however. In addition, Mrs. C. reported that her son displayed other externalizing behavior problems that included occasional cruelty to the family dog (e.g., kicking, pulling fur), lying to defer school and house work, and property destruction. Carter met criteria for oppositional defiant disorder. He often lost his temper when things did not go his way, was argumentative and angry and noncompliant, and deliberately annoyed others and blamed others for his mistakes. Mrs. C. stated that these behaviors caused substantial family disruption.

4 History

Mrs. C. reported that Carter’s difficulties began approximately 2 years prior to the assessment. Carter attended a revolving in-home preschool when he was approximately 4 years of age. Carter’s mother sometimes instructed the children in their home, during which Carter would participate only reluctantly. When academic work was conducted at other homes, however, Carter refused to participate. Carter attended a full-day preschool following a family move at age 5 years. At this time, Carter often refused to leave his mother’s side when separating in the morning. A teacher would regularly need to escort Carter to school following his extensive crying and clinging. In addition, Mrs. C. was occasionally required to bring Carter home early from school due to classroom misbehavior.

Following another family move, Carter was enrolled in an afternoon kindergarten at a public elementary school. Carter’s anxiety about attending kindergarten was severe and persistent, especially when his mother drove him to school. On these occasions, Carter became upset and cried during separation and expressed missing his mother while at school. Such separation difficulties were evident in other situations as well, such as a church-based classroom and birthday parties. Carter did enter kindergarten with less difficulty when other adults drove him to school. He had few classroom misbehaviors and none that required early departure from school. However, he answered only yes/no questions for his teacher and only when she provided him with mints as positive reinforcement.

5 Assessment

The assessment of selective mutism is often designed to evaluate the specific parameters and functions of a child’s failure or refusal to speak as well as related conditions such as school refusal behavior. Behavioral assessment is thus most common to this population and can involve interviews, questionnaires, daily monitoring, observations, and review of academic and other records. Interviewing children with selective mutism can be challenging, though some respond nonverbally to yes/no questions. Interviews with parents, teachers, and other relevant adults are often more productive. Structured diagnostic interviews are available, but key questions can be administered in semistructured fashion. Key topics include diagnostic criteria, specific settings in which a child has difficulty speaking, range of speaking behavior in each setting, circumstances surrounding failure to speak (e.g., to reduce anxiety or avoid aversive directives), contextual factors that can impact a child’s failure to speak (e.g., trauma, language ability), and how significant others respond to a child’s failure to speak in public situations (Kearney, 2010).

The Selective Mutism Questionnaire (SMQ) assesses a child’s willingness to speak to others in school, home/family, and public/social situations. Similarly, the School Speech Questionnaire (SSQ) is completed by a teacher regarding school-based speaking behavior (Bergman, Keller, Piacentini, & Bergman, 2008). Other questionnaires that are relevant to cases of selective mutism include child self-report measures of internalizing problems such as general and social anxiety and depression as well as parent/teacher checklists for internalizing and externalizing behavior problems (Fisak, Oliveros, & Ehrenreich, 2006).

Daily monitoring and behavioral observations are key to assessing children with selective mutism. Parents and teachers may record number of words spoken, mouthed, or whispered that day across several situations. Adults can also rate audibility of words spoken, to whom a child spoke, and oppositional problems such as noncompliance to parent commands to speak. Behavioral observations of children with selective mutism are often conducted at home, in public situations, and at school (Jackson, Allen, Boothe, Nava, & Coates, 2005). Observations may be useful as well during formal speech and language assessment. Carter’s assessment involved a structured diagnostic interview and parent and teacher checklists of behavior problems as well as observations.

6 Case Conceptualization

Carter’s assessment revealed a confluence of anxiety-based and oppositional behavior problems. He met diagnostic criteria for selective mutism as well as oppositional defiant disorder via the Anxiety Disorders Interview Schedule for Children (Silverman & Albano, 1996). In addition, he had elevated scores on the Child Behavior Checklist (CBCL) for anxiety and oppositional behaviors as well as anxiety but not oppositional behaviors on the Teacher’s Report Form (TRF; Achenbach & Rescorla, 2001). Carter appeared to be anxious at school but did not display severe or frequent externalizing behavior problems once inside his classroom.

Consultation with Carter’s guidance counselor and teacher revealed that Carter’s social behavior at school was problematic. He was reportedly afraid of his peers and often tilted his head down, folded his arms across his chest, and hunched his back when peers were near or approached him. He consistently avoided answering questions in class, working or playing in groups, playing at recess, and having his picture taken. His social anxiety abated somewhat in situations where peers were younger than he and when the group size was smaller. Carter would sometimes speak when prompted but often sulked and needed to calm himself for an extended period once he entered the classroom.

The school officials noted, however, that Carter’s most immediate behavior problem was his refusal to enter the school building. A descriptive and experimental (observational) functional analysis (Kearney & Spear, 2013) revealed that Carter’s school refusal behavior was motivated primarily by pursuit of attention from others, most notably his mother. A secondary function was avoidance of school-based distress that intersected with his avoidance of social and academic tasks. Prescriptive treatment for such cases typically involves a combination of exposure-based practices with parent-based contingency management practices (Kearney & Albano, 2007).

Carter’s selective mutism mirrored his school refusal behavior to some extent. Carter was anxious about speaking at school and to others in public situations. He was also quite oppositional and noncompliant in both speaking and nonspeaking situations, often forcing parental attention and acquiescence to respond to others for him. Carter’s overall behavior problems clearly interfered with his and his family’s ability to function on a daily basis. Carter’s most urgent problem at the time of treatment, however, was his general unwillingness to enter the classroom. The therapist saw this as an opportunity to introduce interventions for Carter’s school refusal behavior that would lay the groundwork for treating his anxiety- and oppositional-based selective mutism, which was maintained by similar operant factors, at a later point.

A functional model of selective mutism may be an important behavioral conceptualization that links these various behaviors. Maintaining variables of selective mutism based on negative and positive reinforcement can be identified for instances of failure or refusal to speak as well as externalizing behavior problems that supersede mutism behaviors. In many cases of selective mutism, a pre-therapy process is needed to address the most urgent misbehaviors (e.g., school refusal) that face a family and that set the stage for more parental investment during later exposure-based treatment. In addition, a selective mutism treatment process, even when group-oriented, often contains many instances where techniques must be modified to address resistant behaviors and refusal to speak in addition to exposures. This underscores the need in many of these cases to address both failure and refusal to speak in different situations.

7 Course of Treatment and Assessment of Progress

Personalized individual treatment initially focused on Carter’s school refusal behavior and its attention-seeking nature. Carter attended the first session with his mother and brothers but was reserved and hesitant to speak to the therapist. He was compliant with the therapist’s request to play board games but would display overexcited laughter for no reason and babble in nonsense syllables repeatedly when responding to the therapist’s questions. Carter refused to participate in progressive muscle relaxation and instead giggled at himself.

Parent-based contingency management began with an outline of Carter’s morning routine that included school preparation (7:30-8:45 a.m.), errands with his mother and/or time at home to complete schoolwork (8:45-11:30 a.m.), lunch at home (11:30 a.m.-12:30 p.m.), departure for school (12:40 p.m.), and entry into school (12:50 p.m.). Carter’s mother drove her son and others to school on Mondays and Wednesdays, and other parents drove Carter to school on the other weekdays. Carter had less problems entering school when others drove, but refused to complete schoolwork, engaged in tantrums, attempted to negotiate staying home, or prolonged a delay in separation when his mother drove.

The therapist provided psychoeducation on school refusal behavior and discussed Carter’s negative attention-seeking behaviors. The therapist described contingency management practices and the importance of their consistency and structure with respect to the family’s morning and afternoon routines. The initial step in this direction involved Carter and his mother working on school-related activities approximately 1 hr prior to starting kindergarten each day. In addition, Carter was expected to participate in a designated “work time” after school where the entire family was at a table with homework or an activity to complete. Compliance in these areas would be rewarded with access to television or computer. In addition, Mrs. C. was encouraged to minimize the amount of time needed to facilitate Carter’s entry into school on days that she drove.

The second individual session began with efforts to enhance rapport with Carter via drawing activities and conversational topics of Carter’s choosing such as his dog and favorite movies. Carter had been predictably angry and displayed temper outbursts in reaction to his parents’ decision to implement more structure in the daily routine. Carter did not comply with several requests to complete morning responsibilities such as eating breakfast, bathing, and dressing. He also asked repeatedly for explanation of the new rules in place regarding his routines, and Mrs. C. noted that she took the time to provide the explanation to him each time. The therapist and Mrs. C. discussed strategies for managing Carter’s anger, including disengagement from negotiating and pursuing additional support systems such as a grandmother and family friends from church.

The third individual session involved some direct conversation with Carter, who willingly responded to nonschool questions but refused to speak, giggled, or redirected the conversation when asked about school topics. Therapeutic rapport was continuously enhanced through drawing activities. Mrs. C. indicated that Carter’s compliance to the new daily routine had improved but that it was still difficult to get Carter out of the house on time for school. The therapist and Mrs. C. discussed strategies for managing Carter’s reluctance to comply with her requests and be prepared to leave for school on time. Interactive and decorative contingency management charts for the bathroom, kitchen, and front door with no more than three tasks on each were to be established. In addition, Mrs. C. was encouraged to alter her commands to allow for only one instruction at a time and to set a time limit for compliance.

The fourth individual session revealed that Carter’s noncompliance had decreased throughout the week and that Carter willingly left the car to walk into the school building. Mrs. C. felt that establishing three contingency management charts, one each for the morning, before school, and after school routines, was helpful in this regard. Each chart had approximately three to four tasks and a movable tab for Carter to use once he completed each task. Each chart was linked to a specific reward that was proportionate to the task and that immediately followed compliance.

Mrs. C. expressed concern about a recent incident at school where a classroom activity involving several parents led Carter to cry and refuse to participate. Carter’s teacher was able to calm him by allowing him to assist without participating, but Mrs. C. said this pattern resembled those in other public situations such as restaurants and supermarkets. In addition, Carter was reluctant to speak to the therapist at the beginning of the session and often pointed at objects or state just one word to communicate. Drawing activities were instituted but Carter responded only to non-school-related questions. The therapist discussed an upcoming group for children with selective mutism with Mrs. C.

The fifth individual session revealed continued improvement in the daily routines as well as Carter’s compliance with respect to school attendance. Carter completed tasks on his contingency management charts without being reminded and despite several family disruptions during the week, and the family had identified small rewards (e.g., fruit-flavored chap sticks) that incentivized Carter’s compliance. However, he displayed several instances of anxiety at school. The therapist spent the second part of session with Carter. He was reluctant to speak to the therapist and instead pointed at objects or used just one word to communicate. The therapist prompted Carter talk in full sentences to which he responded variably.

Five additional individual sessions followed. Carter generally displayed good compliance to the daily routines and to school attendance expectations. In addition, his externalizing behavior problems declined substantially. A slip in progress occurred following an extended holiday break, during which Carter displayed some crying and yelling as he was escorted into school, as well as refusal to participate in class. The latter occurred in the presence of a substitute teacher. Appropriate consequences were implemented for Carter’s misbehavior, which were effective. Drawing activities, anxiety reduction techniques, and school consultation were ongoing during these sessions.

The therapist and Mrs. C. also discussed information regarding the selective mutism group treatment and mutually decided that the group would be a good fit for Carter and his family. Mrs. C. said her son continued to refuse to participate in activities requiring social interaction and that his speech with others outside of home remained severely limited in frequency and audibility. Carter had refused to participate in a school holiday production, a medical doctor examination, and occasional discussions with the therapist. He also reported substantial fear related to play dates, grocery stores, restaurants, and church, and often displayed compensatory behaviors such as waving, head nods, and whispers. Carter did attend one birthday party but became quite distressed and began crying in a corner when the festivities became loud and chaotic. Carter’s family attempted to draw him into other social situations as well, but with varying success. Carter indicated that new people, particularly adults, upset him and that his distress increased when adults tried to comfort him.

The selective mutism group consisted of Carter and two girls his age. Parent components of the group treatment, which were conducted separately from the child components, included contingency management-based practices. Child components of the group treatment included anxiety reduction techniques. Both parent and child components also included exposure-based practices (Table 1). The combination of anxiety and contingency management procedures was considered a good fit for Carter given his treatment to this point and given that his selective mutism, including noncompliant behavior within the therapy context, was maintained by operant factors similar to his school refusal behavior.

OPEN IN VIEWER

Table 1.

Summary of Selective Mutism Group Therapy Targets.

Session	Parent targets	Child targets
1	Psychoeducation, somatic anxiety management techniques	Puzzle activity with soft speech
2	Psychoeducation, somatic anxiety management techniques	Self-modeling
3	Construct community hierarchies	Speech with therapist and staff
4-5	Implement community hierarchy tasks, earn and return cards for teachers	Exposure activities simulating a classroom
6	Implement additional community hierarchy tasks	Read stories before others and speak to staff members
7	Develop a school hierarchy and engage in child advocacy	Read stories before others and speak to group members (social skills)
8-12	Implement items from school hierarchy and implement higher level community tasks	Increased difficulty of speaking expectations as well as outside activities during the session, including social skills

The first session of the parent component of the selective mutism group initially involved psychoeducation on selective mutism and its symptoms and risk and maintaining factors. Somatic anxiety management techniques were introduced as well, including diaphragmatic breathing and progressive muscle relaxation. An overview of session numbers and treatment goals followed. Weekly speech and anxiety worksheets for parents, teachers, and the child were distributed; each was to provide ratings of anxiety and number of words the child spoke in public to people other than family members. Parents were instructed to bring a 5-min video of their child speaking for self-modeling purposes. Carter’s parents attended and expressed concern about their son’s defiance in response to increased expectations for speech.

The first session of the child component of the selective mutism group initially involved establishing rapport among the children as well as with the therapist. The therapist utilized various activities and games to engage the children (e.g., drawing, puzzles, “Go Fish,” and feather blowing). Carter was reluctant to enter the therapy room but eventually followed the therapist without clinging to his mother. Carter sat in the corner of the room facing the wall and refused to engage with anyone for 15 min. He declined to make a name card or draw a picture of himself or the way that he currently feels, instead opting to work alone on a puzzle in the corner. Once the therapist brought out a second puzzle and invited the entire group to work on it, Carter completed his name tag and joined the group to help assemble the puzzle. He made soft comments about the puzzle (e.g., “I think this piece goes here”) and exhibited positive affect (e.g., smiles and laughter). Carter earned a prize for making eye contact, waving to a front desk staff member, and producing the funniest noise in a feather blowing contest. Carter was able to say “thank you” to the therapist and give her a high five at the end of the session.

The second session of the parent component of the selective mutism group involved a review of speech successes that occurred over the past week and the outcome of the assigned breathing exercises. This practice was repeated at each subsequent session. Psychoeducation was conducted regarding behavior therapy for selective mutism, including hierarchy development, compensatory behaviors, and nonverbal goal-directed behaviors. Parents were administered worksheets for the upcoming week and asked to bring their child’s favorite book to session. Carter’s parents were present. They expressed some difficulties with school attendance that were triggered by Carter’s failure to ask a teacher’s aide to use the restroom. They discussed incentives for Carter’s behavior that were based on progress made in the individual sessions and indicated that all of their sons enjoyed the breathing exercises.

The second session of the child component of the selective mutism group involved constructing individualized hierarchies for verbal speech situations in the community. The therapist utilized various activities and games to engage the children (e.g., feather blowing, Simon Says). Carter was reluctant to attend the session and did not participate in the activities and games. He did participate in a card game with an assistant in a corner but later engaged in negative attention-seeking behaviors such as throwing crayons and poking the therapist. Carter was later able to engage in verbal speech with the therapist and the assistants but not with other group members. Carter became visibly uncomfortable (e.g., flushed cheeks, chewing on his shirt) when prompted to speak with the group. The therapist was able to construct Carter’s hierarchy for verbal speech situations in the community environment despite his reluctance. Carter was also able to watch his verbal speech home video with the other group members. The therapist and other group members provided positive reinforcement via applause and positive affect throughout Carter’s video. Carter earned a prize for whispering “see you next time” to the therapist privately at the end of the session.

The third session of the parent component of the selective mutism group involved constructing individualized community hierarchies for each child. These hierarchies included various situations that could occur in parks, restaurants, malls, supermarkets, and churches, among other public places. Parents were asked to implement the first tier of their child’s hierarchy 3 to 4 times during the upcoming week. Mrs. C. indicated that her son was stressed at the beginning of the session because he had trouble transitioning into the session and was crying and clinging to her. She described Carter’s anxiety during the past week as variable, especially at school. Mrs. C. was encouraged to help Carter role-play walking into therapy and school so that he would be more comfortable with each situation. Mrs. C. chose the grocery store to be Carter’s first community hierarchy setting.

The third session of the child component of the selective mutism group involved relaxation techniques (e.g., belly breathing, progressive muscle relaxation) and in-session exposure activities (i.e., watch verbal speech home video, play “Go Fish,” read to the therapist). Carter initially engaged in negative attention-seeking behaviors and clung to his mother. An assistant sat with him in the hallway for 50 min. Carter thus did not participate in the relaxation techniques or watch the verbal speech home videos. Carter eventually warmed to the assistant and entered the therapy room to participate in a card game. Once Carter entered the therapy room, he engaged in limited verbal speech with the therapist and assistants. At the end of the session, Carter earned a prize for reading a book aloud to the therapist.

The fourth session of the parent component of the selective mutism group involved a review of each child’s community hierarchy. Problem solving was utilized to discuss barriers or concerns to implementing each child’s initial hierarchy item. In addition, the importance of communication with teachers was discussed, and “earn and return” cards were distributed. Earn and return cards were used by teachers to punch a hole when one of the children in the group would speak in class. A fully punched card (10 slots) meant the child could earn a prize from a classroom treasure box. Parents were instructed to implement the tier of their child’s community hierarchy appropriate for their child (either first or second) and give the earn and return card to their child’s teacher. Carter’s parents said their son was initially quite anxious when responding to a cashier but was able to say hello on a second attempt. Carter also ordered his own food at a restaurant without being prompted. Appropriate rewards were provided.

The fourth session of the child component of the selective mutism group involved continued practice of the relaxation techniques (e.g., belly breathing, progressive muscle relaxation) as well as exposure activities that simulated a classroom environment (i.e., reading to the therapist and practicing raising hand/answering questions). Carter entered the therapy room without difficulty but refused to participate in the relaxation techniques. He was able to earn prizes for entering the room without difficulty; making eye contact with the front desk staff and saying “Hi, nice to meet you”; and reading a book aloud to the therapist and an assistant. Carter participated in a “Questions Game” by raising his hand and answering questions from the therapist and the assistants in the presence of other group members (e.g., “What does 1 + 1 = ”) as well as volunteering to be the leader of the game by asking the questions himself (e.g., “Who’s favorite color is blue?”; “Who has seen the movie The Little Dinosaur?”).

Carter and his parents did not attend the fifth session of the selective mutism group, but this involved a review of each child’s community hierarchy that included how parents could help generalize speaking to other community situations. Parents were also reminded about compensatory behaviors and their reaction to them. Parents were also asked to inquire with school officials about practicing speech on school grounds when no other children are there (e.g., before or after school hours). Children in the group practiced relaxation techniques (e.g., belly breathing) and engaged in exposure activities similar to the classroom environment (i.e., reading to the therapist and answering questions). The various activities of the group included “Red Light/Green Light,” and the question game (e.g., “What color is your shirt?”) in which participants read the question and chose someone to direct the question. The children then participated in a game of “Go Fish” with other group members and were asked to verbally communicate throughout. They were also instructed to speak with a front desk staff person by initiating contact and responding to questions.

The sixth session of the parent component of the selective mutism group involved a review of progress on the community hierarchies as well as psychoeducation regarding collaboration with school officials for upcoming treatment of selective mutism in classrooms. Parents were encouraged to implement the next tier of their child’s community hierarchy as appropriate. Mrs. C. reported that Carter continued going to the store and talked to a butcher, paid for the meat, and talked to a cashier. Carter also spoke in adequate tone to a worker at an indoor playground as well as a substitute teacher he was comfortable with at school. Appropriate rewards were given.

The sixth session of the child component of the selective mutism group involved more intense exposure assignments to elicit verbal speech. Carter entered the therapy room without hesitating and participated in the first activity. He willingly answered questions from the therapist and the assistants about his drawing and provided spontaneous comments. Carter also read a story aloud in front of the therapist, assistants, and other group members. He participated in a “Questions Game” by reading each question aloud and answering questions directed to him. Carter earned a prize for saying “Hello” and “How are you?” to two separate staff members and for responding to their questions (e.g., “What is your name?”). He was also able to earn a prize for saying “Good-bye” to the therapist and for answering one question at the end of the session in front of his mother and other group member’s parents.

The seventh session of the parent component of the selective mutism group involved a review of homework assignments regarding their child’s community hierarchy and their ability to accompany their child to the school setting to practice speaking on the playground and/or the hallways. Parents were also provided with additional information regarding a local child advocacy agency and how to effectively advocate for their child. Parents developed the initial five steps of a school hierarchy for their child. In addition, information was provided on documentation to give to each child’s school regarding possible accommodations for selective mutism. Carter’s parents reported that he had helped conduct errands in the school setting (with another peer) by delivering notes to teachers and speaking with them. They reported interest in having him conduct errands without peer support. Carter also spoke with the cashier at the grocery store but froze on one occasion when asking a worker for food.

The seventh session of the child component of the selective mutism group involved ongoing exposures to elicit verbal speech. Carter spoke to the therapist while checking in at the front desk with his mother, and entered the therapy room, but refused to watch his home video or practice relaxation techniques. Instead, Carter sat in the corner of the room and chewed on his shirt. The therapist utilized one-on-one time to expose Carter to reciprocal conversation about topics while walking around the clinic. Carter was paired with an assistant who took him to various playrooms. Carter was able to engage in one-on-one audible conversations with the assistant throughout the exposure, as well as say “Hi” and give high fives to other group members later. Carter also participated in a silly noise activity and made audible animal noises in the presence of other group members (e.g., “meow,” “woof,” “roar”). At the end of the session, Carter earned a prize for making an animal noise to the therapist in front of his parents and for saying “Good-bye” to other group members.

The eighth session of the parent component of the selective mutism group involved a review of homework assignments as well as collaboration with each child’s teacher. Parents completed the weekly speech homework assignment page and shared their ideas and brainstormed solutions with other parents. Parents were asked to implement the next tier of their child’s community hierarchy that was appropriate for their child. Parents were also asked to implement the first tier of their child’s school hierarchy. Mrs. C. explained that Carter did not like therapy because he is the only boy in the room and that he preferred individual therapy. However, Carter was successful at speaking at a children’s museum, wilderness preserve, and café. He was rewarded via a golf outing with his father. Carter’s upcoming assignments included conducting an errand at school alone, entering the school office to ask for something and then distributing it to his class, and asking for a dessert menu at a restaurant.

The eighth session of the child component of the selective mutism group was to continue exposure assignments to elicit verbal speech. Carter entered the therapy room and answered questions about relaxation techniques (i.e., belly breathing and progressive muscle relaxation) to the other group members. However, Carter refused to actively engage and practice the relaxation techniques. Carter participated in a silly noise activity and made audible animal noises in the presence of other group members (e.g., “meow,” “woof,” “roar”). As a reward for participating in the noise activity, the therapist took the group members to play outside. Carter was also able to answer questions about an earned prize (e.g., “What did you pick?”; “What color is it?”) in an audible tone in the presence of other group members and their parents.

The ninth session of the parent component of the selective mutism group involved a review of homework assignments, and all parents were able to communicate with their child’s teacher. Parents were asked to continue to implement the community and school hierarchies. In addition, parents ended their time early in Sessions 9 to 12 to participate in the main exposures (e.g., ordering food, playing games) conducted in the child component of the group to model appropriate prompting and reinforcing. Carter’s parents expressed that he had behaved and spoken well in school the last few weeks and even did fine when his school had a lockdown. Carter also conducted errands without a peer and was reportedly more comfortable in school. He also attended a birthday party by himself for an hour. Carter’s parents decided to implement a point system instead of providing immediate rewards for completing speech goals.

The ninth session of the child component of the selective mutism group involved exposure assignments to elicit verbal speech. Carter entered the therapy room without reluctance and participated in all activities throughout the session. He was able to make audible animal noises in an adequate tone in the presence of other group members (e.g., “meow,” “woof,” “roar”). Carter was also able to read a book aloud in an adequate tone in the presence of other group members. When other group members read their books, however, Carter twirled in his chair and went to a corner to cry. The therapist ignored his behavior and Carter returned to the group after 2 min and listened to the other group members read their stories. Carter also participated in a game of tag outside and yelled “You’re it” to the person he was tagging. He was able to consistently yell and scream appropriately and give high fives to other group members during the game. During the last part of the session, Carter earned a prize for ordering from a sandwich shop on the college campus by himself. Carter was responded to an employee’s questions: “What kind of cookie do you want?” and “How many cookies would you like?” Carter responded in an audible tone, provided spontaneous speech throughout the interaction, and ended the conversation by telling the employee to “Have a good day.”

The 10th session of the child component of the selective mutism group involved additional exposure assignments to elicit verbal speech. Carter entered the therapy room without reluctance and participated in all activities throughout the session. The therapist introduced a new game to the group members to engage in verbal speech (i.e., “Conversation Cubes”). Carter was able to read various questions and answer in an audible tone while in the presence of other group members. Carter was also able to make audible animal noises in the presence of other group members (e.g., “meow,” “woof,” “roar”). Carter also participated in a game of Duck, Duck, Goose and uttered words in an audible tone. Carter also maintained this level of speech while participating in the game with other group members’ parents. Mrs. C. said she was pleased with Carter’s progress and that he participated in an activity at school 3 times. Carter’s new goal was to enter the first-grade classrooms, deliver a note, and speak to the teacher.

The 11th session of the child component of the selective mutism group involved a substantial number of activities with unlimited prizes for speaking audibly. Carter participated in all activities throughout the session. Carter answered various questions and read multiple books audibly in the presence of other group members. He refused to participate in one game but his mother, who was participating with him in the game, disengaged from him to provide a disincentive. Carter later earned a prize for speaking audibly to a staff member. Carter’s progress was to the point that his next session would be his last. Mrs. C. reported that her son was able to enter other classrooms and speak with other teachers.

The 12th and final session of the child component of the selective mutism group for Carter involved additional assignments to elicit verbal speech. Carter participated in all activities throughout the session. The therapist informed other group members that this session would be Carter’s last. Carter participated audibly in all activities and successfully answered questions from a staff member without reservations. Carter received a certificate of completion from the therapist, and other group members provided praise (e.g., applause, high fives) for his hard work during the group treatment. Suggestions for maintaining treatment gains were provided, and summer plans were discussed. Carter’s parents said their son successfully practiced for his end of year school program and sang with his class. They reported that treatment was most helpful via the use of hierarchies, rewards, using parent time as an incentive, and working together, especially to reduce his distress-related and attention-seeking behaviors.

8 Complicating Factors

Selective mutism and its treatment can be marred by several complications, some of which were evident in this particular case. A key complication is delayed treatment, which often occurs because parents believe their child’s mutism is the result of simple shyness that the child will outgrow. Carter’s family would have likely benefited from earlier treatment. In addition, some parents of children with selective mutism can be reserved themselves and not completely invested in exposure-based practices. Parents may acquiesce to compensatory behaviors or shelter their child from extracurricular and social activities. Many parents require a detailed rationale for treatment to enhance their cooperation for difficult child tasks such as practicing speech in unfamiliar situations, attending social events independently, and controlling intense emotions.

In Carter’s case, his parents were well practiced at acquiescing to his demands to remain home from school and his failure or refusal to speak in various situations. This required extensive efforts at the beginning of the treatment to outline the variables that maintained his behavior, particularly attention and avoidance of school-based and other tasks, and reorient the parents toward effortful practices to change their responses to Carter. In addition, because treatment of selective mutism can be lengthy and heavily reliant on self-practice, parental adherence can be challenging. In Carter’s case, his father’s work schedule prevented him from helping with morning and after school routines, and the parents did not have extended family or many friends in the area. As such, many of the home- and community-based treatment assignments were conducted by Mrs. C., which was enormously taxing for her and led to variable progress.

Another complicating factor for selective mutism treatment involves non-English-speaking parents who rely primarily on another language at home. Home visits, use of interpreters, and collaboration with multilingual school personnel are important in these cases (Jacob, Suveg, & Shaffer, 2013). Parents are also encouraged to practice English at home if this is the dominant language at their child’s school. Many children with selective mutism also have developmental delays in speech and language, so special considerations in clinic and school settings will be necessary. Such considerations may entail nonverbal formal testing and interventions to enhance expressive and receptive syntax, phonology, and vocabulary.

Successful treatment of selective mutism will also require substantial cooperation from school officials, especially guidance counselors and teachers. Children with selective mutism are often most reluctant to speak in school-based situations, so extensive in-school exposure sessions are needed. This could involve a therapist who works with a child in nonclassroom settings (e.g., playground, hallways) or in a classroom in nonintrusive ways. Later practices would ideally be conducted by the teacher who would provide incentives for spontaneous speech where appropriate or for speech provided in response to an academic task or demand. Therapists should work closely with school officials early in the treatment process to determine what treatment techniques will be most feasible and whether daily evaluations of speech frequency and audibility are possible.

9 Access and Barriers to Care

A key barrier to care for youths with selective mutism is the availability of mental health professionals who are willing to accept cases that can be quite intense and of long duration. As seen in Carter’s case, treatment for selective mutism can involve many sessions and frequent out-of-office exposures, which can be taxing for the therapist and costly to parents. Outcome studies for selective mutism are often in specialized, university-based clinical settings, but wider dissemination of extant practices and the development of more concise but equally effective treatments are needed. Increased use of technology for this population is encouraged as well (Bunnell & Beidel, 2013). School officials, particularly school psychologists and speech pathologists, would be excellent choices for a dissemination model (Conn & Coyne, 2014).

10 Follow-Up

Immediate follow-up after treatment termination revealed nonclinical scores on the CBCL and TRF scales mentioned earlier. In addition, Carter no longer met criteria for a mental disorder. Follow-up with Carter and his family was also conducted via telephone 6 months after treatment termination. The family had moved to another state but Carter was adjusting well to his new classroom. He did not engage in temper tantrums while going to school or at school during the new academic year. Mrs. C. reported that she has been able to work with her son’s school officials to implement several skills they utilized in group treatment. Carter was able to meet with his teacher before school began and was introduced to his classroom because he was new. In addition, behavior charts with positive reinforcement were established. Mrs. C. said that Carter speaks well at school, less so than at the end of the previous academic year but more than before treatment. He has also developed friendships that have helped his transition to classes that are new to him such as physical education and art. Mrs. C. expressed satisfaction and gratitude regarding the therapeutic approach.

11 Treatment Implications of the Case

Carter’s selective mutism and its treatment carry several implications. First, consideration of selective mutism as a purely anxiety-based condition can be detrimental to the case conceptualization process. Clinicians must assess for other underlying processes and functions that maintain failure or refusal to speak in public situations, as was true for Carter. Second, a personalized approach to selective mutism is often needed given the nuanced nature of many of these cases. Carter benefited from a combination of procedures that focused on his anxiety as well as his oppositional behavior. In addition, he benefited from individual behavioral therapy (parent management strategies) first to address serious and urgent externalizing behavior problems prior to group treatment that enhanced his frequency and audibility of speech as well as his social skills. Collaborations with school officials during the individual therapy process also laid the groundwork for cooperation during the exposure-based treatment for his refusal to speak in the classroom. Finally, the combination of individual and group treatment allowed for an in-depth and intensive intervention process that addressed several intransigent behavior problems.

12 Recommendations to Clinicians and Students

Many cases of selective mutism are complex. Failure to speak in public situations is often conflated or confused with shyness, anxiety, oppositionality, and communication problems. Keen, Fonseca, and Wintgens (2008) provided several recommendations for this population. First, many professionals in and outside of the educational system must become more familiar with the key features of selective mutism and its assessment and treatment. Therapists must work collaboratively with speech and language pathologists and school and educational psychologists, and these school officials must work collaboratively with regular and specialized teachers to successfully resolve cases of selective mutism. Parents must be invested in these collaborations as well.

Second, earlier screening for selective mutism is needed. Parents and school officials often wait until a child fails to make friends or fails an academic task before taking action, but early intervention following a multidisciplinary assessment approach would prevent problems related to selective mutism from spiraling. A full range of problems should be assessed in addition to speech frequency and audibility. Such problems can involve the comorbid problems discussed here as well as key family variables that may contribute to a child’s reluctance to speak. In related fashion, little is known about older children and adolescents with selective mutism, but intervention for this age group is likely to require even greater intensity and duration.

Finally, treatment for children with selective mutism should not end once a child can adequately speak at school. Many of these youths will still need assistance with friendship development, social skills, impulse control, academic tasks, and advanced anxiety management. In addition, these youths must continue to strive to improve their social functioning in a range of locations and with different people to prevent relapse. Selective mutism is a long-standing condition with a potentially poor prognosis, so a comprehensive and vigilant intervention plan must be pursued in many of these cases.