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Selective Mutism (References (Oerbeck, B., Overgaard, K. R., Stein, M. B.,…
Selective Mutism
References
Oerbeck, B., Overgaard, K. R., Stein, M. B., Pripp, A. H., & Kristensen, H. (2018). Treatment of selective mutism: A 5-year follow-up study.
European Child & Adolescent Psychiatry, 27
(8), 997–1009.
https://doi.org/10.1007/s00787-018-1110-7
American Psychiatric Association. (2013). Selective mutism. In Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Klein, E. R., Armstrong, S. L., Skira, K., & Gordon, J. (2017). Social communication anxiety treatment (S-CAT) for children and families with selective mutism: A pilot study.
Clinical Child Psychology And Psychiatry, 22
(1), 90–108.
https://doi.org/10.1177/1359104516633497
Capozzi, F., Manti, F., Di Trani, M., Romani, M., Vigliante, M., & Sogos, C. (2018). Children’s and parent’s psychological profiles in selective mutism and generalized anxiety disorder: A clinical study.
European Child & Adolescent Psychiatry, 27
(6), 775–783.
https://doi.org/10.1007/s00787-017-1075-y
Cornacchio. D., Furr, J. M., Sanchez, A. L., Hong, N., Feinberg, L. K., Tenenbaum, R., . . . Comer, J. S. (2019). Intensive group behavioral treatment (IGBT) for children with selective mutism: A preliminary randomized clinical trial.
Journal of Consulting and Clinical Psychology, 87
(8), 730-733.
http://dx.doi.org/10.1037/ccp0000422
Dow, S. P., Sonies, B. C., Scheib, D., Moss, S. E., & Leonard, H. L. (1995). Practical guidelines for the assessment and treatment of selective mutism. Journal of the
American Academy of Child and Adolescent Psychiatry,
34, 836–846.
Schum, R. (2006). Clinical perspectives on the treatment of selective mutism.
Journal of Speech-Language Pathology and Applied Behavioral Analysis, 1
(2), 149–163.
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.).
American Journal of Occupational Therapy, 68
(Suppl. 1). S1-S48.
http://dx.doi.org/10.5014/ajot.2014.682006*
Tier 5: Outcomes & Goals
participate in school-
(Occupational Performance, Role competence)
With adult support and visual cues, client will be able to identify and express his/her needs within the school environment 4 out of 5 opportunities to do so, in one quarter.
engage with peers
(Participation, QOL, Well-being)
Client will acquire two new social skills per quarter to a level of 80% accuracy including initiating conversations with peers and adults, participating in turn taking during structured activities and recognizing positive social interactions.
interact with others
(Occupational Justice, Well-being, Participation, QOL, Health and Wellness, Occupational Performance)
By March, 2020, during school lunch, client will engage in 3 positive or neutral 4-word verbal interactions with cafeteria workers 4 out of 5 occasions over a 1 week period as measured by weekly frequency reporting from direct observations.
Tier 1: Client Overview
Symptoms
Diagnostic Criteria - DSM-V
A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (eg. at school) despite speaking in other situations
C. The duration of the disturbance is at least 1 mo. (not limited to the 1st mo of school)
D. The failure to speak is not attributable to lack of knowledge or, or comfort with, the spoken language required in the situation.
E. The disturbance is not better explained by a communication disorder (e.g. childhood onset fluency disorder) and does not occur exclusively during the course of ASD, schizophrenia, or other psychotic disorder.
B. The disturbance interferes with educational or occupational achievement or with social communication
Diagnostic Features
Children do not initiate speech or reciprocally respond when spoken to by others in social interactions.
Lack of speech occurs with other children and adults.
Will speak at home in the presence of immediate family members, but often not in front of close friends or second-degree relatives such as grandparents or cousins.
Refuse to speak at school, leading to academic or educational impairment, as teacher cannot assess skills such as reading
Usually interfere with social communication, though the child may use non spoken or nonverbal means (e.g. grunting, pointiing, writing) to communicate.
May be eager to participate in social encounters when speech is not required (e.g. nonverbal parts in school play)
Onset usually before 5 y/o, but disturbance may not come the clinical attention until entry into school
Comorbidity
Social Anxiety
Separation Anxiety
Specific Phobias
Prognosis
Prognosis is good with proper diagnosis and treatment.
May face social isolation and suffer academic impairment.
Many "outgrow" the diagnosis, but symptoms of social anxiety may remain.
Incidence & Prevalence
In the United States, 1 in 143 children are diagnosed with selective mutism.
Runs in families. It is estimated that 37% of those diagnosed have a first degree relative who has previously been diagnosed.
Prevalence ranges from 0.03% to 1% depending on the setting such as a clinic versus a school versus the general population.
Race and ethnicity does not effect prevalence.
Somewhat more prevalent in girls (1.5/2:1).
More common in young children that in adolescents.
It is estimated that the incidence/prevalence is lower than what is being reported since children are just not getting diagnosed, and therefore not getting treatment
Tier 3: Evaluation Tools
Selective Mutism Questionnaire (SMQ)
The SMQ is a 23-item parent questionnaire, that determines the likelihood of a child having SM. Parents rate the frequency of their child’s speaking on a 4-point Likert scale: 0 (never), 1 (seldom), 2 (often), and 3 (always).
3 Subscales:
Home/Family: Completed by parents
Public/Social: Completed by parents
School: Completed by teacher
Good reliability, validity, and sensitivity.
The SMQ is used in nearly every study on SM, making it the gold standard of evaluation tools.
This parent/teacher reported questionnaire provides subjective information as to how she is functioning socially at home, school, and out in public. This assessment will provide a baseline of behaviors that can be compared to to determine is treatment is working.
Clinical Observation:
Request videos of the child's behavior taken at home during interaction with parents and at school of interaction with teachers and peers to observe her natural behaviors at home and school.
Traditional observation is unlikely to yield beneficial results as the child will revert to maladaptive behaviors with a stranger present for observation.
Assesses social behaviors with family at home and with peers at school. This allows insight to her roles as a student as well as a daughter. This assessment also addresses her ability to participate in IADLs such as participation in formal education as well as play.
Impairment Rating Scale
Completed by the teacher to measure the child's impairment and academic functioning as a function of their current problem, in this case SM.
Used to determine how the child's problems affect their academic progress
To be diagnosed with SM, the behaviors must interfere with educational or occupational achievement. This assessment will determine to what extent the behavior is interfering with participation in education.
Tier 4: Intervention Approaches
Social Communication Anxiety Treatment
(S-CAT)
Evidence from Klein, Armstrong, Skira, and Gordon (2017).
Following 9 weeks of treatment, children showed significant gains in speaking frequency on all 17 items from the subscales of the SMQ. Children also showed decreased levels of anxiety and withdrawl reported by parents.
Results
Duration of SM symptoms did not impact treatment outcomes.
Teachers did not report reductions in anxiety or withdrawal as parents did.
It may have been difficult for teachers to identify anxiety and withdrawal in the classroom as children sat quietly among peers. Additionally, data collection may have been limited by reduced sample data from teachers who were unavailable during the summer.
Children with better family homework compliance showed greater treatment gains
Children made progress quickly, with results seen after only 3 weeks of treatment, By the end of treatment, 95% showed gains in speaking frequency in school, in public/social settings with people with whom they had not previously spoken, and also at home with babysitters and family friends.
Treatment Goals
A main goal of S-CAT is to reduce children’s anxiety about speaking. During initial interaction with the child, the therapist is to be nonchalant in order to reduce the pressure to speak and increasing comfort by not expecting the child to look at the therapist
Another important goal of S-CAT is to reduce enabling behaviors on the part of the parents and to reduce avoidance behaviors on the part of the children. Parents are taught that the more children avoid, the significant the mutism becomes. Parents are encouraged to refrain from speaking for the child, but rather to provide opportunities for the child to engage in low-anxiety communication acts.
Generalization is promoted from the first session by teaching parents how to implement goals by taking activities from the sessions into public places.
Sessions were held once every 3 weeks, for a total of 3 sessions, with SMQ data recorded immediately before hand. During each session, parents were educated on the importance of homework and generalizing activities to different environments. Weekly phone conversations and communication occurred between the therapist and parents
Our client will benefit most from Establish, restore approach (OTPF)
Continued collaboration between the occupational therapist, teachers, family, and other health professionals will be beneficial for treatment continuity. Adding an SLP to the team, even in a consultative role, will help the client gain confidence in communication skills (Dow et al., 1995).
Form small, cooperative learning groups that include the child's preferred peers
Help the child communicate with peers in a group by first using nonverbal methods (e.g., signals, gestures, pictures, writing) and gradually working toward verbal participation
Watch for opportunities to reinforce small improvements
Reassure others that the child is still comprehending even if he/she is not talking
Try to minimize symptoms—the child may not want to talk, but he/she can point, show, gesture, or draw
Avoid speaking for the child, justifying child's silences, or pressuring the child to speak, all of which may reinforce mutism and anxious behaviors
Support peer acceptance of nonverbal participation in classroom and recreational activities
Find nonverbal jobs that the child with selective mutism can perform to build confidence
Maintain the classroom routine, and try making the same request of the child at the same point in the schedule to decrease anxiety
Try to arrange one-on-one time with the teacher and student so that he/she can seek assistance quietly rather than in front of peers (Schum, 2006)
Frame of Reference
Psychodynamic
Guides occupational therapists to find out the conflicts under the behavior by using various techniques and observing variations in the behavior. The OT can discover the nature of the conflicts that produce the dysfunction. Observation is be necessary since the client is non-communicative. Finding the route of the client’s anxiety as well as observing her in various situations will allow OT to get a sense of her problem list.
Model of Human Occupation (MOHO)
It is the duty of a therapist to find out the problem in volition, habituation, and performance. If there is a problem in one of the subsystems, The therapist will focus on the skill training and primary goal will be to resume his/her occupation. Remediation of occupational dysfunction and problem solving with the person to identify and alter a maladaptive occupational lifestyle,while facilitating engagement in occupation by improving the fit between the person and his or her environment will be beneficial for our client.
Model
Person Environment Occupation Performance (PEOP) model
The PEOP model looks at the interaction between the person, environment, and occupation and how they impact occupational performance. In this case there is a negative interaction between the person and the environment that is negatively impacting the occupation of social communication. This model can be used to identify barriers in order to develop an intervention plan.
Tier 2: Occupational Deficits-
IADL's:
-Lack of verbal communication will affect the client’s ability to care for others outside of her comfort zone, communicate with others, be mobile in the community, manage her health, and express spirituality. Her ability to be safe and communicate an emergency is inhibited as well as her ability to participate in formal education, play, and social participation with peers outside of her comfort group.
CLIENT FACTORS:
Specific mental functions of emotional regulation, as she cannot regulate anxiety.
Global mental functions of temperament and personality as she is introverted, not self-expressed, or confident.
PERFORMANCE SKILLS: All social interaction skills are absent outside of communication with her mother.
PERFORMANCE PATTERNS: Her roles as student, family member, member of the community are all affected by her lack of communication with others.
Complex Case Assignment: Case 3
By Sara Haats & Cindy Canaan