Daily Archives: August 24, 2010

Selective Mutism (SM)

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Selective Mutism (SM; 313.23), formerly known as Elective Mutism, typically manifests when a child demonstrates language competence in some situations but fails to speak in others.  (Beare, Torgerson, & Creviston, 2008)  It is also not due to a speech and language problem, e.g. apraxia.  (Moldan, 2005, p. 291)  The DSM-IV-TR diagnostic criteria for 313.23 SM are:

  1. Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.
  2. The disturbance interferes with educational or occupational achievement or with social communication.
  3. The duration of the disturbance is at least 1 month (not limited to the first month of school).
  4. The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
  5. The disturbance is not better accounted for by a Communication Disorder (e.g., Stuttering) and does not occur exclusively during the course of a Pervasive Development Disorder, Schizophrenia, or other Psychotic Disorder.

Instead of communicating by standard verbalization, children with this disorder may communicate by gestures, nodding or shaking the head, or pulling or pushing, or, in some cases, by monosyllabic, short, or monotone utterances, or in an altered voice.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 126)  SM appears most often in extremely shy children with social anxiety. Those who are at higher risk have a close relative with either a history of SM, extreme shyness, or social phobia.  (Sloan, 2007)  The stakes are high for kids who have been diagnosed with SM.  A follow-up study of 41 young adults who were diagnosed with SM as children found that 60% continued to struggle with self-confidence, independence, achievement, and social communication.  (Beare et al., 2008)

In a single-subject research study, Beare and associates (2008) utilized positive reinforcement with fading of prompts to increase the verbal communication of a selectively mute 12-year-old.  The subject, a 6th grader named Luke, was selectively mute in the context of different classroom environments; a resource room, a study room, and a mainstream classroom.  The use of positive reinforcement for speaking, coupled with fading of prompts across settings, was successful in causing Luke to exhibit verbal speech in all three rooms for the first time.  (Beare et al., 2008)

In another single-subject research effort that spanned over 2 years, Trish L. Sloan worked aggressively with the family of a 5 year old girl named Anna.  Utilizing a high touch relationship with the family and the school system, coupled with play therapy, Sloan realized Anna’s goals 2 years after the beginning of treatment.  She had successfully spoken to all her classmates, and had become an active and vocal participant in class.  (Sloan, 2007)  This study underscored the importance of “joining” with the parents and schools to utilize first-hand observation in a non-intrusive setting.

Marian Moldan (2005) garnered success from a multi-modal approach that integrated behavioral, cognitive-behavioral, and modern psychoanalytic methods to overcome SM and enable self-regulation.  From a behavioral perspective, she utilized contingency management in addition to the previously mentioned stimulus fading.  Contingency management involves clients receiving positive reinforcement for verbalizations and non-reinforcement of non-verbal requests, such as gesturing or pointing.  She then integrated cognitive behavioral interventions, introducing graduated exposure to stress related stimuli in a methodical, efficient, and progressive basis.  Finally, she layered the modern psychoanalytic concepts of joining and mirroring (giving the client the feeling that you agree with them), “joining a resistance” methodology, and “contact functioning” to create a tension-free environment in which the client can feel comfortable.  Although complete details are not within the scope of this article, it would suffice to say that her case subject, Jenna (Age 6), made remarkable progress.  Out the outset, Jenna was only able to speak with selectively few children, but no adults.  After several unsuccessful attempts at treatment, including play therapy and pharmacological remedies (Prozac, 15mg/day), she came to Marian Moldan in a totally vacant of emotion and unable to speak.  Currently, Jenna has progressed to separating from her mother for therapy sessions (not possible before), as well has speaking freely and spontaneously on a wide range of topics during both individual and group therapies.  (Moldan, 2005)

Aside from positive reinforcement and play therapy, there may be significant upside in utilizing pharmacological treatments in children diagnosed with SM.  In a comparatively small test group, Manassis & Tannock (2008) found that children who had been treated with selective serotonin reuptake inhibitors (SSRIs) showed greater global improvement, improvement in functioning, and improvement in speech outside the family than children who were un-medicated.  However, most children still met criteria for SM after a 6-8 month follow-up.  In a more comprehensive meta-study conducted by Reinblatt & Riddle (2007), data suggested some benefit of SSRI treatment; however, they acknowledged that non-pharmacological therapy is also an important consideration in the treatment of SM.

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Beare, P., Torgerson, C., & Creviston, C. (2008, Dec). Increasing verbal behavior of a student who is selectively mute. Journal of Emotional and Behavioral Disorders, 16(4), 248-256. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1599495971&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Manassis, K., & Tannock, R. (2008, Oct). Comparing interventions for selective mutism: A pilot study. Canadian Journal of Psychiatry, 53(10), 700-704. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1600713041&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Moldan, M. B. (2005, Sep). Selective mutism and self-regulation. Clinical Social Work Journal, 33(3), 291-307. doi: 10.1007/s10615-005-4945-6

Reinblatt, S. P., & Riddle, M. A. (2007, Mar). The pharmacological management of childhood anxiety disorders: A review. Psychopharmacology, 191(1), 67-86. doi: 10.1007/s00213-006-0644-4

Sloan, T. L. (2007, Jan). Family therapy with selectively mute children: A case study. Journal of Marital and Family Therapy, 33(1), 94-106. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1237297361&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Separation Anxiety Disorder (SAD)

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In order to qualify for a DSM-IV-TR (2000) diagnosis of Separation Anxiety Disorder (SAD; 309.21), a client must present with the following essential features:

A)    Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attacked, as evidenced by three (or more) of the following:

  1. Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
  2. Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
  3. Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
  4. Persistent reluctance or refusal to go to school or elsewhere because of fear of separation
  5. Persistently and excessively fearful or reluctant to be along or without major attachment figures at home or without significant adults in other settings
  6. Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
  7. Repeated nightmares involving themes of separation
  8. Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.

B)    The disturbance must last for a period of at least 4 weeks.

C)    The disturbance must begin before age 18.

D)    The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.

E)     The disturbance does not occur exclusively during the course of a Pervasive Development Disorder (PDD), Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder with Agoraphobia.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 125)

Separation Anxiety Disorder (SAD) is not uncommon; prevalence estimates average about 4% in children and young adolescents.  SAD decreases in prevalence as kids get older.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 123)  Some researchers argue that SAD is actually an early manifestation of panic disorder, rather than just a risk factor or precursor.  (Jurbergs & Ledley, 2005)

Treatment of SAD often involves a multimodal approach that may include psycho-education of the patient and family, school consultation and intervention, pediatrician consultation and pharmacotherapy, and cognitive-behavior therapy (CBT).  Research has repeatedly demonstrated the efficacy of CBT for children with SAD, supporting it as the best-proven treatment.  (Jurbergs & Ledley, 2005)  CBT has become a respected and empirically established model of psychotherapy in adults.  The fundamental principles of CBT can be applied to children with developmental modifications.  David Dia’s (2001) case study of a six year old boy named “Colt” serves as a great example.  Utilizing family education, progressively more difficult stress scenarios, and a token/exchange system; Colt’s belief was challenged and modified.  (Dia, 2001)

Although the cognitive technique of guided discovery and education proved fruitful in Colt’s case, I would underscore the importance of modifying CBT methods that were traditionally designed for adult patients.  Grover and associates (2006) provide the following examples of modification:

Relaxation and breathing techniques can be adapted for the younger child by using balloon (e.g., breath in and make your tummy fill up like a balloon) and robot/rag doll (e.g., tense your muscles like a robot, relax like a rag doll) metaphors. Depending on the cognitive level of the child, cognitive restructuring techniques may be simplified to teaching the child self-statements like, “Everything will be OK,” or, “I can handle my worries by myself.” One 9-year-old boy with SAD liked to use the coping statement, “Mom has always come back for me before.”  (Grover, Hughes, Bergman, & Kingery, 2006)

Pharmacotherapy should be used in conjunction with CBT only when the child’s symptoms have not responded to CBT interventions alone.  Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and benzodiazepines have all been used to treat a number of anxiety disorders in children, including SAD, but no medications have specific indications for SAD.  (Jurbergs & Ledley, 2005)

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Dia, D. A. (2001, May). Cognitive-behavioral therapy with a six-year-old boy with separation anxiety disorder: A case study. Health & Social Work, 26(2), 125-129. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=73283346&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Grover, R. L., Hughes, A. A., Bergman, R. L., & Kingery, J. N. (2006, Fall). Treatment modifications based on childhood anxiety diagnosis: Demonstrating the flexibility in manualized treatment. Journal of Cognitive Psychotherapy, 20(3), 275-287. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1126879061&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

Jurbergs, N., & Ledley, D. R. (2005, Sep). Separation anxiety disorder. Psychiatric Annals, 35(9), 728-736. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=905192971&sid=6&Fmt=4&clientId=4683&RQT=309&VName=PQD