A Review of: “Kearney, C. A. (2010). Helping Children with Selective Mutism: A Guide for School-Based Professionals .”

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  • This article was downloaded by: [University of Glasgow]On: 06 October 2014, At: 06:54Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

    Child & Family Behavior TherapyPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wcfb20

    A Review of: Kearney, C. A. (2010).Helping Children with Selective Mutism:A Guide for School-Based Professionals.Howard A. Paul PhD, ABPPPublished online: 09 Feb 2011.

    To cite this article: Howard A. Paul PhD, ABPP (2011) A Review of: Kearney, C. A. (2010). HelpingChildren with Selective Mutism: A Guide for School-Based Professionals., Child & Family BehaviorTherapy, 33:1, 72-77, DOI: 10.1080/07317107.2011.545017

    To link to this article: http://dx.doi.org/10.1080/07317107.2011.545017

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  • specific document and deliver it to the proper court. Chefs already userecipes to make preferred dishes. The recipes they use are checklists. Policeofficers could use a checklist for making an arrest, ensuring that all proce-dures are properly followed. Various professionals could use checklists to billinsurance companies for services rendered. Psychologists already use check-lists (modularized treatment manuals) that have been shown to improvetreatment efficacy. In fact, when therapists diverge from such standardizedtreatment delivery, the results are often inferior to when fidelity to such treat-ments is maintained.

    Gawande has written a very readable book that can be useful to profes-sionals and the public alike. He shares both personal experiences and thoseof his colleagues, in a clear and upbeat writing style. One possible flaw is thathis reported study did not use a multiple-baseline design (Baer, Wolf, & Risley,1968) inwhich implementing the intervention is staggered across settings(in thiscase, hospitals). Instead, after a baseline period in each hospital, adopting thechecklist procedure appears to have been done simultaneously in each hospital.This leaves the study open to a possible challenge of internal validity. It doesraise some interesting technical notes on re-utilizing multiple-baseline mea-sures, which have grown out of favor in large studies of empirical efficacy.Nevertheless, the real-world examples of checklists and the means for develop-ing them are compelling. Gawande clearly makes a case for checklists in anyfield, as a way to improve consistent and correct application of what is known.

    REFERENCES

    Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of appliedbehavior analysis. Journal of Applied Behavior Analysis, 1, 9197.

    Premack, D. (1959). Toward empirical behavior laws: I. Positive reinforcement.Psychological Record, 66, 219233.

    Kristin M. Funk, MA, BCBADoctoral student, Educational Psychology, Temple University

    Philadelphia, PASaul Axelrod, PhD, BCBA-D

    Professor, Special Education and AppliedBehavior Analysis Temple University, Philadelphia, PA

    Kearney, C. A. (2010). Helping Children with Selective Mutism: A Guide forSchool-Based Professionals. New York: Oxford University Press, v 160pp., $49.00 (hardback), $24.95 (paperback).

    In the mid-1970s I received a faculty appointment at what was then RutgersMedical School. In lecturing to the psychiatry residents I mentioned that I

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  • was having good success in treating what was then called to Elective Mutism.Shortly after one lecture I received a call from the Medical School-based Pre-school Handicapped Therapy Program for severely emotionally disturbedchildren and was then referred a youngster with mutism. The mental healthstaff were somewhat leery of my claim in that, at that time, elective mutismwas seen as a significant and virtually untreatable emotional disturbance,viewed as a harbinger of childhood schizophrenia. It was quite gratifyingto see their surprise when the youngster began to speak after the applicationof basic behavioral principles such as exposure, reinforcement, shaping, andsome positive practice. After that I began to receive referrals of a few childrenevery year with what is now known as Selective Mutism.

    Christopher Kearney, Professor and Director of Training at University ofNevada at Las Vegas, specializes in internalizing disorders of youths, focusingon school refusal, PTSD, and selective mutism. Kearneys book provides hiscurrent explanation of the characteristics of youth with selective mutism,describing methods to both assess and treat this problem. The book is writtenfor school officials who might address the problem of selective mutismincluding school psychologists, school-based social workers, guidance coun-selors, regular and special education teachers, principals, school nurses, aswell as other personnel who might be involved. Kearney makes it very clearthat this book works best for those with only moderate selective mutism. Forcases of mutism that have lasted many years or, who have additional signifi-cant problems such as severe learning disabilities, bipolar disorder, ADHD,conduct and aggression problems, depression, pervasive developmental dis-orders or substance abuse, referral to a psychologist or psychiatrist familiarwith the utilization of behavioral principles would be very much in order.In those cases where there are no or limited comorbidities and there appearsto be no reason but social anxiety as the basis of mutism, then following theplan presented in this book should serve to reduce this problem.

    One key aspect of selective mutism is that, in comfortable situationssuch as at home or with friends, youngsters with selective mutism will speak,and often at length. There are some cases where children may have a comor-bid communication difficulty. In this respect, assessment is required to evalu-ate the impact of any related stuttering or articulation difficulties. It may beprimary in producing the symptoms, or, it may be of only secondary impactand not related to the mutism.

    The diagnostic criteria for Selective Mutism include persistent failure tospeak in specific social situations where speech is expected despite being ableto speak in other situations. To be considered a disorder, this situational mut-ism must interfere significantly with educational, social, or occupationalachievement and communication. The selective mutism must last at least 1month and not be associated with the 1st month of school. It must not be asso-ciated with a lack of knowledge or feeling comfortable with spoken languagerequired in a particular social situation. The disorder must not be better

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  • accounted for by communication disorder or be related to the typical courseof a pervasive developmental disorder or other significant mental illness.

    Several researchers have found a high comorbidity with social anxietyand social phobia such that, not only do these children not speak, they tendto significantly avoid social situations such as initiating conversations or evenanswer the door or telephone. Indicators of anxiety such as trembling, sweat-ing, hyperventilation, accelerated heart rate, nausea, dizziness, and otherpanic like symptoms can sometimes be seen. Many children, however, areunable to report specific anxiety-based thoughts or physiological symptoms.As a group, youngsters with selective mutism are typically described as shy,reserved, and inhibited. Often, parents do not see their children as exhibitingsuch behaviors at home. Some cases of selective mutism are coincident withoppositional, manipulative, or deliberate refusal to speak. Some cases ofselective mutism have been linked to trauma-based reactions.

    Even though children with selective mutism do not speak in certainsituations, they often develop compensatory behaviors so that communi-cation is still forthcoming, thus reinforcing their mutism. Clearly, part of treat-ment per se must attempt to no longer reinforce compensatory behaviorssuch that audible speech has a higher probability of being used for of com-munication. Behavioral analyses of selective mutism notes three explanatoryantecedent conditions. Often, children fail to speak in an attempt to decreaseanxiety, increase social or sensory feedback from others, or to hide having todisplay inefficient or underdeveloped speaking skills. Typical identified con-sequences include parents, peers, or teachers completing tasks for the childor trying to communicate for them, rearrangements of settings to accommo-date the childs mutism and thereby allowing and reinforcing various com-pensatory behaviors.

    Selective mutism is not common. Epidemiological studies depict a rangeof from 2 to 0.2%, with girls slightly more prone to show this behavior thanboys. Kearney carefully explains key interventions, including exposure-based practices, fading, shaping, prompting, modeling, contingency manage-ment, relaxation training, use of negative reinforcement, social skills training,language training and, occasionally, group or family therapy and, whenneeded, pharmacological interventions. Kearney structures this book intoseven chapters and an appendix. Early chapters cover the definition, descrip-tion, and assessment of selective mutism. Subsequent chapters coverexposure-based practices in both home and community settings, use of con-tingency management, strategies for children with communication problemsand lastly, relapse prevention. A useful appendix lists information and cita-tions regarding the measures described in this book as well as additionalreadings and resources. In his discussion of assessment, Kearney providesa helpful worksheet defining situations involving selective mutism orreluctance to speak, detailing many assessment questions focusing on boththe childs reaction and how others respond to the childs lack of speech,

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  • identifying measures specific to selective mutism such as the SelectiveMutism Questionnaire, with an example provided in his assessment chapter.Daily ratings of anxiety by both child and parents are suggested. Kearneyreviews many of the more frequently used scales to assess social phobiaand anxiety as well as depression. Positively, Kearney devotes much detailabout how to conduct a behavioral analysis, likewise providing many helpfulpointers on what behaviors would be best observed.

    Kearney begins his chapter on exposure-based practices in the homewith a review of anxiety, breaking down anxiety into its behavioral,physiological, and cognitive complements. He also provides an overviewof exposure-based practice, offering suggestions on consultation with par-ents to prepare them for the occasional upset that can be initially pro-duced in exposure processes. Kearney also suggest developing ahierarchy to use in the exposure process, providing examples of theneeded detail of such hierarchies, reviewing breathing retraining, relax-ation training, and muscle focused relaxation exercise. Kearney stronglysuggests that much of the initial exposure-based practice be done at homeand further suggests therapists have preliminary exposure by speaking onthe telephone, utilizing e-mail, or speaking from a distance prior to start-ing a home visit, clearly believing in gradual shaping. He reviews theinitial home visits and then spells out the variations in treatment that occurin the mid-treatment sessions and in later home visits. Following success-ful outcome in home-based exposure, community and school settingexposures take place. As with home-based exposure, a community-basedhierarchy is developed, with samples included. Following his format forhome-based exposure, actions and strategies for initial exposure sessions,intermediate exposure sessions, and later community-based exposure ses-sions are well explained with good detail. The final portion of treatmentinvolves exposure-based practices in the school. In the initial school-basedexposures Kearney strongly recommends conducting these exposureswhen few, if any, other children are around. When the child is comfort-ably able to speak in the presence of the therapist or a helping teacher,then stimulus fading, and systematically increasing the difficulty ofexposure can be undertaken. Intermediate school-based exposures entailmoving into the classroom, largely involving interacting with the child firstin the empty classroom and then gradually fading in more stimuli.Kearney provides two caveats, noting that some children prefer that theteacher be the first person in the room that they speak to and secondly,if peers are employed during exposure they must be coached in not beingoverly excited when speech is initiated lest this produce an undesirableamount of anxiety and even reverse progress. In later school-based expo-sures this is much less critical. Final steps involve regular practice ofspeaking to peers and teachers throughout the school day and in a varietyof school settings.

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  • Kearney also suggests that where social anxiety is present with selectivemutism, the addition of social skills training is valuable. He likewise describesboth modeling and use of positive feedback and reinforcement during...

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