Clinical Case Studies

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Assessment and Behavioral Treatment of Selective Mutism

Brian J. Fisak, Jr, Arazais Oliveros and Jill T. Ehrenreich
Clinical Case Studies 2006 5: 382
DOI: 10.1177/1534650104269029

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CLINICAL
10.1177/1534650104269029
Fisak et al. / CASE
TREATMENT
STUDIES
OF/ October
SELECTIVE
2006 MUTISM

Assessment and Behavioral Treatment

of Selective Mutism

BRIAN J. FISAK, JR.

University of North Florida
ARAZAIS OLIVEROS
University of Central Florida
JILL T. EHRENREICH
Boston University

Abstract: Children with selective mutism present with a complicated set of symptoms, as
they not only refuse to speak in particular social situations but are often shy, socially
isolative, anxious, and may present as oppositional and negativistic in their behavior. Lim-
ited research on treatments for selective mutism suggests a need for additional research
examining intervention possibilities. The following case description presents a 10-year-old
male with selective mutism and concurrent anxiety symptoms. Treatment included the use
of a significantly modified version of Social Effectiveness Therapy for Children (SET-C), a
manualized behavioral treatment for social anxiety. In addition to SET-C, treatment also
included concurrent parent training in the management of child anxiety. The rationale for
the treatment selection and a description of treatment course are provided. Further, a dis-
cussion is presented concerning challenges to treatment progress, including cultural differ-
ences between the primary clinician and the client.

Keywords: selective mutism; assessment; behavioral treatment; therapy

1 THEORETICAL AND RESEARCH BASIS

Children with selective mutism (SM) demonstrate a challenging constellation of
symptoms, as they not only refuse to speak in particular social situations but are also fre-
quently shy, behaviorally avoidant, and fearful, in addition to often appearing oppositional
in their behavior (Kehle, Madaus, Baratta, & Bray, 1998). The anxiety-related aspects of
SM, and its high comorbidity with social phobia (SP), have informed the suggestion that
SM may be a particularly severe variant of SP rather than a fully distinct diagnosis
(Lehman, 2002). For example, Black and Uhde (1995) found that 97% of a clinical sam-
ple of children with SM also met the criteria for SP. Specifically, a child with SM may cope
with intense fear of social situations through avoidance of speech. This coping strategy
results in a pattern of behavior that is extremely resistant to change, given that children
CLINICAL CASE STUDIES, Vol. 5 No. 5, October 2006 382-402
DOI: 10.1177/1534650104269029
© 2006 Sage Publications

382

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 Fisak et al. / TREATMENT OF SELECTIVE MUTISM 383

with SM are often negatively reinforced by the subsequent decrease in requests for speech
over time (Kehle et al., 1998). For example, a teacher may ask for a response in class, and
the SM child may repeatedly fail to answer. As a result, the teacher may withdraw the
requests for responses, thereby negatively reinforcing the child’s lack of responding.
Although conceptualization of SM as an extreme form of SP has received empiri-
cal support, a number of studies have found other differences between children with SM
and children with SP. Dummit et al. (1997) found that social anxiety ratings of children
with SM were in the moderate range, suggesting that behavioral factors beyond social
anxiety may also be associated with the presentation of SM. When comparing parental
reports of children with SP versus those with comorbid SM and SP, via responses on the
Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001), parents of SM chil-
dren indicate significantly higher scores on the Delinquency subscale and marginally
higher scores on the Aggression subscale when compared to those with comorbid pre-
sentation (Yeganeh, Beidel, Turner, Pina, & Silverman, 2003). Although Delinquency
and Aggression subscale scores observed in both groups were largely in the nonclinical
range and generally lower than scores on Internalizing subscales, the difference in scores
found in this investigation corroborates clinical observations of significant parental diffi-
culties in managing oppositional behaviors in children with SM, particularly among
those without concurrent SP symptoms.
In summary, SM has been conceptualized as an extreme form of SP; however, this
distinction may not fully characterize SM, as those with SM may also exhibit
oppositional behaviors (Yeganeh et al., 2003). As a result, Yeganeh et al. suggest that,
when compared to treatment of SP, a broader range of interventions may be needed for
successful treatment of children with SM (e.g., parent training, behavior modification,
and interventions to decrease social distress). Further, despite the potential complexities
associated with treating children with SM, structured interventions designed specifically
to treat children with SM are lacking. For example, in a review of empirically supported
treatments conducted by Chambless and Ollendick (2001), there were no specific treat-
ments listed for SM. As a result of these challenges, further research into potentially
effective interventions for children with SM is needed.

2 CASE PRESENTATION
This case description presents the conceptualization and treatment of a 10-year-
old Hispanic male diagnosed with SM whose speech was limited to the home environ-
ment. Given the potential overlap between SM and SP, and the lack of empirically sup-
ported treatment protocols specifically targeting SM symptoms, the clinicians in this
case attempted to use a modified version of a popular social skills treatment protocol for
social anxiety symptomatology (Beidel, Turner, & Morris, 1994), in conjunction with an

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384 CLINICAL CASE STUDIES / October 2006

alternative treatment generalization component in the child’s school and

comprehensive parent training.

3 PRESENTING COMPLAINTS
At the time of initial evaluation, which took place as LM was entering the fifth
grade, he would not speak in class unless the teacher insisted, at which point LM spoke
in a barely audible volume and appeared fearful during speech. In the home setting, LM
spoke freely to his mother, a professional housekeeper; his father, an electrical worker
seeking employment; as well as his 13-year-old brother. According to his father, LM
would show visible distress when faced with social situations (e.g., parties, dances) and
refused to interact with neighboring children. LM did not respond when greeted, even
by familiar acquaintances, and would avoid ordering at restaurants, often having his
brother or his parents order for him. LM denied any difficulties at school (by shaking his
head to indicate “no”) and responded accordingly on questionnaires presented (see
Assessment section).
Mrs. M had few complaints with regard to LM’s behavior, a fact that appeared to
result in disagreement with her spouse during an assessment interview. She relayed mild
concern that LM often used a “baby voice” at home but indicated that this only occurred
with her and that she often enjoyed this type of interaction with him. She agreed that
LM’s activities were mostly limited to those in the home, but in contrast with LM’s
father, Mrs. M was reportedly not bothered by LM’s social constriction, as she felt he was
generally safer inside the home, although the family did not live in a neighborhood that
was considered particularly dangerous or unsafe. Both parents did agree with regard to
LM’s need to speak in the classroom and in other appropriate situations (e.g., ordering
food for himself, greeting others, etc.).

4 HISTORY
LM was born in the northeastern portion of the United States, where he completed
kindergarten through third grade, and he consistently limited his speech to only family
and extremely familiar friends. From all indications, LM’s developmental history was
largely unremarkable. He was the result of a normal and uncomplicated pregnancy and
delivery. All developmental milestones, with the exception of generalization of speech
to certain settings, were met within normal limits. He had no history of surgery or serious
illness and was presently in good health. According to his father, LM was a quiet and
calm baby. LM’s shyness and refusal to speak were first noticed when he entered kinder-
garten. LM’s hearing and speech were tested by his school at that time, but no organic
etiology was found. He also received a psychological assessment when he was in third

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 Fisak et al. / TREATMENT OF SELECTIVE MUTISM 385

grade (age 8), resulting in a diagnosis of selective mutism, but there was no subsequent
treatment provided at that time.
LM’s shyness became more apparent after he moved to his current residence in the
southeastern United States, at age 9, where he initially had no familiar peers except his
older brother. LM apparently chose not to initiate contact or interact with any peers in his
new neighborhood and seemingly rejected his father’s instructions to try to “go out and
make friends.” During the early part of the fourth grade at his new school, LM had a
female classmate who would voluntarily speak for him in class. However, LM and this
peer were then assigned to different fourth-grade teachers, after which LM reportedly did
not talk to any peers in his classroom. LM also stopped talking to the female ex-classmate,
who had made attempts to visit with him at his home.

5 ASSESSMENT
INITIAL INTERVIEW AND MEASUREMENT ADMINISTRATION

During the initial evaluation, LM displayed a variety of behaviors potentially indic-

ative of anxiety, such as facial tension, rigid posture with crossed arms, and
hypervigilance. These behaviors slowly decreased as the initial interview progressed.
LM remained quiet throughout this interview, typically answering questions by nodding
yes or no. As the interview progressed, however, LM began to provide brief (i.e., one- to
two-word) responses to questions. In addition, when LM and his father were in the same
room, LM appeared to become more anxious and withdrawn whenever his father
directed him to speak. LM’s mother was not available during initial interviews due to her
work schedule, whereas LM’s father was unemployed during this period, allowing him
to attend most appointments. As treatment progressed, LM’s mother was available for an
occasional one to two sessions at a time, but his father attended the majority of sessions
with LM alone.
The Parent-Report Form of the Anxiety Disorders Interview Schedule for DSM-IV
(Child Version; ADIS-IV-C/P; Silverman & Albano, 1997), a semistructured diagnostic
interview for parents of children and adolescents, was administered to LM’s father to
assess the extent to which current psychopathology was clinically significant and inter-
fering with LM’s functioning. Results of this interview supported diagnoses of both social
phobia and selective mutism. LM evidenced social phobia via significant fear and avoid-
ance in situations that require social interaction (e.g., parties, class participation),
although this was admittedly difficult to distinguish from his selective mutism symp-
toms. Mr. M endorsed an average severity rating of 6 (on a Likert-type scale from 0 [not at
all] to 8 [very, very much]) in his discussion of LM’s social fears, with the most disturbance
evident in the school setting. Mr. M. rated LM’s specific fears as 6 and above for situa-
tions such as speaking in class and speaking to unfamiliar people.

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386 CLINICAL CASE STUDIES / October 2006

TABLE 1
Summary of Parent and Teacher Ratings of Client’s Behavior
Parent Rating (CBCL) Teacher Rating (TRF)

Scale T-Score Percentile T-Score Percentile

Anxious/depressed 53 62 52 58
Withdrawn/depressed 85a > 97 73
a
> 97
Somatic complaints 50 ≤ 50 60 ≤ 50
Total internalizing behavior problems 66a 95 54
a
92
Rule-breaking behavior 53 63 50 ≤ 50
Aggressive behavior 57 76 50 ≤ 50
Total externalizing behavior problems 56 73 41 18
Social problems 60 84 50 ≤ 50
Thought problems 50 ≤ 50 50 ≤ 50
Attention problems 50 ≤ 50 50 ≤ 50
Total behavior problems 56 73 47 38
Activities competence 28a <3 n/a n/a
Social competence 25a <3 n/a n/a
School competence 43 24 n/a n/a
Total competence functioning 24a <2 50 50

NOTE: CBCL = Child Behavior Checklist; TRF = Teacher Rating Form.

a. Scores in the clinical range.

LM also met diagnostic criteria for selective mutism, owing to his refusal to speak
or answer questions in a variety of settings such as school and parties, despite speaking
frequently in the home environment and with family members or very familiar people.
Mr. M rated the interference of LM’s selective mutism as a 6. No other diagnoses were
apparent at that time.
On the ADIS-IV-C/P (Silverman & Albano, 1997), LM endorsed symptoms con-
sistent with social phobia, including fear and avoidance/distress with regard to giving a
report or reading aloud in front of the class and during musical performances. LM’s
responses throughout this diagnostic interview were mostly head nods or one-word
responses.
LM’s father also completed the CBCL, a questionnaire that provides both general
and more specific indices of a child’s emotional and behavioral functioning (Achenbach
& Rescorla, 2001). LM’s score on the Internalizing Behavior Problems scale fell within
the clinical range. More specifically, LM’s score on the Withdrawn/Depressed scale fell
within the clinical range, indicating that LM often refused to speak and may be secre-
tive, shy, withdrawn, sometimes preferring to be alone, lacking energy, and finding few
things enjoyable. All other scale scores on the CBCL, including the Externalizing and
Behavior Problems scale, fell within the nonclinical range, indicating that LM was not
experiencing difficulty in domains such as inattentiveness or aggressive behavior. LM’s
Total Competence, Activities Competence, and Social Competence scores fell within
the clinical range, whereas his score on the School Competence scale fell within the
nonclinical range. Specifically, LM showed a low level of social interaction (i.e., friends,

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 Fisak et al. / TREATMENT OF SELECTIVE MUTISM 387

TABLE 2
Summary of Parent and Teacher Ratings of Client’s Competence
Z-Score

Scale Mean Standard Deviation Father Teacher

Scholastic competence 2.81 .69 1.25 .28

Social acceptance 2.87 .77 –2.01 –1.56
Athletic competence 2.89 .73 2.59 –1.67
Physical appearance 2.91 .76 –.80 1.43
Behavioral conduct 3.04 .56 –1.32 1.71
Global competence 3.04 .69 –1.32 –.25

group membership) and involvement in activities (i.e., sports, hobbies). See Table 1 for a
summary of the father’s CBCL ratings of LM, including T-scores and percentiles.
LM’s fourth-grade teacher completed the Teacher Report Form of the CBCL
(TRF; Edelbrock & Achenbach, 1985). This profile corroborated parental reports of
LM’s tendency to experience internalizing rather than externalizing emotional and
behavioral difficulties. Specifically, LM’s score on the Internalizing Behavior Problems
scale fell within the clinical range, whereas his score on the Externalizing Behavior
Problems scale fell within the nonclinical range. LM’s score on the Withdrawn/
Depressed scale fell within the clinical range, also corroborating similar parental report.
All other scale scores fell within the nonclinical range, indicating that withdrawn/
depressed symptoms seemed to be the major source of difficulty for LM, according to the
teacher. See Table 1 for a summary of the teacher’s TRF ratings of LM, including T-
scores and percentiles.
To establish a more direct comparison with regard to reports of LM’s competence
across multiple domains, his father and fourth-grade teacher also completed the revised
version of the Perceived Competence Scale for Children (Harter, 1982). This measure
allows for ratings in Scholastic Competence, Social Acceptance, Athletic Competence,
Physical Appearance, Behavioral Conduct, and Global Self-Worth. According to LM’s
father, Social Acceptance and Athletic Competence scores were more than two stan-
dard deviations above the mean, indicating that LM was perceived by his father to have
difficulty making friends and playing sports as well as his peers. LM’s teacher endorsed
similar elevations, but to a slightly lesser extent. Parental and teacher ratings of Physical
Appearance and Behavioral Conduct were disparate (i.e., by more than two standard
deviations), with LM’s father perceiving him as much lower in these domains than his
teacher in terms of competencies related to appearance and conduct. In querying these
discrepancies, it was established that LM’s behavior in the classroom was perceived by
his teacher to be very appropriate, despite his lack of speech in that environment,
whereas LM was more likely to be noncompliant with requests at home, leading to lower
overall parental ratings of LM’s competencies. See Table 2 for z-scores associated with
ratings on this measure by LM’s father and teacher.

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388 CLINICAL CASE STUDIES / October 2006

LM also completed the Revised Children’s Manifest Anxiety Scale (RCMAS;

Reynolds & Richmond, 1985), a measure that includes subscales to assess physiological
anxiety, social anxiety, worry, and total anxiety, along with a Lie scale. His Total Anxiety
(1st percentile), Physiological Anxiety (3rd percentile), Worry (14th percentile), and
Social Anxiety (21st percentile) scores all fell within the nonclinical range. His score on
the Lie scale (90th percentile), however, indicated that LM’s denial of symptoms associ-
ated with anxiety could be attributed to responding in a defensive manner.
Given these circumstances, the RCMAS was readministered to the client 2 weeks
later, following additional rapport building and the therapist’s encouragement that there
were no wrong or right answers for the questionnaire. LM answered all of the anxiety-
related questions in the same fashion he had answered them the first time, receiving
Total Anxiety (1st percentile), Physiological Anxiety (3rd percentile), Worry (14th per-
centile), and Social Anxiety (21st percentile) scores that matched his previous scores,
again falling within the nonclinical range. His score on the Lie scale (10th percentile),
however, showed a notable decrease from the previous session.

ASSESSMENT OF FAMILY VARIABLES

During a clinical interview, LM’s parents reported some difficulties with regard to
child discipline. Specifically, they often disagreed concerning what rules to enforce and
how to enforce them, resulting in inconsistency. Contributing to the parental discipline
difficulties was his parents’ basic lack of correspondence with regard to expectations for
LM’s behavior. LM’s father frequently instructed him to go outside and play with neigh-
bors, whereas his mother reported that she felt uneasy with her son being outside of the
home. However, both parents also reported few interactions with neighbors or friends
outside of the home. LM’s use of baby-talk instead of more comprehensible speech in
some circumstances was undesirable to the father, whereas his mother spoke of it with
endearment, indicating that such talk reminded her that LM was “her baby.” Disagree-
ments like these often led to arguing during subsequent sessions, presenting an overall
picture in which his father’s attempts at behavioral control were impeded by his mother’s
efforts to protect and rescue LM from being “bossed around,” as the mother reported she
had been as a child.
The patterns observed in LM’s family are consistent with literature pertaining to
parenting strategies associated with anxious children. Becoming impatient with an anx-
ious child’s avoidant behaviors and being overly directive in response to a child’s feared
behavior are common parental responses to such symptoms. On the other hand, remov-
ing a child from a feared situation and facilitating avoidance behaviors are also common
behaviors for parents dealing with their child’s anxiety (Rapee, Spence, Cogham, &
Wignall, 2000). This aspect of LM’s daily life was an integral part of his eventual case
conceptualization and treatment.

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 Fisak et al. / TREATMENT OF SELECTIVE MUTISM 389

6 CASE CONCEPTUALIZATION
On the basis of this multimodal assessment, LM’s refusal to speak was conceptual-
ized as a strategy for avoiding feelings of anxiety in speech-related situations and also con-
ceptualized as the result of limited exposure to opportunities that would lead to the
development of adequate social skills. LM’s avoidance strategies had become so effective
that his motivation for change was understandably low. The family trend of sedentary
and nonsocial daily life was serving to maintain LM’s social isolation, despite his father’s
periodic efforts to encourage outside activities. Secondary gains, including decreased
requirements at school and the baby role with his mother at home, also seemed to be
reinforcing a lack of speech outside of the home. These secondary gains and parenting
issues would eventually represent significant challenges to treatment.
To improve LM’s social skills, the initial treatment strategy focused on the usage of
a manualized behavioral treatment for social anxiety in children, Social Effectiveness
Therapy for Children (SET-C; Beidel et al., 1994). The treatment manual had to be
modified from a group treatment format to an individual treatment format; however, the
order in which the educational modules were presented remained consistent with the
original SET-C manual. Sessions always began with a shaping/warm-up exercise with
LM, his parent, and two therapists. This exercise requires repeated vocalization of a
sound, a word, and then a sentence by each member of the “treatment team.” Following
this exercise, one therapist would meet with LM individually to review the previous ses-
sion’s social skill and then present a new social skill (e.g., eye contact, greetings, asking
open-ended questions, topic transitions). After presentation of this educational compo-
nent, the new skill would be role-played during the session. LM also frequently com-
pleted an exposure exercise during the session, wherein he carried out an anxiety-pro-
voking task of increasing self-rated difficulty (e.g., giving a short speech to an audience in
a classroom setting). LM’s speech frequency and volume was also reinforced in the ses-
sion via his preferred reward, trading cards. His speech increased in volume throughout
treatment, and by the end of treatment, LM independently generated sounds, words,
and sentences during the session.
LM’s treatment was complemented with systematic interventions at his school.
However, initial difficulties in establishing cooperation from the school may have
restricted treatment progress in this arena. During a behavioral observation of LM in the
classroom setting, his speech was limited to barely audible answers to questions posed by
the teacher, and he failed to speak to peers, even when his classmates approached him.
Treatment goals in the school setting included increasing opportunities for LM to speak
in the classroom and consistent reinforcement of his speech by his teacher.
To intervene in the family system, parent anxiety management training sessions
were concurrently conducted with LM’s father (and his mother, when available). A step-
by-step guide to aid parents in dealing with their child’s anxiety (Rapee et al., 2000) was
primarily used to introduce both factors contributing to child anxiety and parent training
skills for managing/intervening with the child’s difficulties. An important goal in this

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390 CLINICAL CASE STUDIES / October 2006

form of parent training involves increasing opportunities for social interaction outside of
the home for LM and applying reinforcement for the client’s speech outside of the
home. Other strategies that were encouraged include parental modeling of self-expo-
sure to social-evaluative situations, parental modeling of positive self-talk before and
after engaging in a novel social situation, practicing social skills at home, and reinforce-
ment of social skills practice outside of the home.

7 COURSE OF TREATMENT AND ASSESSMENT OF PROGRESS

ADAPTATION OF THE SET-C

As noted, the SET-C was modified from a group treatment format to an individual
therapy format for use in this case. The implementation of the SET-C as an individual
treatment instead of a group treatment presented a notable disadvantage in that a group
setting would have provided a built-in opportunity for LM to practice skills learned in
treatment with peers. Practicing with peers facilitates generalization of skills discussed in
session and serves as a source of exposure for children who are fearful when interacting
with peers. Nonetheless, owing to the relatively small number of children being treated
for similar difficulties in this treatment setting, a group format for treatment could not be
achieved.
To compensate for the absence of group peers, the therapists used a number of
alternative exposure and skill practice strategies. One strategy included attempts to
engage LM’s older brother (who was of a similar age) in treatment by encouraging him to
help LM with his practice of social skills. A second strategy was to use the clinic staff. The
clinic staff members participated in role-plays with LM and were used as an audience
when LM gave practice speeches. The therapists treating LM also actively attempted to
engage the family and the school in exposure and skills generalization exercises. Details
of how generalization and exposure were conducted will be discussed below.

SESSIONS 1-3

Treatment began after two initial assessment sessions, the latter of which included
psychoeducation concerning the nature and interaction of SM and SP, the rationale for
the SET-C, and the typical course of treatment. Starting in the first treatment session, all
sessions began with the aforementioned “speech game” during which each individual
involved in the treatment session (LM, the family member(s), and both of the
cotherapists) took turns making a sound, followed by a word, and then a complete sen-
tence. The sound was first whispered by each group member, one at a time. The process
was then repeated several times with the volume of the sound gradually increasing to the
point where each member of the group yelled the sound. This process was then repeated

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 Fisak et al. / TREATMENT OF SELECTIVE MUTISM 391

with the word and the sentence. In the typical session structure, after the speech game
was completed, LM would meet individually with his therapist, while a second therapist
would meet with LM’s parent.
The primary agenda for the first session was to inquire about a reinforcement
schedule for LM that was to be used when he successfully performed target behaviors
(e.g., speaking with others, completing exposure tasks, and completing related therapy
homework tasks). Based on inquiries about LM’s interests, it became apparent that his
interests revolved almost completely around a particular type of animated TV show (e.g.,
trading cards, video games, and other activities related to this show). He appeared to have
few other interests, including little interest in physical activity. It is interesting that it is
not uncommon for children with anxiety-related difficulties to have a narrow range of
interests, which may limit the number of common activities and opportunities for inter-
action with other children (Albano, DiBartolo, Heimberg, & Barlow, 1995). In addition
to inquiring about a reinforcement schedule, another goal of the first session was to
begin reinforcement of speech through verbal praise. This process superseded other
psychoeducational goals, as an increase in baseline in-session speech was viewed as vital
to therapeutic rapport and overall progress in treatment.
Beginning with the first session, several approaches were used to assess progress.
Although a comprehensive assessment was conducted before the beginning of treat-
ment, continued use of the initial assessment measures was not sufficient to track specific
behavioral progress. For example, although the ADIS-IV-C/P provides diagnostic infor-
mation, symptom severity ratings obtained from the ADIS were not perceived to be sen-
sitive enough to track subtle behavioral progress from session to session. The RCMAS
could potentially have been used to track progress; however, there was an apparent floor
effect in LM’s reporting of symptoms on this measure. Another issue is that the RCMAS
does not evaluate symptoms specific to selective mutism.
In response to these limitations, the therapists decided to track the number of ver-
balizations that LM made during each session. A verbalization was defined as any verbal
expression in which LM spoke at least one discernible word. All speech conducted prior
to a therapist response was counted as one verbalization, meaning that each verbaliza-
tion could range from one word to, on rare occasions, several sentences. All sessions were
audiotaped and the total number of verbalizations was tabulated for each session (see
Figure 1). Although the average number of words in each verbalization was not quanti-
fied, verbalizations appeared to average approximately three to five words in length. A
second way in which progress was assessed was through monitoring LM’s successful
mastery of designated behavioral exposure tasks. The nature and intensity of the expo-
sure tasks changed as treatment progressed, with a gradual increase in the intensity of
tasks presented (exposure tasks are summarized in Table 3). An early measure of LM’s
comfort with speaking was assessed by asking LM to conduct a 1-minute speech about
himself and about the clinic prior to the second session. During this initial assessment,
he refused to engage in this task.

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392 CLINICAL CASE STUDIES / October 2006

Figure 1. Number of Client Verbalizations by Session

TABLE 3
Exposure Tasks
Session Number Task Was the Task Accomplished?

In session exposure tasks:

Session 2 speech in front of video camera no
Session 4 speech in front of video camera yes
Session 8 speech in front of an audience of 2 yes
Session 9 speech in front of an audience of 4 yes
Session 10 speech in front of an audience of 5 yes
Session 16 speech in front of an audience of 5 (no note card) yes
Assigned exposure tasks for school setting:
Session 18 passing a note that says “hi” to another student yes
Session 19 saying “hi” to another student yes
Session 20 saying a complete sentence to another student yes

The therapeutic agenda for the second and third sessions was to further develop
rapport with LM and to begin to reinforce speech consistently throughout the session.
Contingencies for speaking included verbal praise and small rewards (i.e., trading cards
and stickers). His speech increased significantly during the second session and third ses-
sions (see Figure 1). Based on examination of Figure 1, it is noteworthy that the number
of verbalizations during sessions peaked early in treatment and waxed and waned
throughout treatment. An explanation for this early peak in speech and the fluctuations
is that, as treatment progressed, sessions became increasingly challenging and the lack of
speech may have been, in part, a coping response or oppositional response to newly

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 Fisak et al. / TREATMENT OF SELECTIVE MUTISM 393

imposed therapeutic challenges. Further, it is feasible that he reached a ceiling effect in

the therapeutic context, with his speech reaching more of a typical frequency for chil-
dren his age as the sessions progressed. Despite this, LM maintained a substantial num-
ber of verbalizations throughout treatment, suggesting that he successfully adapted to
the verbal demands of the therapeutic setting.

SESSIONS 4-7

Sessions 4 through 7 included social skills training based on modules outlined in

the SET-C. LM appeared to comprehend the material presented in each of these mod-
ules. In addition to presentation of the social skills training module in Session 4, LM was
also asked to provide a speech in front of a video camera. After development of an outline
for the speech, modeling of the speech by the therapist, and practice, LM was able to
successfully complete the task (see Table 3).

SESSIONS 8-10

Beginning with Session 8, the sessions were moved to an empty university class-
room that was in close proximity to the clinic. The classroom setting was used to simulate
LM’s classroom at his elementary school. During Session 8, LM practiced social skills
presented in previous sessions with his brother. One goal of including his brother in this
session was for LM to begin to practice learned social skills with his brother on a regular
basis. Because in previous sessions LM appeared to have difficulty discussing interests
other than his favorite animated series, a second goal of meeting with LM and his
brother together was to ascertain whether LM had any interests beyond those previously
discussed with his therapists. Other interests could be used to form additional reinforcers
for LM, owing to concerns that the frequency with which the therapist relied on trading
cards and other paraphernalia related to LM’s preferred animated TV show might
decrease their potency as reinforcers over time. This reinforcer assessment was con-
ducted by having both LM and his brother fill out a worksheet that included their own
interests and the interests of their sibling. In addition to the above interventions, a speech
exposure task was again conducted. LM successfully conducted a brief speech in the
mock classroom setting, in front of both his brother and the therapist.
Sessions 9 and 10 included preparing and conducting a variety of increasingly
complex or anxiety-provoking speeches in the university classroom setting. In Session 9,
LM successfully completed a brief speech with an audience of four (therapist, father,
and two clinic staff members), and in Session 10, LM successfully completed a brief
speech with an audience of five (therapist, father, and three clinic staff members; see
Table 3).

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394 CLINICAL CASE STUDIES / October 2006

SESSIONS 11-17

Sessions 11 and 12 included a continuation of social skills training based on the

SET-C modules. After Session 12, a review of his progress with social skills training mod-
ules suggested a number of conclusions. First, when the social skills training modules
were presented, LM appeared to comprehend the material; however, a weekly review of
previous modules indicated that LM appeared to have difficulty retaining the informa-
tion from previously presented modules. Second, his basic social skills appeared to have
improved. Specifically, his eye contact improved, he began to develop skills for introduc-
ing himself, and he was able to discuss his favorite topic (animation). However, despite
these improvements, he appeared to have continued difficulty in his ability to fluently
access and integrate social skills from previous sessions. For example, his voice still
sounded mechanistic and his speech was generally brief. Further, he had continued dif-
ficulties with other skills discussed in previous sessions, such as changing topics during
role-plays, engaging in verbal conversations not related to his favorite topic, and respond-
ing verbally when a comment was made to him. Further, despite encouragement from
the therapists, LM and his parents did not appear to be practicing and reviewing the skills
between sessions.
In response to the above-mentioned difficulties, modules presented in subsequent
sessions were audiotaped and LM was given the tape to listen to at home. Sessions 13, 14,
15, and 17 proceeded in this manner. In addition to social skills training, Session 16
included an exposure task in which LM completed a speech for an audience of five,
without the assistance of a note card (see Table 3).

SESSIONS 18-21

Between Sessions 17 and 18, LM’s therapist observed LM in his regular classroom
and met with LM’s teacher. Based on this meeting, the teacher agreed to include a daily
monitoring log in a folder at LM’s desk. The purpose of the log was to have both LM and
his teacher monitor LM’s speech and monitor his success with school-related exposure
tasks that were assigned during the therapy sessions. The log was to be sent to the teacher
after each of LM’s subsequent sessions via e-mail.
Following the visit to the school, the cotherapists, LM, and his father met together
for the first part of Session 18 to discuss the school visit and plans to focus on extending
the existing treatment plan to LM’s classroom. During the second portion of the session,
LM worked on further developing his fear-avoidance hierarchy, with regard to commu-
nications and interactions with peers at school. The final step of the developed hierarchy
was to give a speech in front of his class. As a first step in the hierarchy, LM agreed to write
the word “hi” on a piece of paper and hand it to the student who sits next to him, and he
agreed to do this task prior to his next therapy session. This information was forwarded to
LM’s teacher via e-mail.

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 Fisak et al. / TREATMENT OF SELECTIVE MUTISM 395

Although LM’s teacher reported that he did not observe LM passing the note, LM
reported that he successfully passed the note to a peer in school. The therapist and LM
continued to work on the hierarchy in Session 19, and the next step on the hierarchy was
to verbally say “hi” to another student. This homework assignment was forwarded to the
teacher along with a self-monitoring log designed to help the teacher monitor LM’s self-
recorded frequency of speech and completion of therapy homework assignments. The
log was to be completed by the teacher on a daily basis. During the next session, LM did
not bring this log; however, he did report successful completion of the homework task.
Despite the fact that the teacher apparently did not give LM the monitoring log, the
teacher reported that LM was making progress in school, primarily in terms of his inter-
actions with the teacher. The teacher reported progress in that LM began to ask ques-
tions verbally instead of making gestures and that LM would say “bye” to the teacher
when prompted. During Session 20, work on the hierarchy was continued and LM
agreed to say a full sentence to another student on one occasion and say “hi” to a student
on another occasion. An updated log was sent to the teacher.
During Session 21, LM reported that he was successful at this homework but
reported that he again had not received the log from his teacher. Although the log was
not presented to LM, the teacher reported that LM’s verbalizations had increased with
regard to brief responding to direct questions in the classroom. A Wechsler Intelligence
Scale for Children–Third Edition (WISC-III) was also administered during Session 21
(Wechsler, 1991). The WISC-III was administered at this time in treatment because the
therapist was not certain that LM would be responsive to items on the verbal scale of the
WISC-III in the earlier stages of treatment. Moreover, although LM appeared to have
obtained basic conversational skills, he still appeared to have difficulty during role-plays
maintaining a conversation, integrating, and using material presented in the social skills
modules. The goal was to rule out significant cognitive difficulties that may be hindering
his progress. Overall, his scores on the WISC-III were in the average range.

SESSIONS 22-23

The school year was completed after Session 21. A final teacher report indicated
that LM continued to make “limited” progress. By Session 21, LM interacted with the
teacher verbally 4 to 6 times a day; however, responses remained brief and sparse and lit-
tle interaction was observed with classmates. Sessions 22 to 24 were conducted during
the summer holiday away from school. Session 23 included completion of the social
skills training modules, and both Sessions 23 and 24 focused on termination of treat-
ment for the summer. Treatment with the SET-C was completed at this time, with LM
demonstrating progress with a variety of in-session exposure activities. At this time, it also
appeared that LM likely reached maximum benefit from treatment conducted at the
clinic. The clinicians concluded that the focus of further interventions should be school-
based interventions.

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396 CLINICAL CASE STUDIES / October 2006

PARENT SESSIONS

Parent sessions were held concurrently and in Spanish for optimum benefit to Mr.
and Mrs. M. Following the assessment phase and the session including LM and his
father to determine possible reinforcers, the objective for the first parent training session
(Session 2) involved orienting LM’s parents to the goals of his treatment, mainly rein-
forcing speech in session and generalizing his speech behavior to other settings. Parent
training henceforth included instruction and role-play of behavioral strategies as well as
psychoeducation informed by a published guide for parents of anxious children, written
by Rapee et al. (2000).
Given Mrs. M’s report of LM’s frequent baby-talk, the concept of reinforcing
appropriate speech while ignoring baby-talk was discussed in Session 2. Mr. and Mrs. M
appeared to disagree with regard to how to handle LM’s avoidant behaviors (i.e.,
demanding speech versus allowing speech avoidance). In contrast to pressuring the cli-
ent to speak, emphasis was placed on providing opportunities for LM to speak outside of
the home and encouraging and praising the client for any attempts at communication.
In Session 3, Mrs. M reported that despite ignoring LM’s baby-talk, he was contin-
uing to use this method of communication. This was normalized and the importance of
consistency in achieving behavioral change was emphasized. During Sessions 4 and 5,
specific parenting strategies were presented, including role-playing with both parents
concerning modeling nonanxious behavior in social situations (i.e., thinking out loud
with coping statements and then performing the interaction in LM’s presence). This
strategy played a dual purpose of encouraging the parents to engage in routine social
behavior, which was reportedly at a low level, and providing a positive technique for
showing LM how one can cope with social situations despite anxiety. In discussing
praise, Mr. M cited an example of “praising” LM’s class participation one day of the pre-
vious year by telling him that he “needs to do more of that.” After this, LM subsequently
ceased his participation in class. The possibility that praise linked with heightened
expectations may have increased LM’s anxiety (as described by Rapee et al., 2000) was
explored. Alternative ways of praising were role-played.
Mrs. M reported during Session 6 that LM continued his use of baby-talk. The dis-
cussion revealed that she was ultimately answering his baby-talk, which was addressed
through further training and in-session practice. Despite reporting that LM had spoken
to a peer and the peer’s parents, Mrs. M denied providing any verbal reinforcement. The
importance of consistency and reinforcement continued to be integral topics in parent
sessions.
The next several sessions included psychoeducation about social skills that LM
was learning and practicing in his individual sessions. Mr. and Mrs. M were encouraged
to role-model and reinforce LM’s use of social skills (e.g., eye-contact, greeting, asking
open-ended questions). In promoting exposure exercises for LM, frequent brainstorm-
ing and trouble-shooting sessions were required. LM’s parents experienced difficulty in
initiating social contacts that would provide such exposure. During Session 8, Mrs. M

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 Fisak et al. / TREATMENT OF SELECTIVE MUTISM 397

reported praising (without pressuring) in response to the client when he stated that he
spoke to a classmate. This new parental practice was reinforced in session.
During Session 11, Mr. M expressed anxiety about future consequences of LM’s
treatment. Having filled out job applications inquiring about psychological treatment,
Mr. M was worried that records of LM’s treatment would prevent him from getting a job.
Confidentiality of treatment was reiterated and concern with regard to a treatment-
related stigma was addressed in the context of LM’s relatively benign diagnosis and the
common use of psychological services.
Mr. M continued to attend the final sessions, which included mostly trouble-
shooting difficulties in providing exposure activities and encouraging parental reinforce-
ment of LM’s practice of social skills. Modeling use of various social skills was role-
played, and Mr. M cited examples of his son’s increasing social behavior. During the
15th week, LM responded on two occasions when greeted by new adults. The next week,
LM interacted for an hour with a peer in his neighborhood, which Mr. M admittedly
failed to reinforce. During the 18th week, LM ordered for himself at a restaurant and
continued to do so from that point on. LM’s social behavior was met with reinforcement
on an increasing basis, and Mr. M stated at one point that all parents should attend simi-
lar sessions to learn how to influence child behavior in a positive way.

8 COMPLICATING FACTORS
One of the complicating factors concerning LM’s treatment, and also a factor typi-
cal for many children with selective mutism, is the long history of secondary gain associ-
ated with LM’s selective mutism behaviors. Regardless of the etiology of LM’s selective
mutism, it became apparent that LM’s refusal to speak enabled him to avoid a number of
situations and behaviors, resulting in reinforcement of his reticence. For example, he
was able to avoid answering questions in class, and this avoidance led to reduction in the
likelihood that teachers would call on him in the future. Based on the abundance of sec-
ondary gain for this client, it was challenging to motivate him to engage in increased
social interactions.
A number of family issues also provided complications for treatment. The initial
complication had to do with overall communication with LM’s parents. Although LM
was fluent in English, both of his parents spoke little English. Therefore, LM’s individ-
ual therapist, who was not bilingual, had difficulty directly conversing with LM’s par-
ents. This difficulty was addressed by recruiting a bilingual cotherapist to conduct con-
current sessions with LM’s parents. The bilingual therapist was also able to translate for
LM’s primary therapist, so that LM’s primary therapist could communicate information
about LM’s progress and homework assignments. In addition, the bilingual cotherapist
conducted sessions with the parents that included parent training and education to
maximize the effectiveness of treatment.

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398 CLINICAL CASE STUDIES / October 2006

Another complication had to do with poor parental compliance with parent anxi-
ety management training and minimal parental facilitation of exposure tasks for LM.
LM’s father reported that economic and time constraints played a role in their inconsis-
tencies with regard to carrying out the prescribed strategies. In addition, cultural differ-
ences associated with Hispanic families may have complicated treatment (McGoldrick,
Giordano, & Pearce, 1996). Specifically, the father’s expectation that children should
obey directives without the use of rewards contributed to resistance related to applying
positive behavior modification strategies. This expectation is consistent with the belief
commonly held in Hispanic cultures that a child should be respectful, compliant, and
well-behaved, or what is referred to as bien educado (e.g., Fontes, 2002).
Another possible factor that may have been associated with limited parental facili-
tation of exposure tasks and limited compliance with prescribed parent training strate-
gies was the minimal amount of social contact outside of the immediate family environ-
ment evidenced by all family members. This isolation meant that, with the exception of
school, LM had few opportunities to practice skills with individuals outside of the core
family unit, and limited modeling of social interactions occurred. Further, the parents
not only were limited in their social interactions but also appeared somewhat resistant to
engaging in social interactions with individuals outside of the family. As a result, the par-
ents may have been modeling avoidance of social interactions. It is interesting that social
isolation may be common for families with a socially anxious child (Burch & Heimberg,
1994).
The limited social interaction may be explained by the aforementioned economic
and time constraints; however, a number of other factors may be associated with the fam-
ily’s limited social interaction. First, although there is a significant Spanish-speaking
population in the area in which LM’s family resides, a limited ability to speak English
may have limited the possible number of opportunities to engage in more common
forms of social interaction, especially for families who are relatively new to a particular
community. Second, both parents appeared to exhibit a relatively high degree of social
discomfort. Such social discomfort may be associated with their reluctance to take part
in the facilitation of exposure tasks for LM. The father’s social inhibition may also be a
possible explanation for his reluctance to provide positive reinforcement to LM in pub-
lic settings. An additional complication was that LM and his father appeared to have few
positive social interactions. As a result, attempts on the part of the father to reinforce
LM’s speaking behavior may not have been very reinforcing for LM.
The contrasting perceptions of LM’s behavior on the parts of his mother and father
also posed a challenge in gaining some consistency concerning parental engagement in
treatment. Fortunately, LM’s father increasingly applied prescribed techniques and
noted improvement in terms of the frequency with which LM engaged in speech out-
side of the home (e.g., responding to strangers’ greetings, ordering food).

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 Fisak et al. / TREATMENT OF SELECTIVE MUTISM 399

Application of reinforcement on the part of the parents was quite inconsistent

throughout treatment, however. To illustrate, during the 22nd week of treatment, LM
agreed to participate in an impromptu yard sale. To his father’s reported surprise, LM
stated the price of items to inquiring neighbors and strangers, described items, and even
negotiated a sale price with a peer. LM’s father noted that although LM tried to speak as
little as possible, he seemed to enjoy this particular activity. Nonetheless, his father
critiqued LM’s reluctance to sell more of his old toys, instead of verbally praising LM’s
speech. Although this is just one example of the apparent intractability of ineffective but
familiar parental behaviors, the practice of social skills with parents did increase
throughout treatment, and LM’s father became increasingly invested in applying the
strategies discussed in session, especially to curtail LM’s noncompliance.
In addition to challenges related to LM’s family dynamics, a number of challenges
emerged when the therapist attempted to enter the school setting. One barrier was that,
due to administrative constraints, it took the therapist approximately 2 months to gain
permission to go to the school for observation and consultation with the school staff.
Once the therapist was able to enter the school, the school was generally receptive to
consultation; however, the teacher did not completely follow through with a number of
designed interventions. For example, the teacher agreed to designate an extroverted stu-
dent as a peer who could actively attempt to engage LM in social interaction and assist
LM in attempts to interact with other students. Second, the teacher agreed to give LM a
folder with a daily monitoring log that could be completed by LM and reviewed by his
teacher. Although the teacher willingly provided updates via e-mail on LM’s behavior,
the two above-mentioned interventions were not implemented.
A final complication had to do with assessment of additional factors that may be
associated with the development and/or maintenance of LM’s selective mutism. It was
apparent that LM exhibited a degree of social anxiety; however, throughout treatment, it
seemed increasingly possible that cognitive and/or speech-related difficulties may have
been impeding his progress, based on his continued difficulty maintaining conversa-
tions during role-plays and integrating social skills presented in the modules. A compre-
hensive screening for cognitive difficulties at the outset of treatment was not feasible dur-
ing the initial assessment phase due to the presenting selective mutism symptoms.
Similarly, before the current psychological intervention, he was referred to a speech
pathologist at his school. The speech pathologist was also unable to conduct a compre-
hensive speech assessment because of LM’s refusal to speak. Nonetheless, when a mea-
sure of cognitive ability was successfully completed with LM, he performed in the aver-
age range, relative to same-age peers. Further testing may help explicate more subtle
learning or developmental issues that may have contributed to LM’s noted difficulties in
session.

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400 CLINICAL CASE STUDIES / October 2006

9 MANAGED CARE CONSIDERATIONS

Although research-based treatments have been shown to be efficacious in
research-oriented settings, a number of considerations and adaptations may be necessary
to maximize the effectiveness of such treatments in other clinical settings (e.g., Jensen,
Hibbs, & Pilkonis, 1996). Specifically, the therapists who administered this treatment in
a university clinic did not have to work within the constraints of the managed care sys-
tem, and a managed care setting may have necessitated a number of modifications to the
above-mentioned treatment process. For example, limitations may be placed on the
number of authorized sessions. Further, therapists in managed care settings may not
have the liberty to use two cotherapists, concurrently working on the same case. In addi-
tion, therapists may not always have the flexibility of being able to visit the school to con-
sult with school staff and to observe the client in the school setting.
One suggestion is that, regardless of treatment limitations, therapists make every
attempt to engage parents in SM treatment, as engaging the parents in treatment may
increase the success rate of anxiety-related interventions (Barrett, Dadds, & Rapee,
1996). Engaging the parents may be of particular importance in time-limited managed
care settings. Parents are able to implement treatment strategies on a daily basis (e.g.,
reinforcement of speech behavior and exposure tasks) and may be able to serve as a liai-
son with the school. Further, parents are vital in creating an environment that would
maintain gains accomplished during therapy. As a result, despite session limitations
placed by managed care, therapists should still spend a significant portion of therapy
educating the parents and engaging them in the treatment process with children
exhibiting SM.
In a managed care setting, facilitating client therapeutic interventions in school
can be accomplished in a number of possible ways. Interventions can include therapist-
teacher phone consultations or assisting the parent in working with teachers to effec-
tively initiate a school-based intervention. Another possibility, when feasible, is the use of
behavior modification specialists assigned to the schools. These specialists may be able
to most effectively implement school-based interventions prescribed by the therapist.

10 FOLLOW-UP
Treatment was completed in mid-summer. At this point in treatment, all SET-C
skills were completed, significant progress was documented (both inside and outside of
the clinic), and LM appeared to reach a plateau in terms of his treatment progress. The
clinicians agreed to contact the family at the beginning of the new school year to assess
the necessity of reinitiating treatment.

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 Fisak et al. / TREATMENT OF SELECTIVE MUTISM 401

A follow-up with LM’s mother at the beginning of the new school year indicated
that LM was reportedly doing well in school and that he liked school. His mother also
reported that the teacher had not reported significant concerns and that LM was partici-
pating in after-school activities on Fridays. In addition, LM’s mother reported that LM
does not seem to shy away from strangers as much as he used to and that he will respond
to strangers with a verbal greeting. His mother reported that they are satisfied with his
behavior and are no longer seeking services at this time; however, she agreed to contact
the clinic if future concerns were to arise.

11 TREATMENT IMPLICATIONS OF THE CASE AND

RECOMMENDATIONS TO CLINICIANS AND STUDENTS

Treatment of SM was accomplished through a number of relevant interventions

that included social skills training for anxious children, exposure to feared situations,
parent training, and a number of additional, specific interventions. This case study sug-
gests that such a combination of interventions in conjunction with parent training and
school-based interventions may be an effective treatment for some children with SM. In
addition, this case adds to the literature suggesting that manual-based interventions
developed for the treatment of anxiety disorders may be effective interventions for chil-
dren with selective mutism (Hudson, Krain, & Kendall, 2001). As a result, more system-
atic research on the effectiveness of the application of manual-based anxiety interven-
tions for the treatment of selective mutism is recommended. Further, it is noteworthy
that other interventions in conjunction with manual-based interventions may increase
the effectiveness of treatment for SM. In addition, this case study highlights both the
importance of parent involvement in treatment and the challenges inherent in working
with parents of anxious and selectively mute children (Barrett et al., 1996; Siqueland &
Diamond, 1998).

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Brian J. Fisak, Jr., is an assistant professor in the Department of Psychology at the University of North
Florida. His primary research and clinical interests are in the areas of prevention and treatment of child-
hood anxiety disorders, developmental psychopathology, and evidence-based treatments.

Arazais Oliveros received her bachelor’s degree in psychology from Florida International University where
she worked in the Child Anxiety and Phobia Program. She is pursuing a doctoral degree in clinical psychol-
ogy at the University of Central Florida and conducting research in the Family P.A.I.R.S. (Perception and
Interaction Research Studies) Lab.

Jill T. Ehrenreich, Ph.D., is a research assistant professor of psychology and associate director of the Child
and Adolescent Fear and Anxiety Treatment Program at the Center for Anxiety and Related Disorders at
Boston University. Her primary interests are in the etiology, assessment, and treatment of child and adoles-
cent anxiety disorders.

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