Meeting Meeky: A case study of a novel cognitive behavioural therapy for selective mutism
MA
*Department of Psychiatry
Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8
**Dr Fung completed this work during a clinical fellowship at the Hospital for Sick Children. He is now an Associate Consultant, Department of Child and Adolescent Psychiatry, Institute of Mental Health, Singapore
For reprint requests and/or correspondence:
Daniel Fung
Child Guidance Clinic
Health Promotion Board Building
3, Second Hospital Avenue, #03-01,
Singapore 168937
Abstract
We describe the use of an Internet based cognitive behavioural treatment on a selectively mute child with improvement during the sessions. The use of cognitive behavioural therapy in selective mutism and the clinical implications of such a novel treatment are discussed.
Key Words: Selective mutism, Cognitive behavioural therapy, Internet, Children
Introduction
Selective
mutism (SM) is a rare condition in which children who speak in some situations
remain mute in others. SM is probably a
heterogenous condition. Early studies focused on family psychopathology and unresolved conflict.
Others noted the evidence of co-existent
developmental disorders (Kristensen 2000).
Current evidence suggests that SM is a form of anxiety disorder (Anstendig
1999). Early case studies proposed
psychoanalytic and family therapies, which were not cost effective. One randomised case-control clinical trial
involving medications has shown some efficacy (Black and Udhe 1994).
Cognitive
behavioural therapies (CBT) have been effective in children with anxiety
disorders (Kendall et al 1994) and long term outcome has been shown to be
favourable (Kendall 1996). Although
treatment of SM children has often been described as CBT, most of these focus
on behaviour modification rather than direct work with cognitive restructuring. We believe that SM children at school age
can be taught cognitive strategies, as they are generally of normal
intelligence (Steinhausen and Juzi 1996).
An Internet based CBT protocol for SM children was adapted from a
manualised treatment that is being used to help anxious children in a
specialised anxiety clinic in a large children’s hospital. In this case study, we report the
successful application of an Internet based CBT program with a 7-year-old SM
child who was seen in our clinic.
We have obtained permission from his parents to describe BPH but details have been changed to conceal his identity. BPH is a 7-year-old child. The parents separated when he was six and have joint custody arrangements. BPH had SM before the parental separation. BPH is attending public school and is in grade two in a French language program. When BPH started school at 3 years of age, he spoke softly to his teacher. On entering kindergarten, BPH stopped speaking in school but there was no traumatic precipitant. The family moved to France during senior kindergarten and BPH continued to be reticent in class. As the family was in a foreign language environment, the parents and teachers were less concerned about BPH’s failure to speak. When BPH returned to Canada in 1999, he was referred to a child psychiatrist. The attending psychiatrist diagnosed SM and suggested using medications. The family declined and no further follow-up occurred. BPH showed improvement the following year. He started speaking to some of his classmates but continued to be mute to others and to his teachers. His parents were concerned that BPH might not benefit from the teacher’s instruction without appropriate interaction, prompting the referral to our centre.
There was no family history of SM or diagnosed mental disorders, although several relatives in the maternal family were described as having mood and anxiety problems. BPH had longstanding shyness, but his early development was otherwise unremarkable. He was medically healthy. Academically, his performance was average apart from difficulty in creative writing.
During assessment, BPH was quiet and looked away when spoken to. He would use gestures such as nodding and shaking his head. He was able to smile when he saw his family members and did not appear sad. He was able to follow instructions.
Vocalization at school consisted of mouthing (without singing) the words of the national anthem. He was speaking to some classmates. When he noticed his teacher watching, BPH would stop speaking. In class, BPH was obedient and not defiant. He had difficulties in some tasks, such as writing in a journal.
Diagnostic assessment revealed SM, but no other Axis I disorder. BPH’s mother completed a structured clinical diagnostic interview based on DSM IV criteria administered through a computerised program to confirm diagnosis. BPH also had an audiometric screen to rule out hearing deficits. The mother also completed a questionnaire on her son’s general health.
BPH underwent an assessment protocol of cognitive, academic and language tests. This was designed to assess SM children using a combination of non-verbal techniques in mute situations and narrative techniques in non-mute situations. It is part of a larger study to characterise the learning and language in SM children. BPH’s non verbal reasoning skills were in the very superior range while his academic tests of spelling and arithmetic were all above average. Receptive language testing also showed superior abilities and he had appropriate phonemic awareness. On expressive language testing based on tape recorded story retelling, BPH was slow and cautious, with poor referencing and adherence to details. His word counts also decreased as the story retelling task moved to increasingly anxious situations (from home to clinic). There was no clinically discernible language disorder.
To assess outcome, pre-treatment measures administered included the Multidimensional Anxiety Scale for Children (March 1998), the Social Anxiety Scale for Children (SASC) (La Greca and Stone 1993), the Children’s Depression Inventory (CDI)(Kovacs 1983), and the Children’s Global Assessment Scale (Shaffer et al 1983). A SM Questionnaire (SMQ) (Bergman 2000) was given to the mother and was used to rate the degree and severity of the SM. These measures were repeated after the child completed the CBT sessions.
The CBT program involved recognition of anxiety, relaxation techniques, cognitive restructuring, problem solving strategies, graded exposure to feared situations and social skills training designed for SM children. It is adapted from the “Coping Bear Workbook” (Mendlowitz 1999). The program is available from the authors. It includes a child workbook and a parent/teacher manual. The parent/teacher manual focuses on psychoeducation and behavioural therapy through graduated exposure.
The treatment consists of 14 individual, weekly sessions of 1.5 hours each. One hour is spent with the child and 30 minutes with the parents. A psychiatrist conducts the treatment. The approach integrates elements of behaviour therapy for anxiety (e.g.; relaxation training, exposure to feared situations) and cognitive processing aspects (recognising distress through the body’s reactions, understanding thoughts and restructuring them, developing a coping plan to deal with distress). The goal is to teach children to recognise the signs of anxious arousal associated with speaking and social situations. They learn to use these as a cue to use the anxiety management strategies that are taught.
The program is divided into 2 segments. The first 8 sessions are the training segment and the second 6 are the practice segment. Homework tasks are provided for each session, and submitted by the child via email. The entire workbook is online and the child works with the materials in an interactive fashion online. The work is then given to the child in a printed format so parents and teachers can access it and encourage the child in the training program.
Each session introduces new skills and concepts while reviewing what was previously taught. By the end of 8 sessions, the child is familiar with the “CHAT Plan”. This plan is analogous to Kendall’s original FEAR Plan for anxiety, and uses an acronym, which facilitates the SM child’s recall. The plan includes: Check your body’s feelings, Having bad thoughts, Attitudes and Actions that can help, Time for a reward. The plan is introduced through the use of a mouse called Meeky, who is the main character in the workbook. Children enjoy stories and the use of an animal character helps them to identify easily with their own symptoms. The workbook starts off with a story about Meeky, which the child read with the therapist. Meeky is introduced as a plush toy whom the therapist presents in a slightly different voice, especially in instances when Meeky speaks about his own difficulties.
The second segment is devoted to applying the CHAT plan in increasingly difficult and anxious situations using an activity (exposure) ladder. Each of the last 6 sessions introduces social skills that are helpful for SM children. These include: understanding people, making and keeping friends (e.g. Saying hello, introducing yourself, doing things together), dealing with unfamiliar situations. In session 8, a “Meeky Soundpad” is introduced. This is a Microsoft Powerpoint presentation with a grid of 6 squares (per page) which is uploaded from the web to the local personal computer (PC) and used to help the child record short messages which can be replayed during the session. If the child is mute, he has 2 alternatives; to record the messages at home on a PC and bring it on a diskette, or to record the messages on an audiotape that can be transferred to the PC in the clinic. This is a novel treatment procedure adapted from a report using an augmentative communication device (Kee et al 2001). The idea is to allow the child to hear his own voice and be desensitised to speaking in various situations.
BPH was the first child in which we used the program. His parents were eager to try this approach because of BPH’s persistent SM. BPH did not appear interested initially and took a long time to perform simple tasks such answering a multiple choice question. He became more enthusiastic as his typing speed improved, and he went on to more sophisticated tasks that required him to type short sentences. BPH was silent up till session 8. He was consistent in completing the homework and these were emailed regularly prior to his visit the following week.
In session 9, BPH was introduced to Meeky Soundpad. He was instructed to make an audiotape of various phrases at home to be transferred into the PC the following week. In session 10, he chose to record additional phrases directly during the session. He asked for his mother to be with him to make him less nervous. Following the soundpad exercise, he started reading the session notes off the PC and was able to answer specific questions the therapist posed such as “What does the CHAT Plan stand for?” The next day, BPH also said his first words to his teacher and he has been speaking in every session since. As a result of BPH’s response to this novel program, we are now embarking on further studies of this approach in SM children with some evidence of social anxiety.
This case study is interesting to clinicians for several reasons. Current practice favours the use of medication and behavioral techniques in persistent SM. The use of CBT in SM with direct training of the child has not been described. Nevertheless, BPH improved dramatically with a relatively brief course of such treatment.
The use of an Internet-based CBT protocol
has also not been described, though computers have been used in CBT with adult
populations. A recent study showed that web-based psychoeducation for anorexic
patients was more effective than group conducted sessions (Celio et al 2000).
Our experience with anxious children
suggests that they are interested in using the PC during therapy. A number of colleagues make use of the
Internet as a reward for completing CBT homework.
Internet administered treatments warrant further investigation. Currently about 50% of the population in North America are connected to the Internet, but this is expected to grow rapidly over the next few years. Internet administered treatments have many advantages including the potential for wide dissemination, for interactive sessions, and for useful repetition of material by patients and families after the clinic session. As children often see the use of the computer as a game, treatment compliance is also often improved.
When interpreting our findings, it is important to note that BPH was an exceptionally bright child to begin with. We feel that CBT used in this manner should be catered to children of at least average intelligence with no learning or language disorders. Such an approach is more suited to older children with persistent SM.
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