ERIC EJ941708: Behavioral Intervention to Treat Selective Mutism across Multiple Social Situations and Community Settings

2011·0.21 MB·English

by  ERIC

JOURNALOFAPPLIEDBEHAVIORANALYSIS 2011, 44, 623–628 NUMBER3 (FALL2011)
BEHAVIORAL INTERVENTION TO TREAT SELECTIVE MUTISM
ACROSS MULTIPLE SOCIAL SITUATIONS AND
COMMUNITY SETTINGS
RUSSELL LANG
TEXASSTATEUNIVERSITY–SANMARCOS
APRIL REGESTER
UNIVERSITYOFMISSOURI,ST.LOUIS
AUSTIN MULLOY
MEADOWSCENTERFORPREVENTINGEDUCATIONALRISK,
UNIVERSITYOFTEXASATAUSTIN
MANDY RISPOLI
TEXASA&MUNIVERSITY
AND
AMANDA BOTOUT
TEXASSTATEUNIVERSITY–SANMARCOS
We evaluated a behavioral intervention for a 9-year-old girl with selective mutism. The
interventionconsistedofroleplayandvideoself-modeling.Thefrequencyofspokeninitiations,
responses to questions, and communication breakdowns was measured during three social
situations(i.e.,orderinginarestaurant,meetingnewadults,andplayingwithnewchildren)and
inthreecommunitysettings.Resultsdemonstratedincreasesinspokeninitiationsandresponses
anddecreasesin communication breakdownsacross allsituations andsettings.
Key words: selective mutism, role play, video self-modeling, communication intervention,
community settings
_______________________________________________________________________________
Selective mutism is a childhood disorder in involved contingency management (e.g., Wat-
which speech occurs in some environments but son&Kramer,1992),practiceorpriming(e.g.,
notinothers(AmericanPsychiatricAssociation, O’Reilly et al., 2008), shaping (e.g., Masten,
2000).Forexample,achildmayspeaknormally Stacks, Caldwell-Colbert, & Jackson, 1996),
at home, but not speak at school or the and systematic desensitization (e.g., Rye &
community park. Estimates of prevalence vary Ullman, 1999).
but are typically less than 1% of the population The current study evaluated a behavioral
(Viana, Beidel, & Rabian, 2009). Selective intervention for selective mutism consisting of
mutism may result in social isolation and role play and video self-modeling (VSM). Role
academic failure (Kolvin & Goodyer, 1982). play involves practicing the desired behavior
Previousinterventionsforselectivemutismhave and receiving feedback and reinforcement. Role
play has been shown to improve social skills in
AddresscorrespondencetoRussellLang,Departmentof people with intellectual disability (e.g., Huang
Curriculum and Instruction, Texas State University–San & Cuvo, 1997). VSM has been demonstrated
Marcos, 601 University Drive, San Marcos, Texas 78666
to be a potentially efficient and effective
(e-mail: [email protected]).
doi:10.1901/jaba.2011.44-623 intervention to improve social and communi-
623
624 RUSSELL LANG et al.
cation skills in children with emotional and situations. Responses were defined as spoken
behavioral disorders (e.g., Baker, Lang, & answers to questions that were loud enough to
O’Reilly, 2009) and autism spectrum disorders be heard and occurred within 5 s of the
(McCoy & Hermansen, 2007). The combina- question. Initiations were defined as spoken
tion of these intervention components seems statements that occurred after a period of 5 s or
likely to improve speech in children with more without a spoken exchange, were loud
selective mutism. enoughtobeheard,andwerenotinresponseto
To date, we are unaware of any behavioral a question. Breakdowns were defined as failures
intervention studies for selective mutism in in communication in which (a) the communi-
which the effects of an intervention were cation partner repeated a question, (b) the
evaluatedoutsidetheschoolandacrossmultiple communication partner asked Leslie to repeat
communitysettingsandsocialsituations.Inthis herself, or (c) Leslie did not respond within 5 s
study, speech was measured during three social of being asked a question.
situations and in three community settings All sessions were recorded using a handheld
following role play and VSM. video recorder, and videos were coded for
dependent variables using frequency recording.
METHOD Interobserver agreement was obtained for 33%
of sessions. Interobserver agreement was calcu-
Participant and Setting
latedfromthevideorecordingsbydividingeach
Leslie was a 9-year-old girl with selective
recorded session into 30-s intervals and com-
mutism.Shespokeclearlyandfrequentlyinher
paringthefrequencyofeachdependentvariable
homebutwouldnotspeakinmanycommunity
within each 30-s interval. Within each interval,
settings. This absence of speech in the commu-
thelowestnumberoftotaloccurrenceswasthen
nity had persisted for more than a year and
divided by the highest and the result was
interfered with activities (e.g., summer camp
multiplied by 100% for each dependent
and swim lessons). Leslie had no previous
variable. Mean agreement across intervals was
history with the experimenter and had never
100% for all dependent variables during
received any systematic behavioral intervention
baseline. During the intervention, mean agree-
prior to involvement in the study.
ment was 89% (range, 80% to 100%) for
Three social situations in which speech was
responses, 87% (range, 66% to 100%) for
expectedbutinwhichLesliedidnotspeakwere
initiations, and 98% (range, 90% to 100%) for
selected for intervention (i.e., ordering at a
breakdowns.
restaurant, meeting new adults, and playing
Treatment fidelity was assessed during 50%
with a new peer). Data were collected at two
of intervention sessions using a checklist based
restaurants and an office building. Each setting
on intervention components. The checklist
was commonly visited by Leslie and her family
combined experimenter presentation of inter-
prior to the study. Both restaurants required
customers to stand at the counter and order vention components and Leslie’s participation
from a large menu board hanging from the and included the following: (a) Leslie watched
ceiling. The office building was on a university the video (i.e., eyes open and head oriented
campus near Leslie’s father’s workplace. towards screen), (b) Leslie spoke during role
play (i.e., audible speech appropriate to the
Response Measurement, Interobserver Agreement, role-play scenario), and (c) the experimenter
and Treatment Fidelity delivered praise (e.g., ‘‘Great work,I could hear
Responses, initiations, and communication you clearly!’’). The occurrence or nonoccur-
breakdowns were measured for all three social rence of each component was recorded during
SELECTIVE MUTISM 625
sessions in which treatment fidelity was mea- Peers were children of staff or doctoral
sured. Treatment fidelity was 100%. students. Peers were told that the purpose of
the study was to investigate the way children
Design and Procedure playedtogether.Leslieandthepeerweregivena
The intervention was evaluated in a multiple table, two chairs, and a board game both
baseline design across the three social situations children knew how to play. Peers were unaware
(i.e.,ordering,meetingadults,andplaying with thatLeslie’sparticipationwasanydifferentthan
peer). their own. The session was ended after 10 min
Baseline. Baseline for ordering in a restaurant or two communication breakdowns.
wasconductedinRestaurant1.Lesliewastaken Role play and video self-modeling. Prior to the
to the restaurant by an experimenter and her intervention, the experimenter asked Leslie
mother, given money, and asked to order which social situation she would like to work
anything she wanted. Leslie’s mother sat at a on first. Leslie chose to work on ordering in a
table a minimum of 5 m away from Leslie, and restaurant first, meeting adults second, and
the experimenter stood next to Leslie. When playing with peers last. Therefore, intervention
Leslie approached the counter, the employee implementation was staggered across social
asked her if she was ready to order (or a similar situations in that order. Intervention sessions
question). After the occurrence of two commu- consisted of role play, video observation, and
nication breakdowns, the session was terminat- reinforcementandwereimplementedatLeslie’s
ed and the experimenter ordered for Leslie and home. Data were collected at the restaurants
completed the transaction. Sessions were termi- (for ordering) or office building (for meeting
nated early to avoid unnecessarily embarrassing new adults and playing with peers) using the
Leslie. Early termination occurred in all three same procedures as in baseline, including the
baseline sessions for all three social situations session-termination criterion. However, no
because Leslie did not speak. Therefore, each sessions ended early because communication
baseline session lasted less than 2 min. breakdowns rarely occurred during the inter-
Baselines for meeting a new adult and vention.
playing with a new child were conducted in The experimenter and Leslie met at Leslie’s
the office building, and each session occurred home and discussed the social situation they
with a different person not previously met. would role play. Leslie was given suggestions
Leslie’s mother was in a different room out of regarding how to respond to specific questions
sight, and the experimenter stood a minimum that would be asked during role play (e.g., ‘‘Do
of 5 m away. The adults were doctoral students youwantthisforhereortogo?’’whenordering
who volunteered to participate in a social skills in a restaurant) and on possible ways she might
intervention and were told that they would initiate (e.g., ‘‘Hi, what’s your name?’’ when
meet for 5 min with a child. Leslie was brought meeting a new person). During role play, the
to the adult’s office, and the experimenter said researcher pretended to be the communication
to the adult, ‘‘I have someone I would like you partner (e.g., cashier at restaurant). Leslie was
to meet.’’ The adults had been told this would able tospeakwithoutdifficulty duringroleplay
be the introduction and to behave as they and was videotaped. Leslie then watched the
normally would when meeting a child. Five- role-play video and video from the previous
minute sessions were planned, but early termi- sessiontakenattherestaurantorofficebuilding
nation following two communication break- (except the first session for each setting because
downs ended baseline sessions in less than only a role-play video was available). Leslie was
2 min. able to identify her responses, initiations, and
626 RUSSELL LANG et al.
Figure 1. Frequency of spoken initiations, responses to questions, and communication breakdowns across three
socialsituations.
breakdowns in the videos. The researcher 4 min). Meeting new adult sessions were set at
praised Leslie for all occurrences of responses 5 min and playing with peers at 10 min.
and initiations observed on the videos. Role
play and VSM lasted 30 to 45 min. Session
RESULTS AND DISCUSSION
durationvariedfrom2to4min(M52.5min)
for ordering in Restaurant 1 and from 3 to Figure 1 displays the frequency of the
5.5 min when ordering in Restaurant 2 (M 5 dependent variables in baseline and interven-
SELECTIVE MUTISM 627
tion. Baseline confirmed the report that Leslie increased, suggesting that generalization across
did not speak in the identified social situations settings may not occur even when the social
and settings. Following the intervention, Leslie situations are similar. Based on this interpreta-
spoke in all three social situations and in all tion, future behavioral interventions for selec-
three settings. Responses per session increased tivemutismshouldinvolveproceduresdesigned
from0inbaselinetomeansof5fororderingin to transfer stimulus control from irrelevant
a restaurant, 6 for meeting adults, and 16 for setting-specificstimulitorelevantsocialstimuli.
playing with peers. Initiations increased from 0 Theinterventiondescribedhereincreasedthe
in baseline to means of 0.3 for ordering in a frequency of speech quickly during targeted
restaurant, 4 for meeting adults, and 5 for socialsituations.Previousresearchinvolvingthe
playing with peers. Few initiations occurred treatmentofselectivemutismsuggeststhatlong
when ordering in a restaurant because the treatment durations are not uncommon (Stan-
cashier quickly asked questions (e.g., ‘‘How dart & Le Couteur, 2003), with many studies
can I help you?’’) and Leslie needed only to reportingdurationsofmorethan1year(Cohan
respond to questions. Communication break- et al., 2006). By contrast, improvement was
downswererareduringintervention(M50.7). observed in this study after very few interven-
tionsessions.Despitethisefficiency,theneedto
In baseline, communication breakdowns were
target each social situation individually is a
the result of not speaking, but they occurred
substantial limitation for individuals with
during intervention because Leslie sometimes
selective mutism who require intervention
spoke too softly to be understood. It is
across numerous social situations. The behav-
important to note that Restaurant 2’s menu
ioral interpretation of selective mutism de-
and routine required the cashier to ask more
scribed above may facilitate the design of future
questions than in Restaurant 1. Therefore, the
interventions that promote generalization by
increase in responses from Restaurant 1 to
focusing on transferring stimulus control to
Restaurant 2 is explained by the increase in
social discriminative stimuli.
opportunity. Although her mother reported
that Leslie did not speak in any restaurant, the
absence of baseline data in Restaurant 2 also REFERENCES
restricted interpretation of those results as American Psychiatric Association. (2000). Diagnostic and
generalization. statistical manual of mental disorders (4th ed., text
rev.). Washington, DC:Author.
Previousresearchhasconceptualizedselective
Baker, S., Lang, R., & O’Reilly, M. (2009). Review of
mutism as a type of phobia (e.g., Cohan,
video modeling with students with emotional and
Chavira, & Stien, 2006). From a behavioral behavioral disorders. Education and Treatment of
Children,33,403–420.
perspective, selective mutism is an example of
Cohan, S. L., Chavira, D. A., & Stien, M. B. (2006).
restricted stimulus control. Specifically, speech
Practitioner review: Psychosocial interventions for
would appear to be under control of setting- children with selective mutism: A critical evaluation
specific stimuli as opposed to the usual social of the literature from 1990–2005. Journal of Child
Psychology and Psychiatry,47,1085–1097.
stimuli (e.g., presence of a listener) and
Huang,W.,&Cuvo,A.J.(1997).Socialskillstrainingfor
motivating operations that evoke speech. This adults with mental retardation in related settings.
behavioral interpretation is supported by the Behavior Modification,21,3–44.
Kolvin,I.,&Goodyer,I.(1982).Childpsychiatry.InK.
currentstudybecausespeechdidnotincreasein
Granville-Grossman (Ed.), Recent advances in clinical
a social situation until intervention directly psychiatry (pp. 1–24).London: Church Livingstone.
targeted that situation. For example, baseline Masten,W.G.,Stacks,J.R.,Caldwell-Colbert,A.T.,&
Jackson, J. S. (1996). Behavioral treatment of a
levels for meeting a new adult remained stable
selectivelymuteMexican-Americanboy.Psychologyin
even after speech when ordering in a restaurant the Schools,33,56–60.
628 RUSSELL LANG et al.
McCoy,K.,&Hermansen,E.(2007).Videomodelingfor Standart,S.,&LeCouteur,A.(2003).Thequietchild:A
individualswithautism:Areviewofmodeltypesand literature review of selective mutism. Child and
effects. Education and Treatment of Children, 30, Adolescent MentalHealth, 8,154–160.
183–213. Viana, A. G., Beidel, D. C., & Rabian, B. (2009).
O’Reilly, M., McNally, D., Sigafoos, J., Lancioni, G. E., Selectivemutism:Areviewandintegrationofthelast
Green, V., Edrishina, C., et al. (2008). Examination 15years. Clinical Psychology Review,29,57–67.
of a social problem-solving intervention to treat Watson, T. S., & Kramer, J. J. (1992). Multi-method
selective mutism. Behavior Modification, 32, 182– behavioral treatment of long-term selective mutism.
195. Psychologyin theSchools,29,359–366.
Rye, M. S., & Ullman, D. (1999). The successful
treatment of long-term selective mutism: A case Received July 27,2010
study.JournalofBehavioralTherapyandExperimental Final acceptance October13,2010
Psychiatry,30,313–323. Action Editor,Rachel Thompson