The nature of the anxiety in children with Selective Mutism. Maria Ivanka Milić Bachelor of Arts

212 Pages·2016·4.02 MB·English

by  Maria Milic

The nature of the anxiety in children with Selective Mutism.

Maria Ivanka Milić
Bachelor of Arts (Hons), Masters of Psychology (Clinical)

Redbank House (Department of Child, Adolescent and Family Psychiatry)
Western Sydney Local Health District, NSW, Australia

Department of Psychology, Faculty of Human Sciences,
Macquarie University, NSW, Australia
20th August 2015

This thesis is presented in partial fulfilment of the requirements for the degree of Doctor
of Psychology (Clinical Psychology)
Table of Contents
List of Tables iv
Thesis Abstract v
Declaration vii
Acknowledgements viii

Chapter 1: General Introduction 1
1. Definition of Selective Mutism 2
2. An historical overview of Selective Mutism 3
3. Descriptive features of Selective Mutism 8
3.1. Demographic features of Selective Mutism
3.1.1. Prevalence 8
3.1.2. Gender 9
3.1.3. Age at onset 9
3.1.4. Referral path 10
3.2. Symptom profile
3.2.1. Speaking behaviour 10
3.2.2. Internalising symptoms 11
3.2.3. Externalising symptoms 13
3.2.4. Comorbidity 13
3.2.5. Course of the disorder 14
4. Risk factors for Selective Mutism
4.1. Internal risk factors
4.1.1. Genetic 15
4.1.2. Temperament 16
4.1.3. Speech and Language skills 16
4.1.4. Auditory processing abilities 17
4.1.5. Social performance skills 18
4.2. Environmental factors
4.2.1. Parent-child interaction 19
4.2.2. Negative life events 19
5. Behavioual/Cognitive-behavioural treatment 20
6. Relationship of Selective Mutism to other Anxiety Disorders 20
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7. Summary and aims of the thesis 22
References 24

Chapter 2: Paper 1 – The development and psychometric properties of the Selective
Mutism Questionnaire-Child (SMQ-C). 40
Abstract 41
Introduction 42
Method
Participants 47
Measures 50
Procedure 57
Statistical analysis 57
Results 58
Discussion 66
References 71

Chapter 3: Paper 2 – Social phobia symptomatology and behavioural inhibition in
children with Selective Mutism: A comparison with children with Social Phobia and
non-clinical controls. 80
Abstract 81
Introduction 82
Summary and hypotheses 86
Method
Participants 87
Measures 88
Procedure 97
Statistical Analysis 98
Results 99
Discussion 113
References 121

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Chapter 4: Paper 3 – Social anxiety and parenting behaviour among parents of children
with Selective Mutism, children with Social Phobia and non-clinical controls. 132
Abstract 133
Introduction 134
Summary and hypotheses 140
Method
Participants 141
Measures 144
Procedure 150
Statistical analysis 150
Results 151
Discussion 159
References 168

Chapter 5: Summary and Conclusions 177
References 185

Appendix A: 190
Selective Mutism Questionnaire – Child (SMQ-C) 191
SMQ-C Pictorial Response Scale 194
Sample individual items of the SMQ-C 195

Appendix B: Ethics 196
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List of Tables

Chapter 2
Table 1: Demographic characteristics of the children in the study………………….....49
Table 2: Primary and comorbid diagnoses in the two clinical groups, SM and SP. …..49
Table 3: Item responses on the SMQ-C………………………………………….…….61
Table 4: Correlations between the SMQ-C, mother’s SMQ, father’s SMQ and SSQ…62
Table 5: Correlations between SMQ-C and parent-and teacher-report on related
constructs…………………………………………………….…………….…63
Table 6: Correlations between SMQ-C and Verbal Interaction Task…………… ……65
Table 7: Correlation between SMQ-C and parent- and teacher-report on externalising
behaviour measures………………………………………………………......65
Table 8: Comparison between groups on SMQ-C Total and Factor Scores…………...66

Chapter 3
Table 1: Demographic characteristics. ……………………………………………….100
Table 2: Primary and comorbid diagnoses in the two clinical groups, SM and SP.….101
Table 3: Internalising symptoms and
temperament………………………………….……………………………...104
Table 4: Non-anxiety variables……………………………………………………….105
Table 5: Behavioural observation tasks………………………………………………109
Table 6: Quality of peer relationships………………………………………………...112

Chapter 4:
Table 1: Demographic variables………………………………………………………143
Table 2: Primary and comorbid diagnoses in the two clinical groups, SM and SP. …144
Table 3: Parent’s self-report, parenting (NFV) and parent-report measures about the
child…………………………………………………………………….……153
Table 4: Mother-child interation on the puzzle task. ………………………….…….. 154
Table 5: Association between mother’s anxiety, mother’s rating of their child’s anxiety
and mutism, and parenting behaviour…………………………………...…..157
Table 6: Association between fathers’s anxiety, father’s rating of their child’s anxiety
and mutism, and parenting behaviour……………………………….………158

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Thesis Abstract
Research demonstrates that children with selective mutism (SM) present with
symptoms of social anxiety and there is a high comorbidity between SM and social
phobia (SP). As a result some researchers have questioned whether SM is a variant of
SP rather than a distinct anxiety disorder. This thesis sought to clarify the association
between SM and SP. Participants were 25 children with a primary diagnosis of SM, 17
children with a primary diagnosis of SP and 15 children identified as “easy-going” who
did not meet criteria for a DSM-IV diagnosis. Children were aged between 4 to 8 years.
Data included mother, father, teacher and child reports, a semi-structured clinical
interview with the child’s mother, and an observational assessment with the child and
their mother.
The first paper in the thesis reports on the development and psychometric
properties of the child self-report measure of mutism, Selective Mutism Questionnaire –
Child (SMQ-C). The SMQ-C was adapted from a similar adult measure and was
designed for children aged from 4 years. The SMQ-C showed good internal
consistency, convergent and divergent validity. Even young children were able to
provide a clear picture of how much they spoke in various contexts.
The second paper systematically compared children with SM, SP and non-
clinical controls on social anxiety symptomatology and behavioural inhibition.
Observational measures showed that children in the SM group were more verbally and
nonverbally inhibited than children in the SP group and nonclinical controls, and parent
report revealed that they were more fearful of negative evaluation than children in the
SP group who did not differ significantly from non-clinical controls. These findings
indicate that children with a primary diagnosis of SM show similar or even greater
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social phobia symptomatology than children with a primary diagnosis of SP and both
are more socially anxious than non-clinical controls.
The third paper explored relationships between social anxiety, parents’ negative
affectivity, and parenting practices among children with SM, SP and controls. No
significant differences in the levels of negative emotion or social phobia
symptomatology among mothers and fathers were found between the three groups, nor
did the study find any significant differences in parent-child interaction with one
exception. Mothers and fathers of children with a primary diagnosis of SM reported
more thoughts of frustration with their child’s reticence in a novel social situation.
Correlational analyses showed a significant association between maternal social phobia
and child anxiety in the SM and non-clinical groups.
Overall, the findings support the idea postulated in the literature that SM is a
more severe form of SP observed in younger children. Speech is the primary form of
communication in all social interactions, the high social anxiety together with the
spoken and unspoken pressures to speak contribute to maintenance of the disorder.

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Declaration
I certify that this thesis contains no material which has been accepted for the
award of any other degree in any university or other tertiary institution other than
Macquarie University and, to the best of my knowledge and belief, contains no material
previously published or writer by other persons, except where due reference has been
made in the text.
I certify that this thesis is an original piece of work and that it has been written
by me. For each primary study, I was responsible for the formulation of the research
questions, ethics application, study and project management, data preparation, statistical
analysis and preparation of the papers. Professor Ron Rapee, as the Primary Supervisor,
and Dr Lorna Peters, as my Associate Supervisor, supervised the research development,
preparation and writing of each paper.
The research was conducted predominately in the time that I was employed as a
Clinical Psychologist at Redbank House, Western Sydney Local Health District.
I give consent to this copy of my thesis, when deposited in the Macquarie
University Library, being made available for loan subject to the provisions of the
Copyright Act 1968.
The conduct of this research was approved by the Western Sydney Local Health
District Human Ethics Committee under approval number HREC/10/WMEAD/179
SSA/11/WMEAD/190, NSW Department of Education and Communities (SERAP
Number 2010175), and the Catholic Education Diocese of Parramatta (letter dated 24-
11-2011). External approval was noted by the Ethics Secretariat of the Human Research
Ethics committee of Macquarie University (REF 5201100751).
Signed:__________________________________ DATE: ________________
Maria Ivanka Milić
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Acknowledgements
The traditional saying “it takes a community to raise a child” describes my
journey. It has taken a community to support me to achieve my goal of translating my
clinical work and learning into research. There are many people to thank.
Firstly, mama i tata (my parents), bez vaše ljubavi, pomoći, podrške i molitve
nebi ovo postigla. My dear children who have watched, helped in their own little ways,
and waited for mama to finish this journey to begin the adventure of working through
the long list of fun things put on hold with the statement “when you finish uni mama
can we…”. My muž, Mario, who has supported me on this journey. My dear brothers,
Filip and Niko, and their partners/my dear sister-in laws, Rita and Anđa, for your
constant support and faith that I could do this. Also, the never ending cuddles from my
beautiful nieces and nephews, Jake, Anica, Luke, Alana, Isabelle and Liliana. My dear
extended family, kumovi (Vera, Lena, Nellie and Natalie and their families), and valued
friends for your unconditional support, many hugs, unconditional faith “you can do it”,
and the everyday help with mama duties and other tasks for which there was not enough
time. Thank you for all the extra cuddles and care you gave my girls in this time.
Secondly, a HUGE thank you to my supervisor Ron, for helping me translate my
clinical learning into a research project. Without your patience, calm reflections,
immense knowledge, input, curious questions and quiet confidence throughout the
journey, I would not have achieved my goal. Thank you also to Lorna for the input and
support in the early stages, especially the emotional ups and downs of trying to juggle
being a researcher whilst being a mama of littlies.
Thirdly, Dr Megan Chambers and Dr John Brennan, for creating the opportunity
to pursue my interest in working with children with Selective Mutism. Megan, your
confidence in my abilities kept me going, particularly at those times that when it got
tough and I became uncertain. And the dear friendships that started at work, Michelle,
Holly, Hris, Antoinette, Melissa and many more, thank you.
Finally, a huge thank you to Chris Basten, Jody and the team at Basten and
Associates.

Hvala Blažena Djevica Marija, čuvala si mene i moju obitelj kroz ovaj dug put.
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CHAPTER 1

GENERAL INTRODUCTION

1