 The Exploratory Use Of Electronic Devices in the Treatment Of A Child With Selective Mutism
Posted By Dr Fung On 9/16/2003 10:21:53 PM In Research
Kee Hsiao Ying Carolyn, BA Honours (Psychology), National University of Singapore; Fung Shuen Sheng Daniel, MBBS, MMed (Psychiatry), National University of Singapore; Ang Ley Keow, Further Professional Certificate in Education, National Institute of Education, Singapore.
Ms Kee is a psychologist, Dr Fung is a psychiatrist, and Mdm Ang is a remedial teacher at the Child Guidance Clinic, Department of Child and Adolescent Psychiatry, Woodbridge Hospital, Singapore. The authors thank Mr Khor Mee Kek, manager of the Singapore Polytechnic Centre for Applications in Rehabilitation Engineering, for the use of the Voice Communicator in this study.
Reprint requests and correspondence to Ms Kee, Child Guidance Clinic, Institute of Health Building, #03-01, 3 Second Hospital Avenue, Singapore 168937; email: dotkee@singnet.com.sg.
ABSTRACT
Selective mutism is a rare childhood disorder. Recent evidence suggests a strong relationship with childhood anxiety. This case study documents the use of an electronic communication device incorporated into the multimodal treatment of selective mutism in a 9 year old Chinese boy. The paper discusses the contribution of the various components of the multifaceted treatment approach to the outcome of the case. Key Words: selective mutism, anxiety, augmentative communication, multimodal treatment.
Selective Mutism
Selective mutism was considered a rare childhood disorder characterized by the consistent failure to speak in specific social situations despite speaking in other situations (American Psychiatric Association, 1994). Recent evidence suggests that selective mutism may be a childhood form of social phobia in its most extreme manifestation (Black and Udhe, 1992). Some authors have also suggested classifying it under the rubric of anxiety disorders (Anstendig, 1999). However, others (Kristensen, 2000) contend that it is separate entity with associated anxiety.
Selective mutism is considered difficult to treat. Many strategies involve the alleviation of anxiety. These include pharmacological, behavioural, individual, group and family approaches (Dow et al., 1995; Wright et al., 1994). There have been few controlled empirical studies to ascertain the efficacy of each. Because of the challenges of treating selective mutism, a multifaceted treatment approach has been suggested to be the optimal intervention strategy (Hechtman, 1993). However, until recently (Russell et al., 1998), the use of a multimodal treatment approach to selective mutism has not been widely reported (Wright et al., 1994).
In Singapore, which has a population of 3 million, the Child Guidance Clinic is the main centre helping children with emotional and behavioural problems. Between 1994 - 1997, 40 children were diagnosed and treated for selective mutism. They were mostly Chinese, ranged in age from 4 to 17, and the ratio of females to males seen was 3:2. We employ a multimodal approach to treating these children. This involves a multidisciplinary team of psychiatrists, psychologists, social workers, occupational therapists and a remedial teacher.
Augmentative Communication
Augmentative communication is the use of aids or techniques that supplement existing vocal or verbal communication (Vanderheiden and Yoder, 1986). These include sign language, communication boards, and electronic aids such as computers, and have been used with persons with mental retardation, autism, sensory impairments (blindness/deafness), brain injury or stroke, and diseases such as Parkinson’s or multiple sclerosis (Mustonen et al., 1991).
The use of communication aids with disabled children has the advantage of enabling them to experience increased control over environmental events and thus to acquire more independence (Behrman and Lahm, 1984). Communication aids also offer opportunities for cause and effect learning, for creativity and experimentation, and act as learning tools for reading and language (Douglas et al., 1988). The child is motivated to use these devices as they are often a source of amusement and fun.
While alternative means of communication in the form of symbols, gestures and cards have been used with children suffering from selective mutism (Dow et al., 1995), the use of electronic communication devices with such children has not been documented. In this case study, the authors experiment with the use of an electronic communication device incorporated into a multimodal treatment program with a 9 year old boy diagnosed with selective mutism.
CASE STUDY History
Meng Wen (not his real name) was referred when he was six for being shy and withdrawn, and not talking in school. His parents reported that he had been refusing to talk since young except to his parents, younger brother and some relatives. When he did speak, his speech was clear and he could verbalize his needs and wants in complete sentences.
Meng Wen started speaking words only at 3 years old and spoke in full sentences when he was about five. He was a loner and only started playing with other children after 4 years of age. Academically, he could not read and write well, had difficulty coping with his work and could not pass his exams. His mother tended to be negative, critical and rejecting towards him and he was not close to his father who worked out of the country.
Meng Wen was diagnosed with selective mutism and an intellectual assessment was performed on him. Because of his refusal to speak, only the non-verbal component of the Weschler Intelligence Scale for Children (III) was administered. He was found to have a non-verbal IQ in the average range. His mother informally administered the verbal items of the WISC-III to him at home and his responses, which were recorded by his mother in writing, suggested that his verbal ability was in the mildly retarded range.
Treatment and Progress
Behavioural Intervention Soon after he was first seen at the clinic, a star chart was given to Meng Wen’s mother who was advised to reinforce him for speaking. This strategy was discontinued as his mother was anxious and critical of him at the time and was not consistent in applying the technique. Meng Wen’s voice was also tape-recorded when he was reading at home and the tape was played back to him within the clinic-setting with the intention of desensitizing him to the sound of his voice in settings outside the home.
Individual play therapy
When he was seven, Meng Wen was treated with individual play therapy for four months. Initially, he was aloof and distant, avoided eye-contact and was poorly responsive to the therapist’s attempts to engage him. After the third session, however, he became friendly, relaxed and cheerful, and established good rapport with the therapist. Although he continued to avoid eye-contact and did not say a word throughout the sessions, he laughed aloud and responded to questions through gestures.
Group play therapy
Following the individual sessions, Meng Wen was seen together with another selectively mute boy of his age for 6 months. Both boys were quiet, shy and withdrawn initially, but warmed up to each other by the third session. Although the other boy tended to take the lead in activities, Meng Wen became more assertive, confident and relaxed as the sessions progressed. However, while the other boy began to speak audibly towards the end of the six months, Meng Wen only made guttural sounds and did not speak a word throughout the sessions.
Supportive counseling with mother
Throughout his treatment, Meng Wen’s mother was supported in her parenting efforts and helped to modify her expectations for Meng Wen’s academic performance. She was better able to accept his limitations and became more positive in her feelings and interactions towards him.
Pharmacological intervention
One theory of selective mutism suggests that it is a childhood variant of social phobia (Black and Udhe, 1992). It was advocated that such children are treated with medication and a controlled study showed moderate levels of improvement (Black and Udhe, 1994). Meng Wen was started on Fluoxetine when he was eight. The dosage was increased from 10 mg to 30 mg over a year. One month after starting on the medication, he was reported to have spoken to his teacher and some peers and to be more cheerful in temperament. The team also noticed him speaking to mother in front of team members.
School management
A school visit when he was eight, revealed that Meng Wen wrote and spelled using a combination of only a handful of the letters in the alphabet. His teachers were advised on the nature of his condition and the school made arrangements to place him in a program for slow learners with more supportive teachers.
Remedial lessons
Meng Wen was nine when he started lessons with the clinic’s remedial teacher who taught children with learning problems coupled with co-morbid behavioural and/or emotional problems. He did not speak audibly during the sessions, but the remedial teacher managed to get him to mouth the words of his responses.
Use of electronic communication device
An electronic communication device, known as a Voice Communicator, was used with Meng Wen shortly after he started the remedial lessons. This device is used locally to facilitate communication with stroke patients and autistic children. The rationale behind this procedure was to desensitize Meng Wen to the sound and use of his own voice in pragmatic settings.
The Voice Communicator had four panels each labeled with a short phrase, namely "Yes", "No", "Thank you" and "Goodbye". By pressing each of the panels in turn, Meng Wen recorded his voice reciting the corresponding phrases for each panel. He did this in a room alone with his mother. Observation through video equipment revealed that his voice was clear and precise.
With his voice recorded in the Voice Communicator, Meng Wen was required to use the device during his remedial lessons. He had to respond to questions that the teacher asked him by pressing the appropriate panels on the device. Observation of the session through a one-way mirror revealed that Meng Wen could use the device to communicate appropriately and enjoyed the activity.
One month after the exercise with the Voice Communicator, Meng Wen’s mother reported that he requested help from a stranger when he hurt himself in a public area. Our remedial teacher also reported that he was willing to read aloud within her hearing, albeit behind a screen separating her from his immediate presence. This was something that he had not done before.
DISCUSSION
Meng Wen’s condition was complicated by the fact that he had co-morbid conditions of speech delay and learning difficulties, which were likely to have contributed to the erosion of his confidence over the years. In addition, he appeared to harbour anger and resentment against his mother who was critical and rejecting towards him.
A multifaceted treatment approach was used with Meng Wen over the course of three years. Because the various interventions often progressed in parallel, it was not possible to tease out the specific contribution and efficacy of each. However, it appeared that the various components of the multimodal treatment addressed different problem areas. Medication was believed to reduce the child’s anxiety (Wright et al., 1995), while play therapy increased his sense of agency, independence and competence. The remedial lessons focused on his strengths and abilities, and further enhanced his sense of competence. Supportive counseling with his mother reduced the tension between mother and child and produced a more positive interaction between the two. Meng Wen showed improvement in his affect, confidence, socialization and communication following many of the interventions. It is believed that the wide range of interventions used may improve the prognosis of this case (Wright et al., 1985).
The approach used in Meng Wen’s case adds the use of an electronic communication device to a combination of previously described interventions for selective mutism. To our knowledge, this is the first documentation of the use of an electronic communication aid in treating selective mutism. The decision to use the device was based on the behavioural principle of desensitization with the purpose of exposing Meng Wen to the use and sound of his own voice in a pragmatic context. It is hoped that with repeated use and exposure, he would become more accustomed to hearing his voice in the remedial setting and progress to the next stage of actually verbalizing his responses. Medication and other forms of intervention would continue as the various components of the multimodal treatment addressed different problem areas and contributed to his progress. In view of the recent reports that Meng Wen has started speaking to some of his peers, the team has plans to reinforce his progress by implementing a school-based behavioral program that includes incentives for speaking in class. A more thorough cognitive assessment will also be considered if his condition improves further.
As the use of the electronic communication device in this case study is exploratory, its applicability and efficacy in the treatment of selective mutism is at present uncertain. Furthermore, the use of the communication device coincided with an increase in the dosage of medication (Fluoxetine was increased from 20 to 30 mg/day), which confounded the results of the interventions. Further research with a larger number of cases and a control group will be required to provide a more objective and standardized evaluation of this technique.
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