Exposure Therapy for Children with Anxiety and OCD

Clinician's Guide to Integrated Treatment

Tara S. Peris, Eric A. Storch, Joseph F. McGuire

• Publisher: Academic Press
• Year: 2020
• Print ISBN: 9780128159156
• eBook ISBN: 9780128162750
• Topic: Psychologie
• Subtopic: Entwicklungspsychologie

Many providers have difficulty implementing exposure-based cognitive behavioral therapy for youth with anxiety and obsessive-compulsive disorder (OCD), despite it being the leading treatment for this condition. Exposure Therapy for Children with Anxiety and OCD: Clinician's Guide to Integrated Treatment provides a step-by-step framework for how providers apply exposure therapy in practice. The book begins with empirical support for the treatment followed by suggested implementation of exposures for specific conditions and ages. Tables of sample exposures and case illustrations are provided throughout the book and common challenges that may complicate implementation are addressed. Intended for busy providers to implement directly into practice, chapters provide clinical excerpts and illustrate techniques in an easy "how-to" format.- Summarizes empirical support for exposure treatment efficacy- Recommends how to implement exposure therapy treatment for anxiety and OCD- Provides guidance on overcoming common challenges when implementing exposures in practice- Offers separate treatment guidelines for children and adolescents- Integrates exposure therapy with other therapy modalities- Includes case studies and clinical excerpts illustrating techniques

Section II

Implementing exposure by diagnosis

Outline

• Chapter 6 Exposure therapy for childhood selective mutism: principles, practices, and procedures
• Chapter 7 Exposure therapy for separation anxiety disorder
• Chapter 8 Exposure therapy for specific phobias in children and adolescents
• Chapter 9 Exposure therapy for children and adolescents with social anxiety disorder
• Chapter 10 Exposure therapy for generalized anxiety disorder in children and adolescents
• Chapter 11 Exposure with response prevention for obsessive-compulsive disorder in children and adolescents

Chapter 6

Exposure therapy for childhood selective mutism: principles, practices, and procedures

Jami M. Furr, Amanda L. Sanchez, Natalie Hong and Jonathan S. Comer, Department of Psychology, Center for Children and Families, Florida International University, Miami, FL, United States

Abstract

This chapter provides an overview of principles, practices, and procedures associated with the exposure-based treatment of childhood selective mutism (SM), a relatively rare but highly impairing anxiety disorder characterized by persistent failure to speak in certain social settings. Recent research has clarified that anxiety and associated avoidance is at the center of SM. In light of growing consensus regarding the critical role of exposure therapy in the treatment of childhood SM, this chapter offers a guiding overview of the key elements of exposure-based treatment for SM—including proper assessment, psychoeducation, reinforcement, stimulus fading, shaping, coping strategies, development of a fear hierarchy, graduated exposures, reinforcement, and homework. We consider important developmental factors throughout, and discuss issues related to promoting generalization of skills in the community, collaborating with schools, calibrating for comorbidity, and improving treatment access. We conclude with a discussion of future directions in the exposure-based treatment of childhood SM.

Keywords

Selective mutism (SM); exposure therapy; behavior therapy; intensive treatment; intensive group behavior treatment (IGBT)

Selective mutism (SM) is a relatively rare but highly impairing anxiety disorder characterized by a persistent failure to speak in settings where speech and socialization are expected (e.g., school or in the community), despite a demonstrated ability to speak in other contexts (American Psychiatric Association, 2013). Although SM only affects roughly 1% of children (Bergman, Piacentini, & McCracken, 2002; Viana, Beidel, & Rabian, 2009), associated challenges negatively impact multiple domains of the child’s life, including social functioning, academic performance, and family relationships (Bergman et al., 2002; Muris & Ollendick, 2015; Viana et al., 2009). SM symptoms often have the most significant impact on the school environment, limiting the child’s ability to communicate effectively with teachers, staff, and/or peers, and compromising academic achievement (Kumpulainen, Räsänen, Raaska, & Somppi, 1998). Accordingly, effective intervention for childhood SM is critical.

SM typically onsets in early childhood—between the ages of 2 and 5 (Cunningham, McHolm, & Boyle, 2006; Kristensen, 2000)—but the condition often goes undiagnosed until around age 5 at the beginning of kindergarten or first grade (Muris & Ollendick, 2015). Similar to other anxiety disorders, SM shows high rates of comorbidity, with social anxiety disorder and separation anxiety disorder among the most common co-occurring conditions (Kristensen, 2000). In addition, several studies indicate that approximately 20% of youth with SM also show co-occurring oppositional behavior problems (Kristensen, 2000; Steinhausen & Juzi, 1996).

Genetic and environmental factors appear to contribute to the etiology of SM in youth. Research finds higher rates of psychopathology among the parents of children with SM versus among the parents of children without SM (Chavira, Shipon-Blum, Hitchcock, Cohan, & Stein, 2007). In one sample, Remschmidt, Poller, Herpertz-Dahlmann, Hennighausen, and Gutenbrunner (2001) found that 18% of mothers and 18% of siblings of youth with SM also had a history of SM themselves—and 51% of fathers and 44% of mothers showed general patterns of behavioral inhibition. In addition, although findings are mixed, higher rates of SM have been found in bilingual children (Toppelberg et al., 2005), with bilingual children in one sample showing nearly four times the rate of SM relative to monolingual children (Elizur & Perednik, 2003). Heightened inhibition in social settings and patterns of parental accommodation can foster negative cycles of avoidance that set the stage for reinforced patterns of nonverbal behavior over time.

A number of factors have historically limited the extent of clinical and empirical attention afforded to SM and its treatment. In addition to the relative rarity of its presentation, the most appropriate conceptualization of SM has been highly debated over the years, and it was only very recently that the condition became classified as an anxiety disorder (Bogels et al., 2010). Many earlier accounts conceptualized the child’s failure to speak as an inability to speak (e.g., a language development problem). Due to its unique and rare presentation, and the long history of misunderstanding of SM, many affected youth have historically been misdiagnosed as having a language disorder, developmental delay, intellectual disability, and/or autism spectrum disorder. Other earlier accounts placed emphasis on the child’s voluntary, or “elective,” refusal to speak, which focused attention on oppositional and noncompliant aspects of the condition rather than on the anxiety-reducing functions of the condition.

As research in recent years has more squarely clarified that anxiety and associated avoidance is at the center of SM, it has become increasingly clear that exposure therapy should be at the center of its treatment (Bergman, Gonzalez, Piacentini, & Keller, 2013; Cohan, Chavira, & Stein, 2006; Muris & Ollendick, 2015). Bergman et al. (2013) conducted the first controlled trial of SM treatment, and found strong support for a 6-month, weekly behavioral treatment that centered on graduated exposure to verbal communication. In fact, 75% of treated children were deemed treatment responders by independent evaluators masked to treatment condition. Since this initial trial, a growing body of literature has provided continued conceptual and empirical support for the use of exposure therapy to treat SM in childhood (e.g., Oerbeck, Overgaard, Stein, Pripp, & Kristensen, 2018; Oerbeck, Stein, Pripp, & Kristensen, 2015). Most recently, in a waitlist-controlled trial, Cornacchio, Furr, Sanchez, et al. (2019) found that up to 50% of children with SM were classified by independent evaluators as clinical responders after participating in a 1-week intensive group behavior treatment (IGBT) program that centered around graduated exposure to verbal communication. Treatment gains associated with this exposure-based summer IGBT endured into the following school year, during which time treated children showed significant improvements in SM severity, global functioning, overall anxiety, and verbal behavior in the home, school, and peer settings. Treated children also showed significantly reduced academic impairments in the year following this exposure-based summer IGBT.

In light of growing consensus regarding the critical role of exposure therapy in the treatment of childhood SM, the present chapter offers a guiding overview of the core principles, practices, and procedures for implementing effective exposure therapy for SM. The key elements of exposure-based treatment for SM—including proper assessment, psychoeducation, reinforcement, stimulus fading, shaping, coping strategies, development of a fear hierarchy, graduated exposures, reinforcement, and homework—are each discussed in turn, as well as issues related to promoting generalization of skills in the community, collaborating with schools, calibrating for comorbidity, improving treatment access, and considering multimodal treatments that incorporate psychotropic medication. But first, we turn our attention to important developmental and clinical considerations.

Exposure therapy for selective mutism: developmental and clinical considerations

Although SM is now classified as an anxiety disorder and most modern conceptualizations of SM focus on the anxiety-reducing function of verbal avoidance, it has become increasingly clear that traditional CBT methods for treating the common anxiety disorders are limited in the extent to which they can adequately address the unique clinical and developmental challenges associated with SM. Given the earlier onset of SM relative to other anxiety disorders, children being treated for SM commonly lack many of the developmental capacities required to effectively participate in thought monitoring activities, cognitive restructuring, mood identification, and perspective taking exercises (Carpenter, Puliafico, Kurtz, Pincus, & Comer, 2014). Accordingly, effective exposure therapy for SM—particularly for early child SM—often places greater emphasis on the behavioral, rather than cognitive, aspects of treatment. Behavioral strategies for treating childhood SM focus largely on reshaping the context of expected child verbal behavior and adjusting contingencies in children’s social worlds associated with verbal and nonverbal child behavior. On a related note, the limited executive functioning, restricted attention, and poor organizational skills that characterize early childhood cognitive development often compromise the extent to which young children with SM can be effectively treated with individual therapy or can be assigned homework exercises to be completed independently. For all of these reasons, family-based approaches—or at least treatments that include a significant parent component—are almost always preferred in the treatment of childhood SM.

Moreover, the unique symptoms of SM (e.g., failure to speak with unfamiliar adults, limited verbal responses to questions) are often treatment interfering behaviors, limiting the extent to which therapists are able to directly engage children in the traditional interactive communication, reciprocal discussion, and Socratic dialogs that are central to supported CBT for the more common child anxiety disorders. Therapists with minimal experience working with children with SM will commonly find themselves either: (1) asking the child lots of questions and awkwardly getting no responses as they try to address their int...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Dedication
• List of contributors
• Preface
• Section I: Basics of exposure therapy for children and adolescents
• Section II: Implementing exposure by diagnosis
• Section III: Developmental considerations
• Section IV: Adaptations for complex presentations
• Author Index
• Subject Index