Denise Lau and Gabi MacNaughton
Anxiety disorders are the most common group of psychological disorders among children and adolescents (Barrett, 2000). Selective mutism (SM) is a rare, early-onset anxiety disorder that affects up to two percent of children (American Psychiatric Association [APA], 2013; Bergman, Piacentini, & McCracken, 2002; Gensthaler et al., 2016; Nowakowski et al., 2011). SM is characterized by a consistent failure to speak in situations where there is an expectation to speak (e.g., school, social settings), despite speaking in other settings (e.g., at home; APA, 2013). Further, children with SM typically display symptoms common to childhood anxiety disorders, such as behavioral inhibition, shyness, withdrawal, and avoidance (Gensthaler et al., 2016; Muris & Ollendick, 2015; Vecchio & Kearney, 2005). When left untreated, SM can lead to functional impairments such as poor academic performance and daily social functioning (APA, 2013), and thus early treatment intervention is key (Barrett, 2000; Oerbeck, Stein, Wentzel-Larsen, Langsrud, & Kristensen, 2014).
Parents play a particularly important role in the treatment of young children with anxiety disorders (Barrett, 2000), as treatment often requires parents’ active involvement and implementation of treatment techniques. However, parents of children with SM are more likely to exhibit their own symptoms of anxiety as compared to parents of non-anxious children (Anstendig, 1999; Gensthaler et al., 2016; Chavira et al., 2007), which might in turn affect the child’s treatment (Barrett, 2000; Hudson, Comer, & Kendall, 2008). Specifically, anxious parents often engage in anxiogenic behaviors (i.e., behaviors that provoke anxiety in others) in their interactions with their children, which has been hypothesized to exacerbate child anxiety (Hudson & Rapee, 2004). As such, this study investigated how parental behaviors affect the treatment outcomes of children with SM.
Parents’ Role in Treatment for Selective Mutism
A recently developed adaptation of Parent-Child Interaction Therapy (PCIT) specifically targeting children with anxiety disorders has shown to be effective in treating symptoms of SM (Carpenter et al., 2014). PCIT focuses on interactions between parents and children, with the goal of breaking the cycles of negative reinforcement that are maintaining children’s lack of speech (i.e., parents enabling children to refrain from speaking by answering for their child or not expecting them to speak in difficult situations). To achieve this, the treatment utilizes parent training and dedicated family involvement (Carpenter et al., 2014). Specifically, parents and other important figures in the child’s life are trained in child directed interaction (CDI), in which adults follow the child’s lead and give labeled praises, behavioral descriptions and verbal reflections, as well as verbal directed interaction (VDI), in which adults prompt the child to speak by asking forced choice and opened ended questions. These skills are used to prompt and reinforce verbalization in a progressive manner across settings, allowing the caregiver to be the mediator of change (Barrett, 2000). Through the systematic use of shaping, stimulus fading, external reinforcements, and social skills training, this behavioral intervention is able to aid young children with SM in overcoming their anxiety and becoming successful in speaking (Cohan, Chavira, & Stein, 2006).
While parents are expected to encourage their child’s speech during PCIT treatment, mothers of anxious children often perpetuate children’s avoidance of speaking and other anxiety-provoking stimuli (Hudson et al., 2008; Rapee, 1997). In particular, mothers of anxious children tend to behave in an intrusive manner, display less warmth, and provide higher levels of aid to their children than mothers of non-anxious children when their children demonstrate negative emotions (Hudson et al., 2008; Rapee, 2001). As such, parental anxiogenic behaviors (e.g., control, overprotection, overinvolvement, encouragement of avoidance, and lack of autonomy granting; Hudson et al., 2008; Rapee 1997) might also impact treatment outcomes for their children.
Parental overinvolvement can be particularly problematic in cases of childhood SM, as it can minimize children’s exposure to situations where speaking is expected (Hudson et al., 2008; Rapee 1997). Shielding children with SM from anxiety-provoking situations can limit the effectiveness of PCIT, given that a central goal of the treatment is to use such anxiety-provoking situations to help the child develop strategies to effectively manage their anxiety. By limiting such exposure to anxiety-provoking situations, parents encourage their children to continue coping with anxiety through the avoidance behaviors that PCIT aims to eliminate (Hudson et al., 2008; Rapee, 1997, 2001). This is likely to undermine the child’s progress in treatment.
Current Study
However, research surrounding the effectiveness of PCIT for children with SM has been minimal, with only two published randomized control trials thus far, both of which demonstrated the effectiveness of PCIT (Bergman, Gonzalez, Piacentini, & Keller, 2013; Oerbeck et al., 2014). Additionally, very few studies have focused on the interpersonal interactions between parents who display anxiogenic behaviors behaviors and children with anxiety disorders in treatment settings (e.g., Hudson et al., 2008; Rapee, 1997; Teetsel, Ginsburg, & Drake, 2014). Therefore, this study builds upon the small body of past research looking at the use of PCIT to treat SM by examining the question: How does the behavior of parents affect the response-to-treatment for children with selective mutism?
Method
Participants and Setting
Participants were sampled from a private clinical psychology consulting practice. Two parent-child dyads, both of which were regular patients of the clinic, were included in the study. The children were one boy and one girl, ages four and five, respectively. The parents observed were both mothers; ages of the mothers were unknown.
Procedure
The researchers obtained data through videos of the Selective Mutism Baseline Observation Task (SM-BOT), stored in the clinic’s patient file database. The Selective Mutism Baseline Observation Task (SM-BOT) is a task adapted from the baseline protocol of PCIT used to assess the severity of the child’s symptoms (Cohan et al., 2006). The researchers collected data from the first five-minute chunk of parent and child interaction, in which the parent and child are alone in the room. The researchers then collected data from the following five-minute chunk while the parent and child interacted in the presence of a stranger (i.e., a clinician, or intern at the clinic). The presence of a stranger creates a situation in which a child with SM may feel anxious and speaking may be inhibited. SM-BOT videos were each coded twice: once to code parent behavior and once to code child behavior.
Child behavior. The researchers used the SM-BOT coding form to record each child’s behavior. This document assigns preset codes to record the type of question asked by the parent (i.e., yes/no, forced choice, or open ended) and the type of response each question elicited from the child (i.e., verbal response, no response, gestural response, or no opportunity to respond). Instances of spontaneous child speech were also recorded. Both researchers’ SM-BOT coding forms were then compared with one another; in cases of numerical discrepancies between the researchers, the higher frequency count was recorded. This decision was made to account for the possibility that one researcher may not have been able to hear a verbalization that was recorded by the other researcher.
Parent behavior. To code for parent behavior, Teetsel and colleagues’ (2014) coding system for examining anxiety-promoting parent behavior was used (see Appendix A). This system was used to assign codes for five parental behaviors: overcontrol, granting of autonomy, hostility/negative affect, warmth/positive affect, and anxious behavior. At the end of each 5-minute segment, both researchers rated each of these behaviors separately on a Likert-type scale from 0 (i.e., behavior did not occur) to 4 (i.e., behavior occurred frequently). Subsequently, both researchers compared one another’s ratings, addressed any discrepancies, reviewed the videos, and established a rating consensus through discussion.
Results and Discussion
Coding of the Selective Mutism Baseline Observation Task (SM-BOT) videos demonstrated a pattern in that both child participants’ verbal responses decreased and nonverbal responses (i.e., points, nods, or gestures) increased after the stranger entered the room. This can be interpreted as avoidant behavior, and is consistent with current literature suggesting that children with SM tend to refrain from speaking when participating in activities with their parents (Nowakowski et al., 2011).
In addition, both parents demonstrated low levels of overcontrol and anxious behavior, as both received a score of one for each (i.e., a score of one indicated that the behavior rarely occurred), regardless of whether the parent was alone with their child or in the presence of a stranger. Additionally, both parents exhibited higher levels of granting of autonomy across both variable settings, as both parents received a rating of three while alone with their child. When the stranger was introduced, however, one parent’s score remained unchanged, while the other’s score increased by one, suggesting that both parents demonstrated relatively frequent autonomy granting behaviors. No similarities were found between the behavior ratings of each parent with regards to hostility/negative affect and warmth/positive affect.
Overall, results from the coding of SM-BOTs showed that parent participants exhibited low levels of overcontrol and anxious behaviors, and higher levels of autonomy-granting behaviors. Past research has suggested that parents of anxious children tend to exhibit anxious behaviors themselves (Chavira et al., 2007), in that they display overcontrolling behaviors, as well as grant less autonomy to their children (Hudson et al., 2008; Rapee, 1997). A contrasting, smaller body of research has indicated, however, that previous models suggesting that parents of anxious children are more likely to exhibit anxiogenic behaviors (e.g., overcontrolling) might not be applicable to all parents of children with anxiety (Drake & Ginsburg, 2011; Hudson & Rapee, 2004). The results of the current study more consistently align with research indicating that overcontrolling and other anxiety-provoking behaviors among parents of anxious children are not consistently present; nonetheless, further research is needed to determine which specific groups of parents tend to exhibit anxiogenic behaviors.
General Discussion
The present study examined how parental behaviors affect treatment outcomes for children with selective mutism (SM). Overall, results align with current literature suggesting that parental anxiety and related behaviors are not always indicative of their child’s expression of anxiety (Drake & Ginsburg, 2011). The present study, however, was limited by the absence of parent screening for anxiety disorders and symptoms of anxiety. Future research should thus determine whether parents themselves are anxious or not, and investigate how this relates to parent and child behavior during treatment for SM. Future research should also examine fathers of children with anxiety in order to more holistically capture the role of parent behaviors on treatment outcomes for children with SM. Finally, the current study is limited in that the method design in the SM-BOT coding made it unclear as to whether differences among children’s response to treatment was due to parental behaviors or to the introduction of a stranger. Thus, future research employing a method design that controls for possible confounding variables (i.e., the introduction of a stranger) could increase the researcher’s ability to measure the direct effects of parental anxiety on treatment outcomes for children with SM. Overall, therefore, the current study represents an important first step towards understanding the role of parent behavior in the treatment of children with SM receiving PCIT.
References
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Appendix A
| Parent Behavior | Description/Examples |
| Overcontrol | Parent provided unsolicited help, completed parts of the task without being asked, took over the task completely (e.g., grabbed the child’s knob or grabbed the board), or frequently directed the child’s behavior by commanding and using harsh tones or language. |
| Granting of Autonomy | Parent explicitly supported or encouraged the child’s approach to working on the task, accepted and acknowledged the child’s suggestions for completing the task, and followed the child’s lead during the task (e.g., the child suggests the parent turn their knob more and the parent complies). |
| Hostility/Negative Affect | Parent appeared angry, irritated, frustrated, annoyed, used harsh/hostile tones, appeared sad or discouraged, made negative statements such as, “This isn’t any fun,” and/or made any verbal or physical threats of aggression directed toward the child or the task. |
| Warmth/Positive Affect | Parent expressed positive emotions toward the child during the task including: praise, encouragement, words/gestures of endearment (e.g., “honey”), affectionate gestures (e.g., laughing, smiling, high fives, rubbing the child’s back), and seemed comfortable with the child. |
| Anxious Behavior | Parent made anxious or fearful statements such as, “Oh no, I think we really messed up,” cautioned the child in the absence of danger/threat, expressed worry, sought reassurance, catastrophized the situation, and/or engaged in perfectionistic behaviors (e.g., wanting everything to be perfect or “just right,” engaged in excessive measuring using paper, pencils, or hands). |