Selective Mutism: Motivation within Varying Treatment Approaches

Elisa Angevin

Selective mutism (SM) is one of the rarest childhood anxiety disorders, with a prevalence rate of less than 1% of children, as demonstrated by epidemiological studies in the U.S.A., Canada, and Great Britain (Bergman, Piacentini, & McCracken, 2002; Busse & Downey, 2011; Young, Bunnell & Beidel, 2012). Although not well known by those outside of the field of psychology, SM is a debilitating disorder that impairs the child’s educational achievement and socialization (Bergman, Gonzalez, Piacentini, & Keller, 2013). Though research on SM is limited due to its low prevalence rate, the consensus among researchers and psychologists alike is that SM is a disorder in which children exhibit a consistent inability to speak in specific social situations, despite speaking in other situations, that is neither a communication disorder nor due to a lack of knowledge with the language (American Psychiatric Association, 2000; Busse & Downey, 2011; Hung et al., 2012; Shriver et al., 2011; Young et al., 2012). Often, a child with SM exhibits excessive shyness, fear of social embarrassment, and social isolation (American Psychiatric Association, 2000).

Furthermore, the child’s level of spontaneous speech (i.e., any unprompted verbalization) in a particular setting varies depending on the presence of factors that increase or decrease the child’s anxiety, such as people outside of the family or unfamiliar environments (Woodcock, Milic, & Johnson, 2007).
The variability of what factors affect anxiety from child to child makes the disorder complex to treat (Woodcock, Milic, & Johnson, 2007). Consequently, common anxiety interventions that treat childhood anxiety disorders cannot adequately address certain unique characteristics of SM (Bergman et al., 2013). For example, SM typically has an early onset and thus, parental involvement and school involvement in therapy is usually deemed necessary compared to other disorders that focus mainly on the child (Bergman et al., 2013). Within treatment, a multimodal approach is often used because combinations of techniques are needed to address multiple aspects of the child’s mutism (Busse & Downey, 2011; Hung et al., 2012; Mitchell & Kratochwill, 2013). Although treatment of SM most commonly uses an integration of treatments, for the purpose of this study and to clearly define the type of motivation that is elicited in differing approaches, each intervention is defined separately.

Research has shown that a child’s motivation to adapt in challenging situations is an important factor in the child actually improving his or her adaptive functioning (i.e., ability to handle common demands in life, such as functioning in a social environment (Dysvik & Kuvaas, 2013; Elliot & Dweck, 1988; Ryan & Deci, 2000). Children with SM benefit from targeting both intrinsic and extrinsic motivation within treatment (Dysvik & Kuvaas, 2013; Elliot & Dweck, 1988; Ryan & Deci, 2000). Each treatment of SM (i.e., behavioral therapies, DIR/Floortime) targets both types of motivations (Dysvik & Kuvaas, 2013; Elliot & Dweck, 1988). However, the different treatment approaches tend to focus on one kind of motivation (i.e., extrinsic or intrinsic) during the onset of treatment (Dysvik & Kuvaas, 2013; Elliot & Dweck, 1988). More information is needed for clinicians and caregivers to understand the most effective way to begin motivating the child in treatment and to be able to generalize verbal communication skills to other contexts. However, research has not explored the link between SM interventions and the specific kind of motivation they are initially targeting.

Motivation

Within the literature, motivation has been dichotomized into intrinsic and extrinsic motivation (Dysvik & Kuvaas, 2013; Ryan & Deci, 2000; Vallerand, 1997). Intrinsic motivation is defined as the motivation to do something for the sake of experiencing the pleasure or challenge inherent in the activity, rather than for a reward or due to pressure from an outside source (Dysvik & Kuvaas, 2013; Ryan & Deci, 2000; Vallerand, 1997). For example, some children are motivated to do well in school because they enjoy the satisfaction of learning something new, rather than because they will receive a good grade or praise from teachers and parents. Extrinsic motivation is defined as the motivation to do something for the sake of receiving a reward, avoiding guilt, or gaining approval (Dysvik & Kuvaas, 2013; Vallerand, 1997), rather than the activity itself (Dysvik & Kuvaas, 2013). When failure occurs, extrinsic motivation can lead to intense feelings of vulnerability (Elliot & Dweck, 1988). For example, if a child is promised a reward for successfully completing an assignment, and the child fails, he or she not only failed the assignment, but also failed at receiving the reward. Despite the overwhelming body of research that supports this notion, Ryan & Deci (2000) propose that the effect of extrinsic motivation differs depending on one’s level of freedom during the act. For example, when a child with SM speaks in order to get a puppy, as many parents do use puppies as a reward, the effect of extrinsic motivation is very different than when a child with SM speaks in order to receive praise from his or her parents. Both examples are extrinsically based, but some clinicians believe the first example prompts internal feelings of pressure because the reward is something tangible that could be taken away, while the second relates to a component inherent in the relationship between a caregiver and their child, leading to a more natural and unpressured freedom for the child to ultimately verbalize (Dysvik & Kuvaas, 2013; Vallerand, 1997). The impact of motivation on a child with SM demonstrates that motivation can greatly influence a child’s communication outcomes during treatment of SM (Dysvik & Kuvaas, 2013; Vallerand, 1997).

Behavioral Approaches

The most common and empirically-based treatments of SM are behavioral approaches, which target changing the environment through particular techniques and specific, observable, and measurable behaviors, such as verbalizing or speaking loudly (Bergman et al., 2013; Christon, et al., 2012; Hawkins, 1986; Hess, 2013; Hung et al., 2012; Mitchell & Kratochwill, 2013; Shriver et al., 2011). Behavioral approaches typically utilize tangible rewards, or contingency management, such as stickers and tokens, or praise (Busse & Downey, 2011). The presence of a tangible reward or praise has often been characterized as positive reinforcement, or extrinsic motivation, in the literature (Christon et al., 2012; Dysvick & Kuvaas, 2013; Mitchell & Kratochwill, 2013; Vallerand, 1997), but this has not been explicitly stated in reference to SM. Positive reinforcement within SM treatment consists of labeled praise, tangible rewards (e.g., stickers, prizes) or possibly the ability to spend time doing an activity they enjoy (Bergman et al., 2013; Christon, et al., 2012; Mitchell & Kratochwill, 2013). Conceptually, this acknowledges that when an SM child speaks and is provided a sticker for doing so, he or she will more likely verbalize again in the future (Ferster & Skinner, 1957). Initially, behavioral approaches target desired measurable behaviors through extrinsic motivation concepts such as positive reinforcement. In contrast, the DIR/Floortime model, a developmental program, targets underlying core deficits as the focus of intervention.

DIR/Floortime Model

Developmental, Individual, and Relationship/Floortime (DIR/Floortime) model advocates for a play intervention focused on the relationship between the caregiver and the child, tailored toward the specific developmental profile of the child (i.e, presenting symptoms, such as silence or lack of interpersonal interaction), the individual underlying neurological processing differences (i.e., biologically based differences in sensory activities prepare the child to respond to interactions differently), and the relationship and affect of the child in his or her interaction with the caregiver (Hess, 2013; Fernald, 2011). With these three components in mind, the caregiver or the clinician (play partner) follows the child’s lead, while simultaneously targeting intentional communication and interaction (Hess, 2013). By relying on play to facilitate an interaction, the caregiver or clinician relies on the child’s intrinsic motivation to play, and further expanding to a desire to communicate with another person (Hess, 2013; Fernald, 2011).
Research has demonstrated that when intrinsically motivated, an individual is able to sustain an activity or behavior longer than when extrinsically motivated (Dysvik & Kuvaas, 2013; Vallerand, 1997). Therefore, the goal of DIR/Floortime is for the child to become motivated by the inherent satisfaction of play, an intrinsic motivator (Dysvik & Kubaas, 2013; Lucket, Bundy & Roberts, 2007). DIR/Floortime clinicians initially focus on the therapeutic relationship through play, believing that the intrinsic motivation to communicate with others will become inherent through this primary relationship (Hess, 2013).
Unlike behavioral approaches, DIR/Floortime does not openly recognize the importance of targeting extrinsic motivation in treatment (Hess, 2013). The approach focuses on intrinsic motivation, believing that using intrinsic motivation to communicate will generalize to domains outside of the targeted playtime (Dysvik & Kuvaas, 2013; Vallerand, 1997), such as academic and social domains, which are often negatively impacted by SM (American Psychiatric Association, 2000). For example, if a child is able to play and communicate with a therapist, the child can recognize his or her self-efficacy and that the act of verbalizing can be enjoyable, and may become capable of communicating with others in the future (Dysvik & Kuvaas, 2013).

Goals of the present study

Despite the important nature of motivation in treating SM, research is limited on the relation between motivation and SM. Some clinicians believe children with SM do not have a desire to speak in certain situations, while other clinicians believe that the desire is present, but their anxiety is overpowering the ability to communicate (Hess, 2013; White, 1959). Finding the best way to initially target motivation in children with SM, through extrinsic or intrinsic means, is imperative. The author of this paper observed in the field that both extrinsic and intrinsic motivation are part of the treatment process, but one may be more important to target initially in treatment than the other. However, research has yet to analyze how a child is initially motivated within the varying treatment approaches of SM. The goals of the present study are to explore how a child with SM is initially motivated to speak within varying treatment approaches, using a qualitative method.

Method

Participants

Eight clinicians who work with children with SM participated in the current study, utilizing behavioral or DIR/Floortime approaches. Six clinicians used behavioral approaches to treat SM, and two clinicians utilized the DIR/Floortime model. All of the clinicians were recommended by Dr. Kurtz, the director of the Selective Mutism Program at Child Mind Institute, and supervisor to the researcher. Dr. Kurtz subscribes to a behavioral approach and consequently, his network of professionals consists of mainly behavioral clinicians. Hence, a limited amount of clinicians who utilize DIR/Floortime could be contacted. Five of the behavioral clinicians were licensed clinical psychologists, while one was a speech language pathologist who specialized in treating SM. One DIR/Floortime clinician was a licensed clinical psychologist, while the other was a speech and language pathologist, currently earning her PhD with a specialization in anxiety disorders. All of the clinicians have been treating SM patients for at least ten years.

Procedure

The clinicians were interviewed either in person or through phone conversations. Interviews lasted an average length of 30 minutes, during which clinicians were asked about their experiences with their individual treatment approaches. Questions included: “Do you believe that the maintenance of the disorder has anything to do with a lack of intrinsic motivation/extrinsic motivation?”, “How do you think your treatment approach relies or does not rely on intrinsic/extrinsic motivation?”, and “Could you give me 3 most recent examples of how intrinsic/extrinsic motivation played a part in a patient’s course of treatment?” The researcher transcribed their responses during the interview, and coded their responses afterward.

Coding and Analysis

Responses to the questions were analyzed for similarities and differences across the two treatment approaches, with a particular emphasis on themes surrounding motivation. After the interviews were conducted, the researcher highlighted any response that referenced motivation, while the responses that did not mention motivation were used as a reference for verifying the clinicians’ use of their prescribed treatment approach. The quantity of responses that mentioned motivation was not coded due to the semi-structured interview format, in which there was a lack of opportunity for the clinicians to voluntarily increase their discussion of motivation. Instead, the themes that arose within the discussion of motivation were separated to determine the different aspects of motivation that were most important to each respective treatment. The purpose of having a semi-structured interview format was to document the concrete differences from each treatment in their approach to motivating a child to speak. The purpose of this study was not to compare the two forms of therapy in their effectiveness, but rather to illuminate the differences in their use and conceptualization of motivation during the initial stages of treatment.

Results and General Discussion

Motivation within the Behavioral Approach

As expected, one hundred percent of the clinicians who use a behavioral approach relied heavily on extrinsic motivation. Dr. Kurtz believes that the treatments do more than rely on extrinsic motivation, but actually conceptualize that SM is partly caused by “insufficient extrinsic motivation.” Seeing a child’s failure to speak as a sign of a lack of extrinsic motivation demonstrates why one of the behavioral clinicians explains that having an extrinsic motivator is essential because “you cannot intrinsically motivate anyone.”

For example, two-thirds of the behavioral clinicians believed that intrinsic motivation to speak was important, but could only be reached by first cultivating extrinsic motivation. Despite the controversial reputation of extrinsic motivation in comparison to intrinsic motivation (Ryan & Deci, 2000), the behavioral clinician maintains that, ultimately, “kids need the external motivator to develop that intrinsic desire to communicate.” Recent literature has shown that the effect of extrinsic motivation differs depending on one’s level of freedom (i.e., ability to end act at any point) during a task (Ryan & Deci, 2000). This is why fifty percent of the behavioral clinicians seem to begin their treatment of SM by evaluating their patient’s initial level of intrinsic motivation. From there, a behavioral treatment plan can be individually tailored to the patient in order to increase the current level of motivation to an adaptive one. One of the behavioral psychologists explains,
“We need to motivate them using what they value, what their beliefs and goals are. By reflecting the discrepancy in their behaviors and their goals to speak, you can give them insight to either change their values, to match their behaviors, or vice versa. This changes their intrinsic motivation.”

However, “a lot really want to communicate, but they can’t…these kids aren’t oppositional defiant. These kids are stuck,” says a behavioral clinician. Therefore, “motivation is a big area of concern when working with kids, especially kids who require initial extrinsic motivation in order to have a pathway to intrinsic motivation. Motivation can change a mutism pattern,” says a behavioral clinical psychologist. Past research suggests that the feeling of effectiveness that is produced from a successful interaction is the reward itself (White, 1959). For those with SM, the confidence after an interaction is never reached because verbal interactions rarely take place (Hung et al., 2012; Shriver et al., 2011). The behavioral clinicians believe that in order to reach that “confident feeling,” one needs an extrinsic motivator.

Similar to the literature’s claim that behavioral approaches aim to diminish the positive reinforcement of silence (Bergman et al., 2013; Christon, et al., 2012; Mitchell & Kratochwill, 2013; Oon, 2010), Dr. Kurtz explains, “There’s an intrinsic motivation working in the opposite direction that you want it. In behavioral terms, the onset of SM requires negative reinforcement, which is an extrinsic motivation paradigm.” Most of the behavioral clinicians in this sample would most likely agree with Dr. Kurtz when he says, “the maintenance of the disorder has nothing to do with a lack of intrinsic motivation, but absolutely has something to do with a lack of extrinsic motivation.”

Motivation with DIR/Floortime Model

In contrast to those who utilize the behavioral approach, both clinicians who subscribe to the DIR/Floortime model believe that motivation is not the true issue in a child with SM. A developmental psychologist, with a focus in DIR/Floortime, explains,
“If a kid says it is because he does not get any rewards, when you press on it, I find that they don’t speak because talking makes them feel bad. Extrinsic motivation is a secondary cover. Kids are frustrated that they can’t speak.”

Therefore, the key to their treatment approach, according to a DIR/Floortime clinician, is building on that relationship foundation, that trust and rapport with their communication partner, to foster intrinsic motivation through a relationship. The DIR/Floortime clinicians believe that SM patients are not motivated by a desire to please necessarily or to gain love and affection, which is considered an external reinforcement (Dysvik & Kuvaas, 2013; Vallerand, 1997). The DIR/Floortime clinician “really feels that it is the social emotional bond that they build. Talking is coming from… the desire to be in a relationship with somebody else. It’s not that kids who aren’t talking don’t have the desire. They still do, but the neurobiological component, that fight-flight system, interferes.” The developmental psychologist expands by describing a particular child who “would do anything in his power to get himself to talk. SM is a neurophysiological process. We need to rewire the brain so they can more correctly interpret the world around them. We approach this through a relationship.” This focus on a relationship is highlighted strongly within the DIR/Floortime model, which advocates for a strong parent-child interaction (Fernald, 2011; Hess, 2013).

If the relationship is the focus of therapy for DIR/Floortime model, does this mean that extrinsic motivation is not involved at all in treatment? When asked about extrinsic motivation, both DIR/Floortime clinicians agree that extrinsic motivation is a component in the cause and maintenance of SM, but it could severely inhibit progress in treatment. One DIR/Floortime clinician says that “it’s never been about that desire to speak, but it’s been at times, the caregiver’s behavior or response to the child’s not talking that can inhibit. The tangible reinforcers, such as bribery or a reward system, I don’t see that there’s a whole lot of value in that.” Hence, the DIR/Floortime model does not target either intrinsic or extrinsic motivation, but rather, makes the act of speaking more comfortable for the child. As a child becomes more comfortable, the brain structure begins to change accordingly and the neural pathways that have been enabling an avoidance to verbalization for years, now begin to facilitate speaking (Cohan et al., 2006).

Conclusion

Behavioral and DIR/Floortime treatment approaches begin with very different goals. The behavioral approach targets specific aspects of verbalization through concrete and structured steps (Bergman et al., 2013; Christon, et al., 2012; Hawkins, 1986; Hess, 2013; Hung et al., 2012; Shriver et al., 2011; Mitchell & Kratochwill, 2013; Shriver et al., 2011), while the DIR/Floortime model targets the desire to interact and communicate with others through an approach with very little structure (Hess, 2013; Fernald, 2011). Because the techniques to reach the goal to communicate are so different, both approaches initially target different types of motivation, but no study to date has attempted to define the accompanying motivations that are targeted within the beginning of each SM intervention approach. This study began to illuminate a more specific outline to the initial treatment goals of motivation.

This qualitative study demonstrated that the behavioral clinicians intentionally target both intrinsic and extrinsic motivation, while the DIR/Floortime clinicians do not target either form of motivation. Both treatment approaches displayed the themes that motivation is a vital factor in a child’s ability to speak, and that when exposed to their capabilities, children desire to communicate. The difference between the two approaches is demonstrated in the way clinicians view their patients’ motivations at the onset of treatment. In behavioral approaches, the clinicians believe the motivation to verbalize is absent and needs to be created through tangible steps, while DIR/Floortime clinicians believe that the patient’s motivation to verbalize is existent, but requires adequate reinforcement in order to be exposed.

This study had many limitations. One such limitation includes the limited quantity of clinicians to interview. Another limitation, which was pointed out to the writer by her supervisor, Dr. Kurtz, is that despite the initial verbal definition of intrinsic and extrinsic motivation to the clinicians, the clinicians all varied on how they operationalized the term. In forming the questions and conducting the interview, the researcher did not notice this discrepancy and consequently, did not use a common definition during the interviews. For future research, the researcher would advise asking the clinicians their definitions of intrinsic or extrinsic motivation. To some, extrinsic motivation encompassed any form of response to talking (i.e., nonverbal or verbal), while for others, extrinsic motivation had to be tangible. Because of this inconsistency, the different treatment approaches may in fact be targeting similar aspects of a child’s motivation.

This qualitative study, although limited in scope, began a dialogue on the topic of motivation within SM treatments. Future research should investigate how targeting motivation differs in diverse treatment approaches, so that researchers can create measurable constructs for classifying intrinsic or extrinsic motivation in SM treatment. Then, future qualitative and quantitative studies can identify how to best target a patient’s motivation to communicate, beginning by concretely defining the forms of motivation utilized in SM treatment. This research can inform treatment of children with SM so that they can have the best outcomes possible.

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