smaller steps and using ‘green’ thoughts to help achieve goals. Session 8 is ‘N’ for Nurture and brings in the idea of role models and support teams as people who help with achieving goals. Session 9 is ‘D’ for ‘Don’t forget to be brave’ and further discusses the concepts of support teams and planning ahead for difficult situations.
Finally, session 10 is ‘S’ for ‘Stay smiling’ and children dress up as their favorite brave person and celebrate their success in completing the program.
Although two previous published studies have evaluated the Fun FRIENDS pro- gram as a universal prevention program (Anticich, Barrett, Silverman, Lacherez, &
Gillies,2013; Pahl & Barrett,2010), there has been only one open treatment trial (Barrett, Fisak, & Cooper,2015) in young children with 31 parents and children (M age5.68 years;SD0.54; range5–7) diagnosed with at least one anxiety dis- order using the Anxiety Disorders Interview Schedule (Silverman & Albano,1996).
Barrett, Fisak, and Cooper (2015) reported that the young children who completed the Fun FRIENDS had fewer mean number of anxiety diagnoses post-treatment com- pared to pre-treatment,t(29)3.80,p< 0.01. However, the authors did not report on the type of anxiety diagnoses at pre- or post-treatment or clinical severity of the anxiety disorders. Additionally, although the authors reported a significant decrease in the total score of the Preschool Anxiety Scale (Spence, Rapee, McDonald, &
Ingram,2001) from pre-treatment to post-treatment,t (29)5.14,p< 0.01, they did not report the actual pre- and post-treatment data. Furthermore, as noted by the authors, attrition in the sample over the follow-up period limited the evaluation of 12-month follow-up data.
Early research with the Fun FRIENDS group CBT program shows promise. Fur- ther research is needed to evaluate this program in the treatment of young children with anxiety disorders using larger sample sizes and more rigorous methodology.
In an early pilot study, Oerbeck et al. (2012) utilized a treatment program that the authors described as CBT. It included parent psychoeducation and an individual treatment protocol of defocused communication with seven three- to five-year-old children (Mage52 months;SD9) who were diagnosed with selective mutism using the Anxiety Disorders Interview Schedule (Silverman & Albano,1996). None of the children were speaking to adults at school at the treatment start, although some spoke with peers during play activities. The two main components of this man- ualized program, which extended over six months, were defocused communication and behavioral intervention that included the use of rewards. The first three weekly, one-hour sessions took place in the children’s home and focused on getting to know the children, developing the goals of treatment, and providing psychoeducation to parents about selective mutism and defocused communication. The following 18 sessions took place twice per week at the preschool/school for 30 minutes each time.
Six speaking levels (1–6) were developed, including 1speaking to the therapist in the presence of the parent, 2speaking to the therapist without the parent being present, 3speaking to one teacher with the therapist being present, 4speaking to teachers and children with therapist present, 5speaking to teachers and children in some settings without the therapist being present, and 6speaking to teachers and children in all settings without the therapist being present (i.e., no different than other same-aged peers).
Results from the early pilot study show improvement in speaking behaviors and in teacher reports of selective mutism symptoms at post-treatment, with six (86%) of the seven children speaking in all kindergarten settings while one of the children (who also had a neurodevelopment delay) was speaking only in some kindergarten settings as assessed by the therapist working with the child and the teacher (Oerbeck et al.,2012). Although children were speaking in the kindergarten, less improvement was noted with respect to speaking in public (e.g., with strangers in the home, to the dentist, in restaurants).
This pilot study was followed by a randomized control trial (Oerbeck, Stein, Wentzel-Larsen, Langsrud, & Kristensen,2014) with 24 three- to nine-year-old chil- dren with selective mutism (Mage6.5 years,SD2.0; 8 boys). Nine (37.5%) of the 24 study children were preschoolers (three to five years of age at study start), while the remaining 13 children were older. Diagnoses were established with the parent Anxiety Disorders Interview Schedule (Silverman & Albano, 1996). All 24 chil- dren had comorbid social anxiety disorder. Fifteen (62.5%) of 24 mothers reported that their children had delays in motor or language development. Children were randomized to what the authors described as the manualized CBT treatment arm or a three-month waitlist control arm. The same protocol used in the pilot study was used in this randomized control trial. Using the School Speech Questionnaire (Bergman, Keller, Wood, Piacentini, & McCracken,2001), a significant increase in speaking behavior was observed in the treatment arm from pre-treatment (M0.68) to post-treatment (M 1.22), (0.54, 95% CI 0.19–0.89, T22 3.22,p 0.004).
No significant changes on the School Speech Questionnaire were reported in the waitlist control arm from baseline (M 0.44) to three months later (M 0.40), T22 −0.08,pn.s. Of interest, using 6.5 years as a reference, a significant time
by age interaction in the treatment arm was noted,Fs1,215.47,p< 0.05, suggest- ing a greater increase in speech for younger versus older children post-treatment.
Although all children in the treatment arm were speaking to the therapist without the parent being present in the preschool/school setting (level 2), only three children (all of whom were preschoolers) were speaking to the teachers and children in some settings without the therapist present (level 5) by the end of treatment.
Children in the 3-month waitlist control then went on to receive treatment. Twelve months after treatment completion all 24 children were assessed (Oerbeck, Stein, Pripp, & Kristensen,2015), at which time 12 (50%) of the 24 children no longer met diagnostic criteria for selective mutism as they spoke freely at school and five of these 12 children also no longer met criteria for social anxiety disorder. The remaining 12 (50% of the 24 children) continued to meet criteria for both selective mutism and social anxiety disorder, although four children spoke freely in some but not all settings at school and to some but not all adults. Oerbeck and colleagues highlight the importance of early intervention, based upon the better treatment response in younger children, as seven (78%) of the nine preschool (three to five years old) participants no longer met criteria for selective mutism at the 12-month follow-up, while only five (33%) of 15 children in the older six- to nine-year-old age group no longer met criteria for selective mutism.
4.4.2 Integrated Behavior Therapy for Selective Mutism
Integrated Behavior Therapy for Selective Mutism is a behavioral intervention devel- oped specifically for young children with selective mutism (Bergman, Gonzalez, Piacentini, & Keller,2013). It consists of 20 individual sessions with the child that take place over a 24-week period. The three initial sessions (sessions 1 to 3) focus on explaining the intervention to the child, developing rapport with the child (e.g., playing non-verbal games), and showing the child ways to assess and communicate anxiety levels. In sessions 4 to 14, therapist, parent, and child work together to imple- ment behavioral exposure exercises within the session and plan for out-of-session exposures. Attempts at exposures are consistently reinforced and when appropriate, selected cognitive restructuring principles are used, such as having the child use cop- ing self-statements when feeling anxious or fearful. The goals of sessions 15 to 20 are to transfer control from therapist to parent and to discuss relapse prevention, with the last two sessions (sessions 19 and 20) occurring two weeks apart, thus extending the time period of the program to 24 weeks.
Using Integrated Behavior Therapy for Selective Mutism, Bergman et al. (2013) completed a randomized control trial with 21 four- to eight-year-old (M age 5.43 years;SD1.16; range4–8) children with selective mutism, as diagnosed with the parent Anxiety Disorders Interview Schedule (Silverman & Albano,1996).
Eighteen (85.7%) of 21 children had both selective mutism and social anxiety disor- der. Children were randomized to either the 24-week (N12) Integrated Behavior Therapy for Selective Mutism arm or a 12-week waitlist control (N9).
No significant differences were noted at baseline between the two arms on all demographic measures or clinical characteristics. Fourteen (67%) of the 21 children who completed the 24-week Integrated Behavior Therapy for Selective Mutism pro- gram no longer met criteria for selective mutism, while no improvements in speaking behaviors were observed in the 12-week waitlist control group,χ2(1)9.69,p 0.002. A significantly higher response rate was seen in the Integrated Behavior Ther- apy for Selective Mutism arm at week 24 (75% vs. 0% in the waitlist control group at week 12),χ2(1)11.81,p0.001, as defined by receiving a rating of 1 (very much improved) or 2 (much improved) by an independent rater blind to treatment condi- tion on the Clinical Global Impression—Improvement scale (Guy & Bonato,1970).
Additionally, significant increases in the Selective Mutism Questionnaire (Bergman, Keller, Piacentini, & Bergman,2008) ratings were reported in the Integrated Behav- ior Therapy for Selective Mutism group from baseline (M 0.79;SD0.36) to week 24 (M 1.74;SD0.54),F1, 1131.08,p< 0.001,η2partial 0.74, while non-significant changes were noted in the waitlist control group,F1, 80.005,p n.s.,η2partial 0.001. Of note, although teachers reported significant improvements in speaking behaviors in children in the treatment group on the School Speech Ques- tionnaire (Bergman et al.,2001), they did not report significant changes in social anxiety symptoms as measured by the Social Anxiety Scale for Children Revised Teacher Version (La Greca & Stone,1993).