Child Behavior - Case Study Example

Client: M.R. Age: 6 years old Education: Prep Gender: Male Ethnic Background: Egyptian Place of Birth: Australia Languages Spoken at Home: Arabic Religion / Spirituality: Muslim Reason for Referral: The referral was collaborative as it was made by MR’s classroom teacher, responsible staff members, and the client’s mother. MR was referred to counselling for not speaking or socializing in and out of classroom. MR was taken into therapy on 4/6/13, which was terminated on 4/10/13. The therapy took one hour on a weekly basis. It consisted of ten face-to-face sessions under the condition that monitoring continued. The expectation was that a multidisciplinary team would be involved (Provisional Psychologist, Speech Pathologist, Special Needs staff, Classroom Teacher as well as the Lower level Coordinator) to consolidate with the assessment, diagnosis and treatment of MR to enable him to function within the school environment and to progress his learning skills. Presenting problem: MR was referred to counselling by his classroom teacher after it was reported that he was not engaging in social interaction while at school. MR’s teacher reported that his only form of communication was by pointing or gesturing towards his peers and teachers. Additionally, MR exhibited was limited use of verbal communication. It was further reported that the client could appear fearful and nervous at times particularly when the teacher was speaking to another client loudly. MR was also easily distracted by any form of sound. MR was said to lack energy and moved slowly hiding behind others as to not attract any attention. It was also noted by other staff members that he did not initiate any interaction with the other students in the classroom and in the playground and mainly walked around by himself. The client was dressed appropriately and showed a flat affect. He also showed the tendency to avoid eye contact. He was not vocally communicating and was passive, alert and was happy to go back to his classroom when asked to. His teacher reported that she had given him the necessary time and understanding but there was no willingness towards any form of communication at all. She commented that she believed that this could be due to his “shy” character and she allowed him the time. However, MR had not shown any improvements within this time. She further noted that if MR was in a situation where he could participate in any activity, he would either nod or crouch down behind a student as a response. The client’s teacher reported she was having difficulty with assessing the client. The communication between them was predominantly non-verbal gestures like nodding or pointing at things. When he was put on the spot or when attention was brought upon him, he would either blush and/or tilt his head. He would look to the ground; freeze up; and/or sit at the back and stare with a blank-look or expressionless face trying to ignore the teacher. Occasionally, he would crouch down behind a student as if he did not like the attention. It was generally believed by supporting staff members involved in the therapy that the contributing factor to MR’s condition was his “shyness”. MR’s mother described him as a happy and talkative child who had no issues at home. She agreed that he was a shy child who did not speak or interact freely with newly met people particularly when they went shopping. However, he was fine with friends who he was well acquainted to. The client’s mother reported that there were no similar issues evident with MR’s two siblings. She further indicated that MR did not suffer from any medical condition that could contribute to his current behaviour. There is no reported information about the triggering point for the mother was not aware of his condition either. Relevant Background History: Family Composition: Placement in the family: 2nd sibling Residing in the family home with: Mother – aged 27 years old – Ethnicity: Egyptian – Occupation: Unemployed Brother – aged 7 years old – Place of Birth: Australia – Grade 2 Sister – aged 5 years old – Place of Birth: Australia – Kindergarten Does not live with: Father – aged 33 years old – Ethnicity: Egyptian - Occupation: Unemployed It is relevant to add that it was difficult to obtain further information from the client’s parents due to cultural beliefs of humiliation surrounding the discussion of family circumstances with others. They were not willing to talk about their personal life or provide any further information and were not responsive towards appointments. Consequently, the information was predominantly obtained from MR’s older brother and his classroom teacher. MR’s older brother reported that although the parents were not officially divorced, they were living separately. He explained that the parents were planning on getting divorced, and that their father was aggressive and abusive and had been removed from their home by the police after he had smashed the windows at home. The client’s brother reported that they had a chance to see their father every time he dropped in for a visit, which was however once in a while. Test Administration: The assessment necessary for a collective team approach included the Special Needs Teacher and me, as the school counselor, to work together from time to time. Formal clinical cognitive assessment was necessary to further assess for other underlying symptoms and/or the impact of the environmental factors that may contribute to the symptoms of shyness, anxiety, social isolation, being withdrawn from peer interaction etc. A referral to the Speech Pathologist was also made to assess and rule out any underlying language deficit or physical problem (e.g. hearing impairment) that may impact or prevent speech from occurring. MR’s cognitive ability and other predisposing factors have been administered for assessment using: Selective Mutism Screening Test (SMST) (see Apendix A) was conducted to examine whether the client displayed symptoms of an inability to speak in certain settings. A Child Behavioural Checklist (CBCL) (Achenbach, 1991) was also administered to the client’s mother to measure the client’s social skills. The CBCL was also completed by the client’s teacher to determine the client’s social interaction as well as Child Daily Ratings of Behaviour (CDRB) (Chafouleas, Kilgus, Jaffery, Riley-Tillman, Welsh, & Christ, 2013) was also administered daily to monitor daily changes in behaviour by MR’s teacher. Mental Examination Status (MSE) was also conducted to check his client’s appearance, behaviour and mental functioning. The assessment procedure set off with the collection background information from the client’s mother and brother -- in relation to the family context. The Special Needs Department was also contacted to gather information on MR’s literacy and written work. It is important to note that a report from the Speech Pathologist has not yet arrived. Risk assessment was not possible due to the client’s condition at this point in time. Additionally, continuous observational assessment was performed to observe the changes. Dynamic assessment was used to understand how the client responded to learning, such as the type of communication mode that the client used including pointing, nodding, gesturing, writing and/or whispering. These observations were also administered in order to explore and clarify the client’s feelings (to identify areas of confusion, sensitivity, boredom, sadness, happiness and anxiety) and thoughts as well as to either confirm or reject the hypotheses of Selective Mutism Disorder (SMD). Formulation: MR’s condition may have been triggered by the traumatic experiences of family separation and his experiences of abuse and violence at the hands of his father. This exposure and may have led to the client developing social anxiety resulting in the absence of speech or interaction in the school setting This is supported by of the absence of reported difficulties at birth; hereditary or genetic causes and the presence of any medical condition by MR’s mother. MR’s current presentation and is maintained by the triggers of social and environmental anxiety. However, it appears that the presence of a supportive and responsive mother, the noted close relationships with his siblings, the removal of his violent and abusive father from the home and receiving support from a multidisciplinary professional team are protective factors for the client. Diagnosis: Axis I 313.23 Selective Mutism 300.23 Social Anxiety Axis II No Diagnosis Axis III None Axis IV Educational problems and Social problems Axis V GAF = 50 (on admission) GAF = 80 (at discharge) Evidence-based theories: The etiology of Selective Mutism still remains unclear. However, it is believed that this disorder is a heterogeneous disorder. Evident literature highlights a variety of theories (Kristensen & Oerbeck, 2006; Anon, 1999) such as: Social Anxiety theorists argue that Selective Mutism is a variation of an anxiety disorder and that this is a mixture of a “shy” biological predisposition, which is then influenced by the environment (Anstendig, 1999). Thus, the failure to speak in certain situations is a symptom of social anxiety indicating that these children have fear of social interaction (Anstendig, 1999; Kryanski, 2003). Family Systems theorists argue that this is a “Family Dysfunction Model” and that Selective Mutism stems from an unhealthy family structure (Sharkey & McNicholas, 2008). They hypothesize that the child’s mutism is due to two factors: (1). having the fear of “betraying the family by unknowingly revealing family secrets” and (2). that mutism as a form of “oppositional behaviour against extreme tanglement, between relationship” and because of an unhappy marriage (Sharkey & McNicholas, 2008). Psychodynamic theorists argue that Selective Mutism is a result of unresolved conflicts in which mutism is developed as a coping strategy from anger, anxiety or means of punishing the parents (Kryanski, 2003). It is argued that these unresolved conflicts arise and children at early age face difficulty in expressing themselves verbally resulting in vocal muteness in certain environments (Anstendig, 1999). Furthermore, Behaviourist theorists argue that mutism is a learnt behaviour and is reinforced environmentally. These theorists suggest that behavioural inhibition can be defined as a tendency of withdrawal when confronted with people or situations they are not familiar with (Kryanski, 2003; Botting and Conti-Ramsden, 1999). Finally, the Posttraumatic Stress Model argues that mutism occurs after a form of psychological shock, such as physical or sexual abuse. Consequently, this model proposes that these children display dissociation through detached state where they surrender voluntary actions of speaking (Dummit, Klein, Tancer, Asche, Martin, & Fairbanks, 1997). Intervention plans The following techniques were used following sequentially depending on the need and the pace of the client: 1. The client was trained and taught breathing techniques to better understand how to relax. He was demonstrated how to gain control over his breathing and to calm down through the techniques to ensure that he is not overacting towards situational anxiety. 2. Different Cognitive Behaviour Therapy (CBT) techniques were used to overcome social anxiety to build client’s self-esteem in accordance with MR’s pace. CBT intervention strategies including: modifying the environment, then systematically practicing (Fish, 1993) new behaviours challenging negative thoughts and emotional sequencing to develop more positive thoughts were used (Tancer, 1992; Hungerford et al., 2003). - Modifying the environment by providing information about the disorder and discussing classroom “to do’s” and “to not to”. - Systematically practicing new behaviours such as giving the client the option to choose whether or not participate in activities. - Challenging negative thoughts such as MR’s traumatic family experiences and addressing them according to his tolerance level, using relaxation and stress management skills. - Homework techniques to integrate the client’s family and to receive feedback of his progress. This was done through providing homework worksheets, to obtain additional information about his feelings and progress completed with MR and his mother. 3. Narrative Therapy (NT) was used to highlight MR’s strengths. This was used to externalize the orientation highlighting that the problem is the problem rather than the client being the problem (Etchison, & Kleist, 2000; Busse and Downey, 2006). This was done through finding ways to familiarize him with the school community, and exposing him to the environment by going around the school like the library, office and staff room (Fish, 1993; Podsiadlo, 2010). - Graded exposure was also used by showing the client similar videos of clients expressing their opinion towards the disorder. 4. Psychodynamic Therapy (PT) was used to incorporate systematic style and to support the efficacy of anxiety disorders in conjunction with the Family System Therapy (FST) that was expected to increase effective outcome (Horowitz, 2001). This was demonstrated by having mother join school excursions and brother join therapy sessions. It was also demonstrated by discussing prior the details of event and asking MR whether he wanted to join. 5. Behaviour Therapy (BT) was used to reinforce desirable behaviours and eliminate maladaptive behaviours (Kryanski, 2003). - Stimulus fading was also used where the child was placed in situations requiring speech such as school library. This involved gradually introducing the library and taking tours with the client on occasions where it was not so crowded before he was able to successfully visit the library during crowded time sessions (Oerbeck et al., 2013). - Mystery motivator technique was also used with MR. His teacher asked him whether he was willing to be assessed. If the client nodded “yes”, then assessment was undertaken in a quiet corner while the classroom was engaged with other activities with the teacher aid. After he was assessed, MR was rewarded with a small wrapped present (pencil, ruler, rubber etc.) or with a sticker of his choice to reinforce his engagement in tasks requiring speaking. - Desensitization techniques were used to reduce MR’s sensitivity, including asking the teacher to speak in a quieter volume when addressing the classroom. 6. As previously discussed, parental involvement was used and included the client’s mother attending school excursions and/or the brother attending counselling sessions. 7. Art/Play Therapy was also used. This was demonstrated by having the client choose the activity of playing card games to making birthday cards for parents. It was used to support MR’s anxiety to support him feel safe. Intervention delivery: The interdisciplinary support network team including the Lower Level Coordinator, Speech Pathologist, Special Needs Teacher, client’s classroom teacher, client’s mother and the Provisional Psychologist collaborated in the assessment and formulation of the client. Weekly Face-to-face counseling sessions that lasted for one hour as well as group sessions were administered to the client. The objective was to enable him to engage with other children who are not from his classroom and who were engaged in activities that did not require vocal communication. There were also observation sessions held in the client’s classroom. Therapy sessions began by building rapport and demonstrating accurate empathy. They followed a standard structure that included conceptualizing with the client and collaborating towards MR’s needs, setting the tone for a working atmosphere and maintaining continuity between sessions. Overall, setting an agenda that was discussing with the client, performing mood check to monitor the feeling continually between sessions, continuing the discussion of the previous session to maintain continuity between sessions, setting provision of homework and feedback collaborating with MR’s mother were also used throughout the sessions. The final stage involved discussing progress, therapy and termination Review Homework success. It involved relapse prevention and introduce self-management sessions. Furthermore the client was also escorted to excursions as well as around the school for two terms. Delivery was not difficult due to working collaboratively with the school staff. In addition, the support from MR’s mother and tailoring the intervention towards client’s needs as well as the pace made it easier to implement and deliver planned interventions. Evaluation of Intervention Outcomes: The client presented with the problem of not speaking in class or interacting with others, primarily reported by his classroom teacher. Certain factors were found to contribute to this condition such as his shy temperament and past and current family situation. It appeared that the triggers to the condition were related to the traumatic experiences of aggressive outbursts by the client’s father as reported by his brother. This was supported by the client’s reports of being frightened when teachers shouted in classroom. It also appeared that MR’s social anxiety was triggered by certain activities when he was put on the spot -- such as in a group activity within the classroom. MR’s “shy” character was also found to be a likely contributor to his condition. MR’s results on the Peabody Picture Vocabulary Test showed a substantially high score, which indicated that his condition was not due to difficulties in vocabulary and verbal ability. The hypothesis was that the client had the symptoms of Selective Mutism, which manifested itself as social anxiety. It was also hypothesized that client’s family background and traumatic experiences impacted his anxiety level. In addition, the impact of MR’s shy temperament within the social context including the classroom setting contributed to his behavior. Obtained test results from the SMST and CBLC from parent regarding MR’s competencies, behavioural and emotional problems revealed that the findings were consistent with the hypothesis. Thus, CDRB provided daily monitoring that the therapy was affective over the period of treatment. Analysis of the client’s involvement within the classroom showed that the client was nonresponsive towards classroom discussions. At first he did not communicate with anybody including his teacher. He would crouch down behind a client to avoid being noticed. His responses started off by pointing or nodding. As counseling sessions proceeded, these changed to gesturing, writing and now he is whispering to his teacher. He is still very cautious about talking to classmates and also cautious towards group conversations. However, the outcome obtained has been very positive when considering his shy character. Moreover, this has made it possible to assess and acknowledge that he is learning, which was the primary concern of school staff and his teacher. Time showed that the intervention structure was effective. MR was able to whisper as he walked in the corridor travelling towards the library or around the school. Future precautions for continuous improvement are suggested. It is highly recommended that MR’s teacher should continue using soft and non-threatening tones when addressing the classroom. Narrative Therapy is also strongly suggested, as this has been useful in identifying and addressing the client’s feelings and changing his negative thoughts around his condition. Ongoing therapy is also recommended until the client fully acquires the aforementioned techniques to better manage social anxiety and become confident in social context. References Achenbach, T. M., (1991). Manual for the Child Behavior Checklist and Profile. Burlington, VT: University of VT, Department of Psychiatry. Anon. (1999). Selective Mutism: The sources of Syndromes. LinguiSystems. Retrieved from: Anstendig, K. D., (1999). Is selective mutism an anxiety disorder? Rethinking its DSM classification. Journal of Anxiety Disorders, 13(4), 417-434. Botting, N. & Conti-Ramsden, G. (1999). Pragmatic language impairment without autism: The children in question. Autistic Society 3(4) 371–396 Busse, R. & Downey, J. (2006). Selective Mutism: A Three-Tiered Approach to Prevention and Intervention. Contemporary School Psychology, 15, 54-63 Chafouleas, S. M., Kilgus, S. P., Jaffery, R., Riley-Tillman, T. C., Welsh, M. E., & Christ, T. J. (2013). Direct Behavior Rating as a school-based behavior screener for elementary and middle grades. Journal of School Psychology, 51, 367-38 Dummit, E. S., Klein, R. G., Tancer, N. K., Asche, B., Martin, J., & Fairbanks, J. A., (1997). Systematic assessment of 50 children with selective mutism. Journal of the Academy of Child and Adolescent Psychiatry, 36(5), 653-660. Etchison, M., & Kleist, D. M., (2000). Review of Narrative Therapy: Research and Review, Family Journal 8(1) 61-67 (2000) Fish, V. (1993). Post Structuralism in Family Therapy: Interrogating the Narrative/Conversational Mode. Journal of Family Therapy 19(3) 221-232. Galeas, R. (2013). Practical Recommendations and Interventions: Selective Mutism. Retrieved from: Horowitz, M. J., (2001). Cognitive Psychodynamics – from Conflict to Character. Wiley Hungerford, S. Edwards, J. & Lantosca, A. (2003). A Socio-Communication Intervention Model for Selective Mutism. American Speech-Language-Hearing Association Convention, Chicago, IL November, 2000 Kristensen, H., & Oerbeck, B. (2006). Is selective mutism associated with deficits in memory span and visual memory? An exploratory case-control study. Depression and Anxiety, 23(71), 71-76. Oerbeck, B. Stein, M., Wentzel-Larsen, T., Langsrud, O. & Kristensen,, H. (2013). A Randomised Controlled Trial of a Home and School-based Intervention for Selective Mutism - Defocused Communication and Behavioural Techniques. Child and Adolescent mental Health, 1(1), 1-8. Podsiadlo, M. (2010). Interventions for Children with Selective Mutism. Arizona: Arizona State University Tancer N. K., (1992). Elective mutism: a review of the literature. In Advances in Clinical Child Psychology (p 265-288). New York: Plenum. Sharkey, L., & McNicholas, F. (2008). ‘More than 100 years of silence’ elective mutism: A review of the literature. European Journal of Child and Adolescent Psychiatry, 17 Appendix A: SCREENING TEST FOR SELECTIVE MUTISM Student’s name: ____________________________________ Grade: ________________ Gender: Male □ Female □ Age: _________ D.O.B: _____ /____ /____ Date of Referral: _____ /____ /____ Cultural Background: ________________________ Dominant Language Spoken: __________________ Referred by: _______________________________ (Teacher Parent Self YLC HOS) Date of Referral: _____ /____ /____ ___________________________________________________________________________________ Does the child have any of the symptoms below? (Please answer Yes or No to each question) 1. Does the child have an ongoing fear of social situations involving unfamiliar settings? 2. Does the child have a persistent and unreasonable fear of speaking in the classroom, to other kids or adults including from the school settings, restaurants or stores? 3. Does the anxiety interfere with the child’s daily life? 4. Does the child appear anxious when interacting with peers? 5. When the child is expected to speak does he/she react by having a blank expression on his/her face? 6. Does the child cling to parents or hide in a corner of the room when an outsider visits the home? 7. Does the child smile in photos taken by professional photography (other than snapshots taken at home)? 8. Does the child worry excessively about being called upon by the teacher in class to verbally respond? 9. Has the child suffered in classroom performance due to non-verbalization? 10. Is the child reluctant to go to school or avoid age appropriate social activities? 11. Does the child experience headaches or stomachaches about attending school? 12. Does the child speak at home in a normal voice but does not verbalize in public? 13. Has the non-verbalization in school or public setting been for more than one month? _______________________________________________________________________________ Reference: Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR 2000), 4th edition, Washington DC, American Psychiatric Association 2000. Read More

MR’s mother described him as a happy and talkative child who had no issues at home. She agreed that he was a shy child who did not speak or interact freely with newly met people particularly when they went shopping. However, he was fine with friends who he was well acquainted to. The client’s mother reported that there were no similar issues evident with MR’s two siblings. She further indicated that MR did not suffer from any medical condition that could contribute to his current behaviour.

There is no reported information about the triggering point for the mother was not aware of his condition either. Relevant Background History: Family Composition: Placement in the family: 2nd sibling Residing in the family home with: Mother – aged 27 years old – Ethnicity: Egyptian – Occupation: Unemployed Brother – aged 7 years old – Place of Birth: Australia – Grade 2 Sister – aged 5 years old – Place of Birth: Australia – Kindergarten Does not live with: Father – aged 33 years old – Ethnicity: Egyptian - Occupation: Unemployed It is relevant to add that it was difficult to obtain further information from the client’s parents due to cultural beliefs of humiliation surrounding the discussion of family circumstances with others.

They were not willing to talk about their personal life or provide any further information and were not responsive towards appointments. Consequently, the information was predominantly obtained from MR’s older brother and his classroom teacher. MR’s older brother reported that although the parents were not officially divorced, they were living separately. He explained that the parents were planning on getting divorced, and that their father was aggressive and abusive and had been removed from their home by the police after he had smashed the windows at home.

The client’s brother reported that they had a chance to see their father every time he dropped in for a visit, which was however once in a while. Test Administration: The assessment necessary for a collective team approach included the Special Needs Teacher and me, as the school counselor, to work together from time to time. Formal clinical cognitive assessment was necessary to further assess for other underlying symptoms and/or the impact of the environmental factors that may contribute to the symptoms of shyness, anxiety, social isolation, being withdrawn from peer interaction etc.

A referral to the Speech Pathologist was also made to assess and rule out any underlying language deficit or physical problem (e.g. hearing impairment) that may impact or prevent speech from occurring. MR’s cognitive ability and other predisposing factors have been administered for assessment using: Selective Mutism Screening Test (SMST) (see Apendix A) was conducted to examine whether the client displayed symptoms of an inability to speak in certain settings. A Child Behavioural Checklist (CBCL) (Achenbach, 1991) was also administered to the client’s mother to measure the client’s social skills.

The CBCL was also completed by the client’s teacher to determine the client’s social interaction as well as Child Daily Ratings of Behaviour (CDRB) (Chafouleas, Kilgus, Jaffery, Riley-Tillman, Welsh, & Christ, 2013) was also administered daily to monitor daily changes in behaviour by MR’s teacher. Mental Examination Status (MSE) was also conducted to check his client’s appearance, behaviour and mental functioning. The assessment procedure set off with the collection background information from the client’s mother and brother -- in relation to the family context.

The Special Needs Department was also contacted to gather information on MR’s literacy and written work. It is important to note that a report from the Speech Pathologist has not yet arrived. Risk assessment was not possible due to the client’s condition at this point in time. Additionally, continuous observational assessment was performed to observe the changes. Dynamic assessment was used to understand how the client responded to learning, such as the type of communication mode that the client used including pointing, nodding, gesturing, writing and/or whispering.

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