Anxiety and Selective Mutism in
Youth Workshop
Dr. Alissa Pencer
Registered Psychologist
Outline
Part I: Anxiety Disorders in Youth
Part II: Selective Mutism

Part I: Anxiety Disorders in Youth
 When is anxiety a problem?
 Prevalence and course
 Common Anxiety Disorders
 Causes
 Cognitive Behaviour Therapy for Anxiety Disorders



Realistic Thinking
Exposure
Case Examples and Group Exercises
A. Pencer October 2012
2
Fear, Anxiety, and Worry

Everyone worries, everyone gets anxious and
everyone is afraid of something.
 Very young children are often fearful of
strangers, the dark, animals and insects.
 Older children and adolescents are often
fearful of peer rejection and are more selfconscious and strive to fit in with their peers.
 Adults often worry about public speaking.
A. Pencer October 2012
3
A. Pencer October 2012
4
When is Anxiety A Problem?

Most children, adolescents and adults use
anxiety to help them make good decisions,
e.g., looking both ways before you cross the
street, putting on your seatbelt, setting your
alarm so you aren’t late, studying for tests,
budgeting time to complete assignments.
 Anxiety becomes a problem when it makes the
decisions for you, interferes with your life
and/or causes significant distress.
A. Pencer October 2012
5
Inverted U-Shaped Relationship
Between Arousal and Performance
Hebb, D. O. (1955). Psychological Review, 62,
243-254
A. Pencer October 2012
6
Examples





Not being able to join extracurricular activities.
Not being able to speak in front of the class.
Not handing an assignment in because “not
perfect”.
Not being able to go to school because
overwhelming.
Washing your hands 30 times a day.
A. Pencer October 2012
7
How Common are Anxiety Disorders?
Anxiety disorders are the most common
psychological problem found in children
and adolescents.
 Approximately 1 in 10 youth meets the
criteria for an anxiety disorder.
 Despite this, often mental health centres
see more children with aggressive
difficulties, attentional problems, eating
disorders, or suicidal tendencies.

A. Pencer October 2012
8
6 Month Prevalence Rates of Mental or Addictive
Disorders in Children 4-17






Anxiety Disorders
ADHD
Conduct Disorder
Mood Disorders
Substance Use Disorders
Any Disorder
14
%
7
5
4
4
1
Waddell et al, Can J Psychiatry, 2002
A. Pencer October 2012
9
How Does Anxiety Effect Youth?

Anxious youth tend to have:




Fewer friends
Difficulty meeting new people, joining clubs and
groups
Academic problems because they avoid homework,
don’t make full use of the resources, and have
difficulties concentrating because they worry
School avoidance
A. Pencer October 2012
10
Long term

In the long term, anxious without
treatment have:
Restricted choices in terms of opportunities
for careers
 Lower self esteem
 Increased likelihood of becoming an
anxious and/or depressed adult

A. Pencer October 2012
11
What Does Anxiety in Youth Look
Like?
No two anxious youth will behave exactly
the same way, nor will they worry about
the exact same things.
 However, there are common anxiety
patterns which roughly translate into the
anxiety disorders.

A. Pencer October 2012
12
What is an Anxiety Disorder?
Interfering with daily activities
 Causing significant distress
 Reaction is too extreme for the situation
 Trigger is not an actual threat

A. Pencer October 2012
13
Anxiety Disorders

Separation Anxiety Disorder: separation from
caregivers and concern bad things will happen
to them
 Generalized Anxiety Disorder: worry
excessively about many areas of life
functioning (e.g., school work, family, friends,
health)
 Social Phobia: fearful of social or performance
situations
A. Pencer October 2012
14
Anxiety Disorders cont’d

Specific Phobia: fear of particular objects or
situations
 Panic Disorder: misinterpret bodily changes
and have a fear of losing control
 Obsessive Compulsive Disorder: the presence
of intrusive repetitive thoughts or behaviors
A. Pencer October 2012
15
Causes
& Treatment
A. Pencer October 2012
16
What Causes Anxiety Disorders?

Genetics
Anxiety runs in families
 Common for at least one parent to be
somewhat anxious
 Research has shown that what is passed on
from parent to child is not a specific
tendency to be shy or worry but a general
personality to be more emotionally sensitive
than other people.

A. Pencer October 2012
17
What causes anxiety disorders?

Parent Reaction


Modeling


Parent reactions or the way they handle their child
or teen’s anxious behaviour might also play a role
(e.g., being over-protective).
Children and adolescents copy their parents coping
strategies (e.g., avoiding fearful situations).
Stressors

Bit by a dog, death of a loved one, being bullied,
getting sick
A. Pencer October 2012
18
Interventions that Help
Psycho education
 Treatment:

Group CBT for youth and parents
 Individual CBT
 Medication

A. Pencer October 2012
19
Evidence for CBT in Anxiety Disorder Treatment

Individual CBT (Kendall,1994 and 1997)
 Study 1: 64% of treatment group no longer with dx
 Study 2: 71% of treatment group no longer with dx
 Results in both studies maintained at 1 year
 At 7 years post-treatment, anxiety disorder no longer
primary in 92% of youth

Up to 84% no longer have dx if parent component added
(Barrett et al., 1996)

Individual vs. Group CBT(Manassis et al, 2002; Rapee,
2000)
 Group CBT as effective as Individual CBT
A. Pencer October 2012
20
Three Components of Anxiety
Feeling
(Physiological)
Cognitive
(Thoughts)
Doing
(Behaviors)
A. Pencer October 2012
21
Physiological Component
A. Pencer October 2012
22
A. Pencer October 2012
23
Anxiety and the Brain
Limbic System
-scans all sensory input, flight/fight
response, integrates memory,
emotion
Prefrontal Cortex
- decision making,
planning, emotion regulation
Locus coeruleus
-Alarm system:
sympathetic nervous
system activation
A. Pencer October 2012
24
Fight-Flight Response

In fearful situations teens become “pumped
up” or aroused. This is the fight-flight
response.


Immediate or short-term anxiety is named the fightflight response. It’s the body’s way of protecting
you from danger.
The fight-flight response causes you to sweat,
increase heart rate, tense muscles, make you
breath faster, feel hot or cold, dry mouth, and feel
lightheaded or dizzy.
A. Pencer October 2012
25
Fight Or Flight?
A. Pencer October 2012
26

In youth with anxiety disorders, the fightflight response occurs when there is no
immediate danger, but instead a perceived
danger.
Being in a classroom filled with other students
 Using a restroom at school
 Going to the cafeteria
 Doing a presentation
 Having your heart race
 Paragraph you just wrote is “just not right”

A. Pencer October 2012
27
Cognitive Component
A. Pencer October 2012
28
Examples (Cognitive)

Anxious children and teens have
thoughts that center around harm or
threat.
“I can’t leave to go to school and be away from
my mom or something bad will happen to her.”
(Separation)
 “I can’t do this presentation because my
classmates will think I’m dumb.” (Social)
 “If I don’t check the back door lock, someone will
break in.” (OCD/GAD)

A. Pencer October 2012
29
Behavioral Component
A. Pencer October 2012
30
Anxious behaviours

Anxious children and teens often behave
differently:
They pace, fidget, cry, cling, shake.
 They avoid.

Refusing to go somewhere alone
 Refusing to go to school


They seek reassurance.
“Am I going to die?”
 “Am I going to fail?”
 “Is everyone going to laugh at me?”

A. Pencer October 2012
31
Core Components of CBT
Realistic Thinking/Cognitive Restructuring
 Exposure **
 Skills Training (e.g., deep breathing and
relaxation, problem solving, social skills,
assertiveness, stress management)

A. Pencer October 2012
32
Thinking Errors

Anxious children overestimate how likely it is
that an unpleasant event will happen.
 They overestimate how bad the
consequences will be if the event does
happen.
 They underestimate their ability to cope with
the anxiety and the unpleasant event
A. Pencer October 2012
33
Realistic Thinking
Event
Thought/Belief
Emotion
Parent is late
Parent is late
Parent is late
there has been a crash
stuck in traffic
stopped to get pizza
worry,anxiety
annoyance
happy
A. Pencer October 2012
34
Steps in Realistic/Detective Thinking
1) Identify the situation that is making you
worried
2) Identify the worried thought
3) Look for “Realistic Evidence” to
challenge your worried thought
4) Look for alternative outcomes
5) Identify a more realistic thought
A. Pencer October 2012
35
Questions for collecting “evidence”







What is the evidence that this thought is true? What is
the evidence that this thought is not true?
What would I tell a friend if he/she had the same
thought?
Am I 100% sure that ___________will happen?
How many times has __________happened before?
What was the outcome?
What is the worst that could happen? What is likely to
happen?
If it did happen, what can I do to cope with or handle
it?
Am I confusing “possibility” with “certainty”? It may be
possible, but is it likely?
A. Pencer October 2012
36
Situation
Feeling 0-10
Anxious
Thought
Evidence?
A. Pencer October 2012
Realistic
Thought
Feeling 0-10
37
Exposure
By avoiding, children minimize direct and
prolonged contact with feared situations.
 Anxious children have no opportunity to
learn that the situation is harmless.

A. Pencer October 2012
38
High
First time
Anxiety
Second time if removed at
point B
Second time if taken out of
situation
A
B
Low
Time
A. Pencer October 2012
39
Fighting Fear by Facing Fear
 The
Keys to Stepladders:
 gradual
(start low on anxiety thermometer)
 stay in step “long enough” (until anxiety
decreases)
 use coping strategies
 need to repeat steps
 importance of rewards
A. Pencer October 2012
40
Creating Stepladders
1.
2.
3.
4.
5.
6.
Write a practical goal
Brainstorm all possible steps to reach the
goal
Child/Teen should give each step a worry
rating
Choose steps that cover the entire range of
ratings
Write chosen steps in order
Negotiate rewards for each step and ultimate
reward for achieving the goal
A. Pencer October 2012
41
Common Problems




Step too hard
Not enough repetition
Speeding through
Look out for subtle avoidance (e.g.
lucky charms)
A. Pencer October 2012
42
School Based Version of “Cool Kids”


Cool Kids Anxiety Program School Kit
This package is an adaptation of the Cool Kids
program for use within a school setting. It is
designed to be run by school therapists and
related mental health professionals. The
therapist's manual describes in detail how to
conduct each session of the program including
exercises and comments to assist successful
implementation.
http://centreforemotionalhealth.com.au/pages
/resources-products.aspx
A. Pencer October 2012
43
CASE EXAMPLE(S)
and
GROUP EXERCISES
A. Pencer October 2012
44
Case example #1
Ten year old boy with separation anxiety
who was recently bullied. Now needs
parents to drive him to school, won’t go
into school without parent present, won’t
attend class unless parent remains in the
school. Defiant if confronted about
attending.
A. Pencer October 2012
45
Case Example #2
Thirteen year old girl, diagnosed with
Generalized Anxiety Disorder (GAD).
Perfectionist qualities. Very concerned
that people will think she is “stupid”.
Spends an inordinate amount of time
on homework checking for errors.
A. Pencer October 2012
46
Case Example #3
15 year-old male with social anxiety
disorder.
a)
b)
c)
d)
e)
Will not talk to people at school.
Cannot do presentations at school.
Will avoid any social gatherings with more
than 3 people and rarely goes to friend’s
houses.
Will not eat in the cafeteria.
Misses school very often.
A. Pencer October 2012
47
A. Pencer October 2012
48
Helping Children with Selective
Mutism
Acknowledgment to Dr. Melanie Vanier
A. Pencer October 2012
49
Outline

Part II: Selective Mutism
Common characteristics
 Prevalence and course
 Contributing factors
 Assessment
 Intervention approach
 Case example/group exercise
 General discussion

A. Pencer October 2012
50
Common Characteristics
• Fearful of being seen or heard
speaking in certain situations (at
school)
• Visibly anxious when expected to
speak
• May communicate nonverbally
• Social phobia symptoms
A. Pencer October 2012
51
Influenced by Situational Factors
 People
 Activity
 Location
A. Pencer October 2012
52
Prevalence and Course
• ~1% of young children
• Seems more common in girls
• Onset in preschool years
• Little known about the course
• Without effective intervention, may
persist for many years
A. Pencer October 2012
53
Possible Contributing Factors
• Shy or anxious temperament
• Family history of shyness or anxiety
• Speech - language difficulties
• New culture
• Limited socializing with school peers
A. Pencer October 2012
54
No Evidence SM Caused By:
• Trauma
• Family Dysfunction
• Manipulation
A. Pencer October 2012
55
APA Diagnostic Criteria
• Consistent failure to speak in specific
situations
• Speaking in other situations
• Interferes with: educational achievement
or social communication
• At least one month duration
• Not due to: communication disorder or
unfamiliarity with the language
A. Pencer October 2012
56
Initial Assessment Considerations
• Speech – language difficulties
• Autistic spectrum disorder
• Hearing impairment
• Cognitive/ learning difficulties
• Co-occurring anxiety disorders
• Shyness
A. Pencer October 2012
57
Initial Assessment Process
• Parent interview/ detailed history
• Parent and teacher reports:
- norm-referenced behaviour
questionnaires
(e.g., CBCL)
- selective mutism questionnaires
• Direct observation (classroom, office)
A. Pencer October 2012
58
Intervention Approaches
• Most approaches have not been
systematically evaluated
• Approaches useful in treating anxiety have
been applied to selective mutism:
 behavioural therapy
 cognitive-behavioural therapy (CBT)
 medication
A. Pencer October 2012
59
Behavioural Approach
● Most evidence based approach
(Cohan, Chavira, & Stein, 2006)
● Emphasis on modifying the
environment
● Stimulus fading/ graduated exposure
is key
A. Pencer October 2012
60
Intervention: First Steps
● Establish “management
team”
● Provide psychoeducation
● Reduce pressure to speak
● Encourage nonverbal participation
● Begin regular monitoring
A. Pencer October 2012
61
Key Intervention Goals
● To develop an exposure hierarchy
involving gradual steps
● To learn and implement strategies to
move child along hierarchy, to transfer
comfortable speaking from one situation
to others
A. Pencer October 2012
62
Creating the Exposure Hierarchy
● Develop separate hierarchies for
people, activities, and locations
• Then combine into one integrated
hierarchy
A. Pencer October 2012
63
Exposure Hierarchy: People Dimension
● Consider people in terms of potential
“conversational partner”
● Generally, children with selective mutism
are most likely to speak to parents at
school first
● List people the child: speaks to in any
setting, speaks to selectively, will interact
nonverbally, tends to avoid
A. Pencer October 2012
64
Exposure Hierarchy: Activity Dimension
● Consider activities in terms of speaking
demands and the child’s comfort level
● Generally, children with selective mutism are
more likely to speak during activities that are
familiar and fun, and least likely to speak during
academic activities
● List activities from ones child
is already comfortable doing
to those that would be increasingly
anxiety-provoking
A. Pencer October 2012
65
Exposure Hierarchy: Location Dimension
● Consider school locations in terms of comfort
level, privacy, and novelty
● Generally, children with selective mutism are
more likely to speak at school in locations that
are unlike the classroom and have not been
associated with a pressure to speak (e.g.,
playground, unfamiliar room)
● List school locations from ones that are quieter,
private, and novel, to those that would be
increasingly anxiety-provoking
A. Pencer October 2012
66
Integrated Hierarchy:
The “Conversational Ladder”
● Combine the separate dimension lists to
form a series of increasingly anxietyprovoking, school-based speaking
situations
● Child should continue speaking at each
new step
● Be prepared to insert an intermediate step if
the child stops speaking
A. Pencer October 2012
67
Integrated Hierarchy:
The “Conversational Ladder”
● Repeated exposure (practice) at each step
until child becomes confident
● Initial steps should involve changes in
activity and location, then practice similar
steps with a new person
● Track progress to identify next step(s)
A. Pencer October 2012
68
Ways to Promote School Participation
• Encourage nonverbal participation
(e.g., jobs in the classroom;
nonverbal communication with
teacher)
• Playdates at home with classmates
• Re-arrange classroom seating to
increase comfort
• Alternative evaluation methods
A. Pencer October 2012
69
Conversational Visits
• Opportunities for child to practice
comfortable speaking at school with
conversational partner(s)
• Very important if child is not
speaking at all or very little
at school
• Short-term strategy
A. Pencer October 2012
70
Conversational Visits
• Begin with a person child speaks
comfortably to (often parent) in a private
space at school
• Comfortable speaking transferred to new
activities and locations, then to other
conversational partners
A. Pencer October 2012
71
The Use of Positive Reinforcement
(Praise, Rewards)
● Positive reinforcement creates positive
memories of approaching, not avoiding.
● Praise the child’s bravery (emphasis on
effort, not outcome). Low key praise is
best.
● Incentives (rewards) can be
helpful in some circumstances.
A. Pencer October 2012
72
General Strategies: Building Social Skills
● Practice social skills at home (role playing with
puppets; conversations with older children)
● Help the child develop strategies to solve
problems
● Gently provide direct instruction and feedback
as needed
● Arrange real-life opportunities for practice (find
activities that play to the child’s strengths)
A. Pencer October 2012
73
General Strategies: Anxiety
Management
• Psychoeducation re: anxiety
• Help the child learn relaxation
strategies (so they can tolerate
discomfort)
• Use other anxiety management
strategies as appropriate
A. Pencer October 2012
74
CASE EXAMPLE
and
GROUP EXERCISES
A. Pencer October 2012
75
Case Example
Sarah is a 6-year-old girl who has been diagnosed with
selective mutism.

Sarah attends first grade at a small, rural school.

Sarah is described as quite talkative at home, and loves
spending time playing “school” with her younger sister and
chatting with her grandmother. She has a younger, close
friend (Michelle) who goes to her school and lives down the
street and they both enjoy doing crafts and playing board
games.

Her parents recall that she has always been a quiet girl who
needs time to warm up to new people or new situations.
A. Pencer October 2012
76

She does not speak to any of the children at school,
although the classroom teacher thinks she may have
seen Sarah speak to another little girl (Lisa) from her
class on the playground once.

Sarah has not spoken to her teacher, and blushes and
looks away when her teacher asks her a question.

The teacher is not concerned at all about Sarah’s
learning, and has told her parents that Sarah seems to
be taking everything in and follows classroom routines
well.
A. Pencer October 2012
77
QUESTIONS/
GENERAL DISCUSSION
A. Pencer October 2012
78