A Review and Controlled Single Case Evaluation of Behavioral Approaches to the Management of Elective Mutism

This paper reviews 33 individual case or group studies describing the application of behavior therapy techniques to the management of 41 electively mute children. Management strategies included stimulus fading, reinforcement, stimulus fading plus reinforcement, and escape or avoidance procedures. Reinforcement procedures proved most effective when a minimum operant level of speech existed in the treatment setting. In the absence of baseline speech, stimulus fading procedures were successful in transferring speech stimulus fading procedures were successful in transferring speech from settings in which the child spoke comfortably, to new individuals and situations. Response cost contingencies improved the efficacy of both reinforcement and stimulus fading plus reinforcement procedures. Among the 37 cases reporting individual observations at treatment termination, 57% (21) spoke spontaneously and 43% (16) responded to prompts or questions. Follow-up observations on 32 individual cases over intervals ranging from 3 weeks to 11 years revealed spontaneous speech in 79% (26 of 33) and prompted speech in 18% of the cases (6 of 33). A deterioration in speech was noted in only 1 case. Outcome appears to be closely related to treatment duration with spontaneous speech emerging in those studies reporting more extended periods of treatment. Finally, since most studies have been based on undocumented case reports, controlled single case designs were used to evaluate the use of stimulus fading and stimulus fading plus reinforcement procedures with 3 and 15 years old electively mute boys.