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Parent and Child Psychological Services PLLC 
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Selective Mutism: Understanding Treatment Options and Key Terms in PCIT-SM by Kate Gibson, PsyD, ABPP

10/30/2022

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There are different types of therapy offered for treating Selective Mutism. Some are offered by Speech Pathologists and some by mental health practitioners. All use different strategies to work toward the same goal of increasing the child’s ability to speak when anxious. This blog focuses on understanding Parent-Child Interaction Therapy for Selective Mutism (PCIT-SM), the approach offered at our practice and created by Dr. Steven Kurtz.

PCIT-SM is a behavioral treatment approach that uses positive reinforcement to help children increase their brave talking while decreasing the negative reinforcement cycle that is maintaining their anxious avoidance of speaking. Positive reinforcement of brave talking involves rewarding the desired behavior of talking. The negative reinforcement cycle that maintains SM involves children being self-rewarded by avoiding talking because avoiding talking is the quickest way they know to decrease their own anxiety.

Before focusing on brave talking PCIT-SM devotes time to building a relationship between the therapist and the child without prompting for speech. Activities that the child is interested in are completed together. This phase of treatment is called the Child Directed Interaction (CDI). This phase is essential for building comfort in treatment for the child before tackling the challenge of working on their anxiety. CDI is used to help a child warm-up at the start of each session. CDI is usually done in the presence of an adult such as a parent that the child already talks to. CDI is also used as a warm-up when a new person is introduced or another variable is changed. The concept of contamination plays a role throughout PCIT-SM.
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  • Contamination is the phenomenon of a child or teen with SM already having experience not speaking to a person, in a place, or in a situation. Children or teens with SM will be unable to speak with any contaminated subject without intensive practice and support. We avoid contamination by completely avoiding questions and heavily relying on the use of CDI skills from PCIT-SM. We also work to un-contaminate previously contaminated individuals in VDI by thoughtfully fading in people who are contaminated and/or working in places or situations that are contaminated.

When the therapist is ready to have the child work on their brave talking the Verbal Directed Interaction (VDI) phase of treatment is begun. Here are some key terms that will come into play during VDI: fade-ins, rehearsal, shaping, living and exposure lifestyle.
  • Fade-ins are the process of helping a child with SM talk to a new person. It involves slowly getting a child or teen comfortable speaking in front of and eventually to a new person, scaffolded by gradually moving the person being “faded in” closer to the child to encouraging interaction, and then passing the talking baton from the familiar person to the new person.
  • Shaping is used to establish a behavior that does not currently get performed. It involves breaking the ultimate goal down into smaller steps to take toward that goal. Shaping is a process of taking small steps starting with a lower difficulty action and gradually increasing the difficulty working progressively toward the ultimate goal. You want to wait until your child has more confidence with the step they are working on before increasing the difficulty. If you take things a step harder and your child is completely unable to do it then you probably need to break the steps down into smaller steps toward their goal. In PCIT-SM the therapist will support you in pacing the shaping steps. We think of it as taking steps up a ladder with each step or rung on the ladder being slightly harder than the last.
  • Rehearsal means practice! If you want your child with SM to order their own donut, they will need to practice first. If nonverbal greetings are also hard and you want your child to wave at their friend as they walk up to the school building, they will need to practice first. They will likely need to practice many times and in a variety of settings. Practice will happen in session but practice outside of session is essential for progress to generalize to your real life. Do not underestimate the power of practice in getting your child ready to face a new challenge with their brave talking or participating. Rehearsal could mean practicing with you multiple times, it could mean practicing with a bunch of different people, it could mean practicing in a bunch of different places. We call looking for any opportunity to practice “living an exposure lifestyle.” Pretty much anywhere you find people is a chance to practice and live that exposure lifestyle.

There are different intensities of treatment available for children with Selective Mutism. PCIT-SM can be delivered individually or in group. Generally children begin with individual therapy and after making progress may be referred for a weekly SM group. Sometimes children with SM take a good amount of time to warm up, making a traditional hour a week therapy model not the most effective approach. In these cases more intensive individual treatment may be recommended first. Intensive treatment could be a few longer sessions each week for a period of time or could be as much as full days of treatment spanning an entire week either in the office or in your home/school/community. Weekly SM groups are allow children to work on talking with adults and other children in activities that simulate things that happen in a classroom. Groups are a great opportunity to work on higher level goals. Some children also benefit from a more intensive group treatment approach. The SM camp models are known as Intensive Group Behavioral Treatments (IGBTs). Our practice will be offering an SM camp this coming summer 2023 called Mighty Mouth Kids Sarasota based on the MMK model developed by Dr. Steven Kurtz.

Your therapist in PCIT-SM will guide you every step of the way in using the strategies discussed here in and out of session to help your child succeed and will help guide you in the intensity of treatment your child needs to succeed!

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The treatment principles and terms in this Blog are drawn from PCIT-SM developed by Dr. Steven Kurtz of Kurtz Psychology Consulting.

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Understanding Oppositional Defiant Disorder (ODD) By Rachel Funnell, LMFT

10/21/2022

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Everyone knows that all children are defiant at times, especially when they are tired, hungry, stressed or upset. They will talk back, refuse to listen, yell, and argue. The truth is that oppositional behavior is a normal part of developmental for two year-olds to three year-olds and early adolescents. Oppositional defiance becomes an issue when it’s consistent and stands out when compared to other children of the same age and developmental level and when it affects the child’s family, social and academic life. So how do you know if your child’s defiant behavior is typical or not? Below are the signs and symptoms you want to look out for. 

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists criteria for diagnosing Oppositional Defiant Disorder (ODD). The DSM-5 criteria include emotional and behavioral symptoms that last at least six months.

Angry and irritable mood:
  • Often and easily loses temper
  • Is frequently touchy and easily annoyed by others
  • Is often angry and resentful

Argumentative and defiant behavior:
  • Often argues with adults or people in authority
  • Often actively defies or refuses to comply with adults' requests or rules
  • Often deliberately annoys or upsets people
  • Often blames others for his or her mistakes or misbehavior

Vindictiveness:
  • Is often spiteful or vindictive
  • Has shown spiteful or vindictive behavior at least twice in the past six months

These symptoms can occur in just one setting or across multiple settings like home, school and in the community. 
ODD can sound like a very scary diagnosis to parents. It can make a parent feel like they aren’t good parents or they did something wrong. Or it can feel like something is wrong with their child. The truth is that there is no known single cause of ODD. However, there are lots of different treatment options for parents and their child. 

First, it’s important to get properly diagnosed. A lot of times, the child may have some signs and symptoms of ODD but don’t meet the specific criteria. Also, there are times that the child has another disorder that needs to be treated too, like ADHD, learning disabilities, depression or anxiety disorders. Without knowing the full picture, it will be hard to treat the ODD effectively. If your child doesn’t meet the criteria, the type of treatment might be a little different depending on the areas of need. 

Once properly diagnosed, the parent needs to look for specific treatment that treats ODD. Not every type of therapy is effective with ODD. The following are more effective treatment:    
  • Parent Management Training - this helps the parent and others learn how to manage the child’s behaviors. Parent-Child Interaction Therapy (PCIT) is a great type of parent management training that works with kids ages 2-10.
  • Individual Psychotherapy - this can help the child learn more effective anger management techniques.
  • Family Psychotherapy - this can improve communication and mutual understanding between the family.
  • Social Skills training - this increases flexibility and improves social skills to help increase frustration tolerance with peers. 
  • Medication - this can help control some of the more distressing symptoms and treat any coexisting conditions. 

In addition to the above, there are several things that the parents and others can do to help the child. 
  • Catch the child being good. Praise the child every time you see them doing a behavior that you want to increase. Be specific about what you like when talking to younger children. That lets the child know what you like and what they need to do next time. 
  • Avoid arguing. A child with ODD will argue if you engage with them. So pick your battles. If you can give options, then do that. Otherwise, pick your battles.
  • Take a break if you think you’re about to get elevated. This is a great way to model for the child to take a break. Also, allow them to take a break if they want one. 
  • Set limits that are age appropriate and reasonable. Be consistent with the consequences and make sure they can be enforced. No empty threats.
  • Manage your own stress so that you can stay calm during those challenging moments. 

A child with ODD can be challenging but it is treatable. With treatment, the child can have a very successful and fulfilling life. 

https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Children-With-Oppositional-Defiant-Disorder-072.aspx
​

https://www.mayoclinic.org/diseases-conditions/oppositional-defiant-disorder/symptoms-causes/syc-20375831


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What Teachers Should Know about OCD By Tara Motzenbecker, LMHC, NCSP

10/14/2022

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What is OCD?
Obsessive-Compulsive Disorder (OCD) is a disorder related to anxiety, and kids who have it struggle with obsessions, compulsions, or often both. Obsessions are unwanted and intrusive thoughts, images or impulses that make the child feel anxious or scared. The child will often attempt to ignore, suppress or neutralize the thoughts (by performing a compulsion). Compulsions are things kids are driven to do to get rid of the anxiety or distress. They may be repetitive behaviors or mental acts. The compulsions are time-consuming or cause significant distress or impairment. 

It is like being bitten by a mosquito.  It itches (distress) so the child scratches it to make it better.  It feels better while scratching (compulsion), but as soon as the child stops scratching, the itching gets worse (distress). The scratching worked great for the child in the short-term, but made the long-term problem worse. 

How to recognize it at school
You might notice that a child is scared of germs.  They may be handwashing or using sanitizer in excess.  They may avoid touching other children or items. They might be asking to go to the nurse often because they are afraid they are sick. 
They might also be thinking they have to do something to prevent something bad from happening (e.g. they have to touch the doorway three times so their parent does not die in a car crash). It can be hard to know the mental part of this, but if teachers are seeing repetitive acts, it is a sign of OCD. 

They may ask to check-in with their parents frequently.  This may be coming from a need for reassurance that nothing bad has happened or that the parents will be picking them up. Or maybe they are frequently checking their backpack to make sure they did not lose something. 

They might have a case of the “what if’s”.  “What if there’s a fire alarm in the middle of the test?” “What if the water stops working?”

They might need to line up items or put things in particular spots without being able to explain why.  They just know that it doesn’t feel right until they fix it. You may see children getting up to fix placement or put things the “right” way repeatedly throughout the day. 

If you are noticing concerns, how do you bring it up to the parents?
Chances are, the parents are seeing some similar compulsive behaviors at home.  There is also the chance that it is only happening at school. Scheduling a parent-teacher conference to mention the symptoms present at school is a very gentle way to alert parents to the issue. Be sure to mention how distressing the symptoms appear to be for the child and/or the level of impairment the symptoms are causing at school.  Try not to use the term “OCD”.  Rather, explain that you are seeing some concerning compulsive behaviors or intrusive thoughts that are impacting the child at school. Check with your school counselor for referrals to professionals who specialize in the evaluation and treatment of anxiety-related disorders.  

How to assist in the treatment
If you have a student receiving treatment from a mental health professional for OCD and the symptoms are present in the school environment or with homework, you will need to be involved to some extent in the treatment. If the parent has not signed a release of information form allowing the therapist to communicate with you, ask the parent to complete one so you can speak directly with the therapist.  You may be asked to complete some questionnaire assessments about the child. Completing those as openly and transparently as possible will be beneficial for the child’s treatment. At times, the therapist may ask you to reduce accommodating a symptom.  For example, if the therapist and child are targeting the compulsion of erasing and rewriting, you may need to take the paper from the child after they have written their first draft answer.  
 

However, if the child is not ready to tackle that particular compulsion just yet, they may need accommodations. For example, a child who compulsively erases and rewrites and is not ready to tackle this symptom in their treatment plan, may need extra time to complete tests and school work. 

Frequent and open communication with the parents and treating professionals will ensure a quality team-approach to defeating the OCD. 

Further Resources
  • The International OCD Foundation is a great resource of information and research: https://iocdf.org/about-ocd/
  • Students with OCD: A Handbook for School Personnel by Dr. Gail B. Adams (2011)   https://www.amazon.com/Students-OCD-Handbook-School-Personnel/dp/0983436401

Tara Motzenbecker, LHMC, Registered Play Therapist, Licensed School Psychologist is organizing an in-depth teacher training on this topic.  This training will be open to individual teachers and to schools.  If you are interested and would like to be notified of scheduled trainings and further talks on this topic, please email
info@ChildTherapySRQ.com.

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    Parent and Child Psychological Services is a private practice serving children and families in the Sarasota, Florida area. The practice is owned and operated by Dr. Gibson, a Licensed Psychologist who is Board Certified in Clinical Child and Adolescent Psychology. ​

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Parent and Child Psychological Services PLLC 
info@childtherapysrq.com
941.357.4090 (Office)
727.304.3619 (Fax)                                                                                                                                                               
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