Gamificiation of Therapy: Treating Selective Mutism

Introduction

Selective mutism is a psychiatric disorder most commonly observed in children and adolescents (American Psychiatric Association, 2013). Selective mutism is characterized by a withdrawal of speech in situations during which speech would be expected typically. Recently, it has been categorized as an anxiety disorder, likely due to the vast research literature suggesting a high co-occurrence between selective mutism and other anxiety disorders, particularly social anxiety disorder (e.g., Young, Bunnell, & Beidel, 2012). In fact, more often than not, children with selective mutism report elevated levels of social anxiety, adding to the complexity of the disorder and its treatment. Treatment of selective mutism is difficult and often requires lengthy intervention before significant treatment gains are observed. Effective therapy makes use of behavioral interventions, which can be difficult to administer for untrained clinicians (Pionek Stone, Kratochwill, Sladezcek, & Serlin, 2002). Briefly, shaping procedures (rewarding the child for successive approximations of speech) are extremely effective. Over time, children are required to produce more complex sounds and eventually are rewarded for verbalizing letters and words at increasing volume.

Several barriers to the successful treatment of selective mutism have been noted, and often contribute to the difficult and lengthy process of successful treatment outcome. For example, children are often resistant to treatment, whether due to elevated levels of anxiety associated with speaking or the child’s resistance to a transition from “the kid who does not talk” to one who does. Children with selective mutism also experience reinforcement in their natural environment to withhold speech, including both positive (i.e., presentation of a reward following a behavior) and negative (i.e., removal of an aversive stimulus following a behavior) reinforcement. This reinforcement may make it difficult to engage children in treatment, as the natural reinforcers may be stronger than the rewards offered during therapy. Given these barriers as well as possible limitations in the training of community clinicians with regard to behavioral interventions, a therapeutic tool which provides both strong reinforcement for treatment progress as well as assists a therapist in the treatment of selective mutism would prove dually advantageous. This chapter presents a new method by which these goals might be achieved, specifically via the use of tablet PC applications during the treatment of selective mutism.

The first section of the chapter introduces selective mutism and its associated features, as well as theories associated with the etiology and maintenance of the disorder. Literature examining the behavioral treatment of selective mutism is reviewed and a detailed discussion of the barriers to this treatment is included. Recommendations are provided regarding the use of tablet PC applications during the treatment of selective mutism, and case study data for four children treated successfully while making use of such applications. Finally, a description of an application development effort for treating selective mutism is provided in detail. The results of a small usability study are discussed, which other developers may find applicable to their work. The final section of the chapter will discuss future directions, such as how this app—and others like it—can become even more mobile and be generalized to treating a variety of mental health issues.