Helping Your Child, Treatment

Exposure Therapy: Climbing the Ladder

When a person is fearful of something, they tend to avoid it. The more they avoid it, the more the fear grows. Exposing a person to the thing they fear in a safe, supportive way helps them to break this cycle and become less fearful and avoidant. This type of treatment, called exposure therapy, can be effective in many types of anxiety disorders, including selective mutism.

The goal of exposure therapy in selective mutism is to help the child take small, consistent steps to face their fear of speaking without overwhelming them. They are not thrown into a scary situation, rather supported while they gradually take one step at a time toward the anxiety-provoking situation. It can be helpful to create a hierarchy or brave speaking ladder in which your child helps to rank speaking activities (sometimes starting with non-verbal activities) in order from easiest to hardest. They can then start at the bottom of the ladder and work their way up to more difficult challenges.

Why is exposure therapy important? Some children with selective mutism will not progress to speaking even when measures are taken to decrease their anxiety. These children need extra support to break the cycle of avoidance. Also, there are always going to be some situations in life when anxiety cannot be completely reduced. As the child matures, they will need to learn that they can face their fears and overcome them. Implementing speaking exposures tailored to your individual child when they are ready can help them gain this kind of confidence.


Advantages

  • The child participates in planning by helping to rank their fears.
  • The repeated exposures help the child to habituate – in other words, the feared situation no longer produces anxiety.
  • It targets specific goals or steps.
  • Can be used to generalize speech to more locations and people.
  • The actual exposure can be quite short (as opposed to fading-in).
  • You can do exposures anywhere.

Disadvantages

  • Requires some preparation beforehand: creating a ladder, practicing at home, brief warm-up time.
  • If doing exposures with strangers, it may not be possible to prepare the stranger beforehand (but sometimes it isn’t necessary).
  • It may take some trial and error to find the right steps.
  • Young children may not be able to help rank their steps or even identify what part of a situation is challenging for them.
  • Children may be very reluctant to do the exposures.

How to do an exposure

  1. Choose your brave speaking challenge (based on the speaking ladder you created) including the activity, the location, and the person or people who will be involved.
  2. Prepare your child beforehand. Include them in planning and give them choices.  Role play and practice at home.
  3. Just before the exposure, take a few minutes to help your child warm-up, get comfortable, and relax. Practice again on location if possible.
  4. If appropriate, prepare the other people involved. Let them know your child’s goal and how they can help and what not to do.
  5. Stay positive, low-pressure, and make it fun! Give your child encouragement for any efforts.
  6. Have a reward system in place to help motivate your child. (Note: some children may not respond well to external rewards.)
  7. Be prepared with a plan B in case the challenge ends up being too difficult. You could do some more warm-up time, practice and then try again, or go back down a half step on the ladder. You want your child to be successful in some way so you don’t reinforce the avoidance.

Our experience with exposure therapy

We found starting exposure therapy to be beneficial after we had used the fading-in technique for several months with teachers and friends. When Buttercup and Petunia were ready to generalize their speech to more types of activities, people, and locations we began doing planned exposures. The girls have progressed faster with some people and locations than others so we adjust our exposure activity based on the situation.

Planned exposures are a great way to help your child move along, but sometimes it is hard to get it right. I think the biggest challenge for us is figuring out what steps it will take to reach the goal. My daughters and I have often overestimated their ability to reach a step and we have to go back and insert some intermediate steps. That is totally okay!

We have found that Petunia gets overwhelmed by making a ladder with all the steps. So, with her, I have a general idea in my mind of what the ladder would look like, but we wait until she has mastered one step and then decide together what her next step will be. Don’t be afraid to modify any treatment technique to fit your child’s individual needs.

How we did it

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Here is one example of an exposure we did with Buttercup.

  1. We planned to go to one of Buttercup’s favorite places – the pet store! Her goal was to ask an employee if they had any bunnies she could see.
  2. Buttercup and I practiced at home beforehand. I pretended to be the employee and she asked me her question about the bunnies. She figured out exactly what words she wanted to use. We also talked about what she might want to see if they did not have bunnies and she practiced asking if they had guinea pigs or hamsters too.
  3. When we arrived at the pet store, we took a few minutes to look around. We watched the dogs getting groomed and looked at the hundreds of cool fish. We talked about how cute bunnies are and how fun it would be to see one. When Buttercup was ready, we found a place we could be alone and practiced one last time.
  4. For this exposure, we did not prepare the employee beforehand. Buttercup had done several similar exposures in the past without hesitation. However, I did catch the employee’s attention and began the conversation. I told him that my daughter had a question that she would like to ask and then turned to her. She asked if they had any bunnies but unfortunately they did not. When the man asked Buttercup what else she would like to see she answered “guinea pigs” as we had practiced. (If I had wanted to prepare the employee beforehand I could have said something like, “Buttercup here is working on brave talking and would like to ask you a question. You can help by not looking directly in her eyes and by giving her a little time to work up the courage to speak.”)
  5. We made this activity fun by choosing a location that Buttercup loves and asking about her favorite animal. She was really motivated to ask to see a bunny.
  6. The reward system we had in place for Buttercup at that time was to earn tokens that she could turn in for certain prizes on a menu.
  7. If Buttercup had been unable to ask the questions as planned, I would have prompted her once or twice by saying, “What was it that you wanted to ask?” and wait a few seconds. If still no response I would have continued (going back a half step), “What animal is it that you wanted to see?” If still no response I could ask (going back another step) “Would you like to see the cats or the bunnies?” If Buttercup was still stuck I could tell the employee that we might be back in a little while to try again. Then we would do some more warm-up and practicing and try again.

Helpful Hints

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  • Good planning is so important to make exposures successful. The more prepared you and your child are for the exposure, the less anxious they will be and the better their chances for success. Don’t forget that your plan may look good on paper, but end up to be too difficult in real life. Make adjustments as needed.
  • When creating a brave speaking ladder keep in mind the verbal communication load of the activity. Start low and move up. Here are some general guidelines, but each child is different and may not follow the same order.

Low communication load – counting, reciting the alphabet, days and months, answering yes/no questions.

Medium communication load – answering forced-choice questions (choice between x and y), identifying opposites, giving a definition, personal information such as name, age, birthday, address, and phone number, asking a question after being prompted to speak.

High communication load – answering open-ended questions, stating likes and dislikes, social greetings like hello, goodbye, please, and thank you, telling jokes, sharing opinions and feelings, initiating conversation.


Related Posts:

Treating Selective Mutism – What Works?

Fading In: Our Go-To Technique

How Shaping is Used to Treat Selective Mutism

 

 

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