fluoxetine for the treatment of selective mutism with elevated social anxiety symptoms

200 Pages·2015·4.95 MB·English

by  Justin Barterian

FLUOXETINE FOR THE TREATMENT OF SELECTIVE MUTISM WITH ELEVATED
SOCIAL ANXIETY SYMPTOMS: A NONCONCURRENT MULTIPLE BASELINE DESIGN
ACROSS FIVE CASES

By

Justin A. Barterian

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

School Psychology – Doctor of Philosophy

2015
ABSTRACT

FLUOXETINE FOR THE TREATMENT OF SELECTIVE MUTISM WITH ELEVATED
SOCIAL ANXIETY SYMPTOMS: A NONCONCURRENT MULTIPLE BASELINE DESIGN
ACROSS FIVE CASES

By

Justin A. Barterian

Selective mutism is a debilitating disorder with academic and social consequences, yet
little research is available regarding psychopharmacological interventions (Carlson et al., 2008).
This dissertation study examined the utility of fluoxetine (Prozac) for the treatment of five
children, ages 5 to 14, diagnosed with selective mutism, who also demonstrated elevated levels
of social anxiety symptomology. A non-concurrent multiple-baseline design with a single-blind
placebo-controlled procedure was used to examine treatment outcomes. Effectiveness was
evaluated by a multi-gate analysis process, including: a) visual analysis (Kratochwill et al.,
2010); b) the Wampold and Worsham (1986) randomization test; and c) the Kendall’s Tau +
Mann-Whitney U (Tau-U; Parker, Vannest, Davis, & Sauber, 2011) effect size calculation.
Multiple methods of assessment including Direct Behavior Ratings (DBR; Chafouleas, Riley-
Tillman, & Christ, 2009) and standardized measures [e.g., the Multidimensional Anxiety Scale
for Children – Second Edition (MASC-2; March, 2012)] were used. Information regarding
adverse effects with an emphasis on behavioral disinhibition and ratings of parental acceptance
of the intervention were also gathered. Visual analysis of all five cases indicated fluoxetine did
not demonstrate utility for the reduction of social anxiety symptoms and was ineffective in
increasing spontaneous speech. However, as predicted a significant increase in responsive speech
with unfamiliar adults (p = .03; Tau-U: .44, p < .01) was noted. Two of the five children
experienced some acute occurrences of minor behavioral disinhibition, but did not experience
any other side effects during the course of treatment. Behavioral disinhibition did not correspond
to changes in social anxiety symptoms, responsive speech, or spontaneous speech. Parents found
the use of fluoxetine for the treatment of selective mutism highly acceptable.
Copyright by
JUSTIN A. BARTERIAN
2015
ACKNOWLEDGEMENTS

I am indebted to many who supported me throughout my graduate studies and the
completion of this dissertation project. First, I am grateful for the guidance of my dissertation
chair, Dr. John S. Carlson, who continually pushed me to be better with high expectations,
patience, and encouragement. I am appreciative of the collaboration of Dr. Joel Sanchez and his
willingness to be the psychiatrist on this project. This study could not have been completed
without the collaboration of the professionals at the Michigan State University Psychiatry Clinic,
especially Dr. Christopher Giuliano. Further, this project substantially benefitted from the
support of my dissertation committee members, Drs. Jed Magen, Sara Witmer, and Evelyn Oka,
who helped shape the ideas proposed at the beginning of this process. Additionally, I am
thankful for the time and effort provided by my project assistants Allison Siroky, Brittany Mash,
Marianne Clinton, and Elizabeth Snyder. This study was funded by a generous grant from the
MSU School Psychology Program and a Dissertation Completion Fellowship provided by the
Department of Counseling, Educational Psychology, and Special Education.
I could not have made it this far without the sacrifice and support of my parents, Anthony
and Michelle, as well as the support of other family members such as my brother Jonathon, my
grandmother Eleanor, my Aunt Debra and those I have lost during my graduate studies: my
grandparents Joseph and Rosina. I am forever grateful for the humor and camaraderie provided
by the lifelong friends and colleagues I made during my time at MSU, who were excellent
examples of working hard and having fun in the process. Finally, I would like to dedicate this
paper to my fiancé, Alicia Spangler, whose unwavering support helped me persist and bring this
paper to completion. I look forward to everything that comes next for us.
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TABLE OF CONTENTS

LIST OF TABLES ..........................................................................................................................x

LIST OF FIGURES ..................................................................................................................... xii

CHAPTER 1 ....................................................................................................................................1
INTRODUCTION ..........................................................................................................................1

CHAPTER 2 ....................................................................................................................................6
LITERATURE REVIEW ................................................................................................................6
Selective Mutism ........................................................................................................................6
Diagnostic criteria of selective mutism ...............................................................................6
Associated features .............................................................................................................7
Differential diagnosis ..........................................................................................................9
Prevalence rates ................................................................................................................11
Demographic characteristics .............................................................................................11
Prognosis ...........................................................................................................................12
Etiology of selective mutism ............................................................................................12
A joint biopsychosocial framework of selective mutism and social
anxiety disorder .....................................................................................................12
Biological factors of selective mutism and social anxiety ........................13
Psychosocial factors of selective mutism and social anxiety ....................15
Pediatric Psychopharmacology and Selective Mutism .............................................................16
Ethics in pediatric psychopharmacology research and practice .......................................17
Selective Serotonin Reuptake Inhibitors ...................................................................................18
The intended effect of SSRIs .............................................................................................20
Side effects associated with SSRIs ....................................................................................22
Intended effects of SSRIs vs. behavioral disinhibition related to selective
mutism................................................................................................................................24
Current Evidence-Base of Selective Mutism Treatments ........................................................25
Psychosocial treatments for selective mutism ..................................................................25
Behavioral and cognitive-behavioral therapy .......................................................25
Selective serotonin reuptake inhibitors for the treatment of selective mutism .................26
Fluoxetine .............................................................................................................26
Quasi-experimental studies .......................................................................27
Case studies ...............................................................................................28
Critical summary of fluoxetine studies ......................................................30
Sertraline ...............................................................................................................30
Critical summary of sertraline studies .......................................................32
Paroxetine and fluvoxamine .................................................................................32
Critical summary of fluvoxamine and paroxetine studies .........................33
Single-Case Research Design ....................................................................................................33
Rationale for single-case design within selective mutism research ...................................33
vi
Multiple-baseline designs ..................................................................................................36
Concurrent versus nonconcurrent multiple baseline designs .................................37
Visual analysis of single-case design data .............................................................39
Quantitative analysis of single-case design data ....................................................41
Randomization tests for the analysis of single-case design data ...............41
Effect size calculations for single-case design data ...................................43
Single-case design in selective mutism psychopharmacology studies ..............................44
Current Study ............................................................................................................................45
Research questions and hypotheses ..................................................................................46

CHAPTER 3 ..................................................................................................................................54
METHODS ....................................................................................................................................54
Participants ................................................................................................................................54
Measures ...................................................................................................................................59
Social anxiety ....................................................................................................................60
Direct behavior rating (DBR): Social engagement ...............................................60
Multidimensional anxiety scale for children – 2nd edition (MASC-2) -Social
anxiety scale (SAS) ...............................................................................................62
Clinical global impressions (CGI): Anxiety/Shyness ...........................................63
Frequency of speech .........................................................................................................64
Direct behavior rating (DBR): Speech ..................................................................64
Selective mutism questionnaire (SMQ) ................................................................64
Clinical global impressions (CGI): Mutism ..........................................................65
Adverse events ..................................................................................................................65
Clinical global impressions (CGI): Side effects ...................................................65
Side effects form for children and adolescents (SEFCA) ......................................66
Behavioral disinhibition ....................................................................................................67
Parent version of the young mania rating scale (P-YMRS) ..................................67
Treatment acceptability .....................................................................................................68
Treatment evaluation questionnaire – acceptability scale (TEQ-P) ......................68
Medication compliance measure ...........................................................................69
End of study form .................................................................................................69
Procedures ................................................................................................................................69
Project personnel ...............................................................................................................70
Project coordinator ................................................................................................70
Project assistants ....................................................................................................71
Study psychiatrist ...................................................................................................71
Training .............................................................................................................................71
Study psychiatrist ..................................................................................................71
Project assistants ....................................................................................................72
Teachers .................................................................................................................72
Parents ...................................................................................................................73
Study Phases ..............................................................................................................................73
Project overview ...............................................................................................................73
Inclusion and exclusion criteria .........................................................................................74
Screening ...........................................................................................................................75
vii
Consent and assent procedures .........................................................................................76
Baseline .............................................................................................................................76
Treatment ..........................................................................................................................78
End of treatment phase.......................................................................................................79
Experimental Design ................................................................................................................79
Data Analysis ............................................................................................................................80
Multi-gate analysis ............................................................................................................80
Question one ......................................................................................................................83
Question two ......................................................................................................................83
Question three ....................................................................................................................83
Question four .....................................................................................................................84
Question five ......................................................................................................................84

CHAPTER 4 ..................................................................................................................................88
RESULTS ......................................................................................................................................88
Question One .............................................................................................................................88
Question Two .............................................................................................................................90
Question Three ...........................................................................................................................91
Question Four.............................................................................................................................93
Question Five .............................................................................................................................96
Individual Improvements ...........................................................................................................98

CHAPTER 5 ................................................................................................................................100
DISCUSSION ..............................................................................................................................100
Fluoxetine Treatment for Associated Social Anxiety ..............................................................100
Fluoxetine Treatment for Speaking Behaviors .......................................................................102
Behavioral Disinhibition and Other Adverse Events ...............................................................105
Medication Compliance ...........................................................................................................108
Treatment Acceptability...........................................................................................................109
Implications for Research ........................................................................................................110
Limitations ...............................................................................................................................111

APPENDICES .............................................................................................................................115
Appendix A: Young Mania Rating Scale – Parent Version (Adapted) ..................................116
Appendix B: Letter to School Psychologists, Private Practitioners, and Early
Childhood Mental Health Workers ....................................................................118
Appendix C: Recruitment Flyer ...............................................................................................119
Appendix D: Letter to Principals .............................................................................................120
Appendix E: Inclusion and Exclusion Criteria ........................................................................121
Appendix F: Correlation Matrix ..............................................................................................122
Appendix G: Medication Log ..................................................................................................123
Appendix H: Early Exit Form ..................................................................................................124
Appendix I: End of Study Form...............................................................................................125
Appendix J: Direct Behavior Rating Forms – Teacher and Parent ..........................................126
Appendix K: Multidimensional Anxiety Scale for Children – 2nd Edition: Social
Anxiety Scale .....................................................................................................130
viii
Appendix L: Clinical Global Impressions (Severity and Change) – Clinician,
Parent, Teacher ...................................................................................................131
Appendix M: Selective Mutism Questionnaire........................................................................142
Appendix N: Adapted Side Effects for Children and Adolescents (SEFCA) .........................145
Appendix O: Answers on the Parent-Mania Rating Scale that May Indicate
Behavioral Disinhibition as a Result of Fluoxetine Treatment ...........................146
Appendix P: Treatment Evaluation Questionnaire, parent version .........................................148
Appendix Q: Consent Forms and Assent Procedures for Participation (Parent,
Teacher, Child) .................................................................................................149
Appendix R: Medical, Developmental, Psychosocial, Family, Substance Abuse,
and Legal History Form – MSU Psychiatry Clinic ............................................161
Appendix S: Consent for Release of Confidential Medical, Treatment, and School
Records ...............................................................................................................169
Appendix T: History of Treatment Form for Previous Treating Professional .........................170
Appendix U: Physical Exam ....................................................................................................172
Appendix V: Visual Analysis Decision Tree ...........................................................................173

REFERENCES ............................................................................................................................175

ix
LIST OF TABLES

Table 1 DSM-5 Criteria for Selective Mutism ............................................................... ...7

Table 2 FDA Approval of SSRIs for Anxiety Disorders in Children and
Adolescents ......................................................................................................... 19

Table 3 Published Case Studies on Fluoxetine Treatment for Selective Mutism ............ 29

Table 4 Rationale for Single-Case Designs in Psychopharmacology Studies with
Children Diagnosed with SM............................................................................. 34

Table 5 What Works Clearinghouse Requirements to Be Rated “Meets Evidence
Standards” for SCD........................................................................................... 36

Table 6 Research Questions, Hypotheses, and Planned Assessment Procedures ........... 48

Table 7 Demographic Characteristics and Baseline/Intervention Ratings for Six
Participants ........................................................................................................ 56

Table 8 Pre-Treatment, During Treatment, and Post-Treatment Ratings by
Treatment Schedule ........................................................................................... 58

Table 9 Assessments Planned for Each Phase ................................................................ 60

Table 10 Randomized Multiple Baseline Design Baseline and Treatment
Schedule ........................................................................................................... 78

Table 11 Percent Completion Rate of Data Forms per Observer .................................... 82

Table 12 Means of Social Anxiety Symptom on Outcome Measure Across
Baseline and Treatment Phases ........................................................................ 85

Table 13 Direct Behavior Ratings – Mean Speaking Behaviors Across Baseline
and Treatment Phases ....................................................................................... 86

Table 14 Means of Supplementary Selective Mutism Outcome Measures Across
Baseline and Treatment Phases ......................................................................... 87

Table 15 CGI – Means of Global Side Effect Ratings..................................................... 93

Table 16 Answers on the TEQ-P Across Participants ..................................................... 97

Table 17 Medication Compliance Rates per Phase .......................................................... 98
x