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Children Who are Anxious in Silence: A Review on Selective Mutism, the New Anxiety Disorder in DSM-5
Abstract
Selective mutism (SM) is a relatively rare childhood disorder characterized by a consistent failure to speak in specific settings (e.g., school, social situations) despite speaking normally in other settings (e.g., at home). The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists SM among the anxiety disorders. This makes sense as the current review of the literature confirms that anxiety is a prominent symptom in many children suffering from this condition. Further, research on the etiology and treatment of SM also corroborates the conceptualization of SM as an anxiety disorder. At the same time, critical points can be raised regarding the classification of SM as an anxiety disorder. We explore a number of such issues in this review. Recommendations for dealing with this diagnostic conundrum are made for psychologists, psychiatrists, and other mental health workers who face children with SM in clinical practice, and directions for future research are highlighted.
... The Diagnostic Features and Associated Features to Support the Diagnosis of SM sections of SM in DSM-5 include additional clinical features such as high levels of social anxiety, withdrawal, externalizing behaviors, and impairments in communication skills [1]. These clinical features reflect the findings that (social) anxiety is a central phenomenon in the majority of children with SM [2,3], and that also additional symptoms beyond anxiety (e.g. externalizing behavior, delayed speech development) may occur in affected children [4]. ...
... SM causes severe impairments in academic and social functioning [5,6], typically emerges during preschool age [7] and can last for several years [8]. According to epidemiological studies, the average prevalence is 1% [3,7]. ...
... While it is acknowledged that SM can result in impairments [5,6], the diagnostic criteria for SM in DSM-5 only define a single symptom, namely failure to speak, without specifying a syndrome. Considering the high importance of anxiety in SM [3] and first evidence of additional symptoms in children with SM (see below), the diagnostic criteria of SM may be imprecise. The precision of diagnostic criteria is crucial because a valid diagnosis based on empirically identified symptoms is necessary to identify individuals affected by a specific mental disorder, to apply a particular treatment approach, or to study a mental disorder's pathomechanisms [9]. ...
Understanding the symptoms of a mental disorder is essential for accurate diagnosis or selecting appropriate treatment targets. Despite this, there is a surprising lack of systematic research on the symptoms of selective mutism (SM). While the DSM-5 defines failure to speak as the only core symptom of SM, sparse research suggests that children with SM may experience additional symptoms. Previous studies have been limited in their identification of symptoms of SM, either by using a predefined set of symptoms or by only asking for anxiety-specific symptoms. This may have resulted in important symptoms being overlooked. In this study, we provided n = 86 parents of children and adolescents with SM (3–18 years) with a symptom definition appropriate for the target group. Additionally, parents were asked an open-ended question about any other symptoms they had observed in their children, beyond the failure to speak. The symptoms reported were categorized using qualitative content analysis (QCA) and examined for frequency and association with symptom severity. Ten different symptom categories were identified, with fear, freezing, and avoidance/security behaviors being the most prevalent. On average, parents reported M = 4.74 (SD = 2.37) symptoms from different symptom categories. Only fear was found to be related to symptom severity of SM. As the findings suggest that SM encompasses various symptoms beyond failure to speak, a more sophisticated understanding of SM as a mental disorder with multiple symptoms seems essential. The clinical implications of this are discussed in further detail.
... It is also used in the latest International Classification of Diseases, Eleventh Revision (ICD-11) and has replaced the less common term, elective mutism, which is used in the Tenth Revision (ICD-10). [1][2][3][4][5] The etiology of SM is still somewhat unknown, but it is likely that it comprises genetic, environmental and neurodevelopmental factors [6]. The prevalence of SM is quite low, at 0.18-1.9% ...
... The prevalence of SM is quite low, at 0.18-1.9% [6,7]. It has been reported to be slightly higher, at 2.2%, in immigrant populations [8]. ...
... We are not aware of any studies on SM and suicidality. SM is often comorbid with social anxiety disorders (SAD) [10] and it has even been suggested that SM could be an extreme form of SAD [6,15,23,24]. A systematic review on the long-term outcomes of SAD found that it was common for clinical subjects with SAD to have chronic symptoms [25]. ...
Background
Selective mutism (SM) is a childhood onset anxiety disorder, and the main symptom is not speaking in certain social situations. Knowledge about the duration and long-term outcomes of SM have been lacking and the aim of this systematic literature review was to address this gap in the literature. We investigated how long SM symptoms persisted as well as other psychiatric outcomes associated with SM in later life.
Methods
The PubMed, PsycInfo, Web of Science, Cochrane Library and Embase databases were initially searched from inception to 11 September 2023. Studies were included if they were published in English and had followed up subjects with clinically diagnosed SM for at least two years. The review followed the Preferred Reporting Items of Systematic Reviews and Meta-analyses guidelines and the protocol was registered with the Open Science Framework. The papers were assessed using the Quality Assessment with Diverse Studies tool.
Results
This review screened 2,432 papers and assessed 18 studies. Seven case series studies were excluded from discussion because of the low number of subjects and the fact that their findings could not be generalized to wider populations. In the end, nine clinical cohorts and two case control studies were reviewed. These provided a total of 292 subjects and the sample sizes ranged from 11–49. The overall quality of the studies was moderate. The review found that 190 of the 243 subjects in the studies that reported recovery rates showed moderate or total improvement from SM during follow up. Other anxiety disorders were the most common psychiatric disorders later in life, although these results should be interpreted with caution. Older age at baseline and parental psychopathology might predict greater impairment, but further studies are needed to confirm these results.
Conclusions
Most subjects with SM recovered from this disorder during adolescence, but anxiety disorders were common in later life. Early detection and treatment are needed to prevent symptoms from persisting and other psychiatric disorders from developing.
... Various intrinsic factors have been associated with the etiology of SM, including genetics, temperamental and neurodevelopmental factors (Muris & Ollendick, 2015). For example, behaviorally inhibited temperament has been identified as an important etiological precursor of SM (Gensthaler et al., 2016;Muris et al., 2021). ...
... Various environmental and familial factors have also been suggested as associated with the etiology of SM (Muris & Ollendick, 2015). Having an immigration background (Elizur & Perednik, 2003;Steinhausen & Juzi, 1996), older father, lower socioeconomic status, and being raised by a single parent elevated the odds for offspring SM (Koskela et al., 2020). ...
... The findings of the current study have some important clinical implications. Although parental characteristics are only part of the factors contributing to SM severity (Muris & Ollendick, 2015), it may be important to pay clinical attention to these features. Due to the non-speaking nature of SM and children's developmental level, parents are often involved in all components of their child's treatment. ...
This study examined whether parental psychopathology (depression and social anxiety), parenting styles (authoritative, authoritarian, permissive) and practice (parental accommodation), and parental beliefs about children’s anxiety are related to symptom severity in pediatric patients diagnosed with Selective Mutism (SM). Participants included 78 children, aged 3.5-8.5 years, with SM diagnosis, and their primary care-giving parent. The measures included clinical interviews, clinicians and parents’ reports, and behavioral observations. Clinician reports of less severe SM symptoms in children were associated with more positive parental beliefs about their children’s anxiety. Parents’ reports of less severe symptoms in their children were associated with lower levels of parental social anxiety and accommodations, as well as with more authoritative and authoritarian parenting styles. Parental accommodations mediated the relationship between parental social anxiety and severity of children’s symptoms, such that parents who are more socially anxious were also more accommodative, and this was related to greater SM severity. The findings of this study highlight important parenting characteristics involved in SM. These findings may lead to refining the psychological interventions for children with SM by allocating greater attention to parents’ characteristics.
... In addition, The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), states that the disturbance caused by SM must interfere with educational achievements or social communication, is not explained by a communication disorder and does not occur exclusively during the course of ASD or psychotic disorders [3]. The prevalence of SM tends to be relatively low, varying from 0.18 to 1.9% in published studies, depending on the study protocol and diagnostic criteria used [4,5]. Follow-up studies have reported that the symptoms of SM lasted a long time, but improved during follow-up, and that social phobias, phobic disorders and communication problems were common later in life [6][7][8]. ...
... Follow-up studies have reported that the symptoms of SM lasted a long time, but improved during follow-up, and that social phobias, phobic disorders and communication problems were common later in life [6][7][8]. Although academic skills and abilities did not seem to differ from average levels in some studies [9,10], difficulties in communication might have affected academic performance [5]. ...
... When we examined specific disorder groups, the highest ORs were observed for childhood emotional disorders, ASD, ADHD and conduct disorders, which all are usually diagnosed during childhood. Our finding showed a higher level of childhood emotional disorders among the siblings of SM subjects and this was in line with previous studies [5,23]. These studies reported that childhood emotional disorders, such as SM and childhood social phobias, occurred frequently among the siblings of subjects with SM [5,23]. ...
The siblings of children with mental disorders are more likely to experience mental health issues themselves, but there has been a lack of sibling studies on selective mutism (SM). The aim of this population-based study was to use national registers to examine associations between children with SM and diagnoses of various mental disorder in their siblings. All singleton children born in Finland from 1987 to 2009, and diagnosed with SM from 1998 to 2012, were identified from national health registers and matched with four controls by age and sex. Their biological siblings and parents were identified using national registries and the diagnostic information on the siblings of the subjects and controls was obtained. The final analyses comprised 658 children with SM and their 1661 siblings and 2092 controls with 4120 siblings. The analyses were conducted using generalized estimating equations. Mental disorders were more common among the siblings of the children with SM than among the siblings of the controls. The strongest associations were observed for childhood emotional disorders and autism spectrum disorders after the data were adjusted for covariates and comorbid diagnoses among SM subjects. The final model showed associations between SM and a wide range of disorders in siblings, with strongest associations with disorders that usually have their onset during childhood. Our finding showed that SM clustered with other mental disorders in siblings and this requires further research, especially the association between SM and autism spectrum disorders. Strong associations with childhood onset disorders may indicate shared etiologies.
... Selective mutism (SM) is an anxiety disorder characterized by a consistent failure to speak in particular public settings (e.g., school), while being able to speak normally in other situations (e.g., home) [1,2]. The disorder is listed among the anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition (DSM-5) [2]. ...
... The prevalence of SM among children is estimated between 0.03% and 1%, and the mean age of onset is between 2 and 5 years, thus indicating that SM is a relatively rare childhood disorder [1,2]. SM has a mean duration of 8 years, after which the total lack of speech in certain settings usually dissipates [3]. ...
... In terms of treatment, the international literature suggests that behavioral or cognitive-behavioral interventions and pharmacotherapy with selective serotonin reuptake inhibitors are effective for treating SM [1]. Individualized treatment plans with the combined effort of teachers, parents, and clinics has been recommended to help children overcome SM [13]. ...
Background
Selective mutism (SM) is an anxiety disorder characterized by a consistent failure to speak in particular public settings despite speaking normally in other situations. However, quantitative SM research from China remains scanty at best. In response, this study aimed (1) to describe the sociodemographics and experiences of children and families with SM in China and (2) to identify sociodemographic and environmental correlates of SM in China.
Methods
This case-control mixed-methods study was composed of 172 cases with SM and 179 controls, recruited by online surveys. Multilevel logistic regression was performed to examine the association between potential correlates and SM.
Results
Only 51.2% of SM cases were diagnosed by a professional, and 31.1% of SM cases that received treatment were guided by a professional. Child SM was associated with: having two parents with an introverted personality (Adjusted odds ratio (AOR): 15.05, (95% confidence interval (CI): 5.39 – 42.07), being born to a mothers aged ≥ 35 (AOR 6.44, 95%CI: 1.24-33.43), and having a sibling (AOR 1.92, 95% CI: 1.00 – 3.70). However, child SM was inversely associated with ever receiving bilingual (AOR 0.20, 95% CI 0.10-0.39) education or being enrolled in an international school (AOR 0.12, 95% CI 0.04-0.35).
Conclusions
Findings suggest that many children with SM in China have not received professional treatment or interventions. Hereditary and social environmental factors may be contributing to childhood onset of SM in China. Novel policies such as access to special education resources, SM-training for therapists, and school support are needed to enhance the early detection and treatment of SM in China.
... social fears or clinginess) are indeed outlined in the associated features section of SM in the DSM-5. Given that SM shares numerous features with anxiety and social anxiety in particular [8] and has a high co-incidence with other anxiety disorders (especially SAD) [9], it seems reasonable to assume that additional anxiety-related symptoms occur together with silence as well. However, the section on associated features of SM in DSM-5 comprises also non-anxiety-related symptoms such as externalizing behaviors and communication disorders. ...
... However, the section on associated features of SM in DSM-5 comprises also non-anxiety-related symptoms such as externalizing behaviors and communication disorders. This reflects research findings that anxiety is not the central phenomenon in all children with SM and the symptom domains mentioned here may also be important [8,10,11]. However, little research has systematically examined the significance of possible circumscribed symptoms of SM and distinguished them from symptoms of other disorders (e.g. ...
... Here, studies suggest the temperamental trait of behavioral inhibition (BI), which is expressed, for example, in terms of distress to novelty, shyness, and fear responses such as a strong inhibition in new environments or toward strangers [16], to be important in children with SM [17,18]. Furthermore, it has been consistently shown that children with SM have, on average, clinically relevant levels of social anxiety [8]. However, latent profile analyses of children with SM indicate that only a minority of children with SM are exclusively characterized by elevated anxiety and that most children with SM exhibit other symptoms in addition to increased anxiety [10,11,19,20]. ...
Background
Silence in certain situations represents the core symptom of selective mutism (SM). However, it is unclear what additional symptoms are part of this disorder. Although knowledge of symptoms is essential for diagnostics and intervention, to date, only scarce research exists on circumscribed symptoms of SM. Given the large overlap between SM and social anxiety disorder (SAD), it remains also unclear which symptoms can differentiate both disorders.
Methods
A network analysis of potential symptoms of SM was performed based on a mixed sample of N = 899 children and adolescents with and without indication of SM (n = 629 with silence in certain situations). In a preliminary analysis, we demonstrated that children with and without silence in certain situations do not differ with respect to their network structure, justifying an analysis on the entire mixed sample. Possible communities (symptom clusters) within the network and thus potential latent variables were examined, and symptoms were analyzed in terms of their centrality (the extent to which they are associated with other symptoms in the network). To investigate the differentiability of symptoms of the SM network from symptoms of SAD, we computed a network that additionally contains symptoms of SAD.
Results
In the resulting network on symptoms of SM, silence was, as expected, the symptom with the highest centrality. We identified two communities (symptom cluster): (1) symptoms associated with the fear response of freezing, (2) symptoms associated with speech production and avoidance. SM network symptoms and SAD symptoms largely formed two separate symptom clusters, with only selectivity of speaking behavior (more talkative at home and taciturn or mute outside the home) falling into a common cluster with SAD symptoms.
Conclusions
Silence appears to have been confirmed by analysis as a core symptom of SM. Additional anxiety-related symptoms, such as avoidance behavior or motor inhibition associated with freezing, seem to co-occur with silence. The two communities of SM potentially indicate different mechanisms of silence. The symptoms of SM appear to be distinguishable from those of SAD, although there seems to be overlap in terms of difficulty speaking in situations outside the home.
... Selective mutism (SM) is an anxiety disorder characterized by consistent difficulty to speak in certain social situations where speaking is expected [1]. Numerous studies have shown that SM is associated with anxiety, particularly social anxiety [2,3]. However, until recently it had not been clarified what specific type of social anxiety people with SM feel. ...
... Although SM is an anxiety disorder, there is a lack of fear or anxiety-related items in the DSM-5 diagnostic criteria for SM [3]. Therefore, until this issue is resolved, it has been proposed that treatments target the core symptom, the failure to speak [7], and current intervention studies primarily focus on the speaking behavior [18,19]. ...
... Even though SM-experienced people may be able to speak, they did not feel that their SM had been cured and that alleviating their interpersonal anxiety and difficulty speaking with others was more important than improving their communication skills. Although the diagnostic criteria for SM in DSM-5 do not include descriptions of anxiety, fear, and difficulties in speaking with others [3], the results of the present study suggest that a reduction in interpersonal anxiety and difficulties to speak with others are necessary for the feelings of being cured of SM. ...
Some long-term outcomes for participants with selective mutism (SM) are elevated rates of phobic disorders, particularly social phobia, persistent communicative problems, and reduced self-esteem. However, data on the long-term outcomes of SM are scarce. In this study, by analyzing interpersonal anxiety, communication skills, and self-esteem among those who experienced SM and felt cured (SM-C-group: 30 females, 6 males, mean age 28.0, SD = 7.42, range 19–47 years), those who experienced SM and did not feel cured (SM-NC-group: 37 females, 4 males, mean age 27.4, SD = 7.24, age range 19–50 years), and those who had not experienced SM (Non-SM-group: 30 females, 30 males, mean age 26.4, SD = 7.62, age range: 20–48 years), we examined the long-term outcomes of SM and the factors that influence the feeling of being cured of SM. Results showed that the SM-C-group and SM-NC-groups had significantly higher interpersonal anxiety and significantly lower communication skills than the Non-SM-group. Moreover, the SM-C-group showed significantly lower interpersonal anxiety and significantly higher communication skills than the SM-NC-group. However, while there was no significant difference in self-esteem between the SM-C and SM-NCgroups, there was a significant difference between the SM-NC and Non-SM groups. The SM-C and SM-NC groups did not differ on the retrospective symptom load (SMQ-J), but did on the Current level of difficulty with speaking. The results of the logistic regression analysis predicted that communication skills and self-esteem did not influence the feeling of being cured of SM, but interpersonal anxiety and Current level of difficulty to speak did. Therefore, it is speculated that the intensity of this interpersonal anxiety and whether people with SM still felt difficulty in talking to others may have affected the feeling of being cured from SM.
... 6 The prevalence of SM worldwide is estimated to range from 0.18% to 1.90%, while its prevalence in Japan is 0.21%. 7,8 The average age of onset of SM is between 2.7 and 4.6 years, and it may continue into adulthood. 9,10 SM is comorbid with neurodevelopmental disorders (ND) such as autism spectrum disorder (ASD), as well as social anxiety disorder, excretory disorders, oppositional defiant disorder, and communication disorders. ...
... Due to the low prevalence of SM, 7,8 conducting largescale sampling within a specific region is challenging. The advantages of Internet surveys include obtaining a relatively large sample across regions, focusing on specific groups for sampling, and receiving honest responses to sensitive topics. ...
Background Selective mutism (SM) is an anxiety disorder in which children struggle to speak in specific social situations, and parents often have trouble coping with their child’s symptoms. We analyzed parents’ issues and support needs regarding SM through their responses to two open-ended questions, examining how these needs varied with diagnosis and comorbid conditions.
Methods Quantitative content analysis was conducted on responses obtained from 70 parents of children with SM (ages 29–63 years) recruited through SM information exchange group and social networking service. The participants responded to two open-ended questions regarding the issues they faced and the support they needed for their children’s SM symptoms.
Results The results showed that issues faced by parents of children with SM could be divided into five groups: (A) Regret over Delayed Initial Response, (B) School Non-attendance in Children with SM, (C) Inadequate Support from Teachers, (D) Inconsiderate Communication Lacking Empathy from Others, and (E) Communication Barriers Leading to Bullying and Social Isolation. The support needs of parents were categorized into four groups: (a) Places for Consultation and Obtaining Information, (b) Growth in the Number of Supporters Who Understand SM, (c) Opportunities to Improve Knowledge about SM, and (d) Specific Methods for SM Improvement. Furthermore, although comorbid conditions did not significantly affect parental issues and support needs, slight differences were observed based on the presence of a diagnosis.
Conclusion This study highlights that parents of children with SM are troubled by professionals’ lack of knowledge and their children’s symptoms, driving them to seek better understanding and more resources. The results also suggest that the support needs of these parents vary depending on whether their child is diagnosed with SM. Future research should globally identify parental issues and support needs, determine the core elements, and establish a more comprehensive support system.
... Stein et al. linked the CNTNAP2 gene to SM, suggesting a genetic influence [2], while Gensthaler et al. identified behavioral inhibition as a key temperamental factor contributing to SM [3]. The prevalence of SM is estimated to range from 0.18% to 1.90% [4]. It typically manifests around age 4.6 (range: 2.9 to 5.2 years) and can follow various courses, with some cases resolving early and others persisting into adulthood [5,6]. ...
... Given the low prevalence of SM in the population [4], conducting large-scale sampling within a specific region presents significant challenges. Online surveys allow the collection of large, geographically diverse samples and facilitate targeting specific groups [14]. ...
Background
Children with selective mutism (SM) typically exhibit SM symptoms in educational settings, which has led to extensive research on SM in such environments. However, SM symptoms also manifest in medical settings, where parents experience various challenges when seeking healthcare for their child with SM. Nevertheless, there is a lack of research on the specific challenges parents face when seeking medical care for their child with SM. In this study, we investigated the challenges faced by parents of children with SM when seeking healthcare services and explored strategies to reduce these challenges.
Methodology
In this study, we conducted an online questionnaire survey with 31 parents (mean age: 41.7 years) of children diagnosed with SM. Participants responded to open-ended questions about the difficulties they faced when seeking medical care for their child. The open-ended responses were qualitatively analyzed using the KJ method.
Results
Parents of children with SM reported the most challenges accessing medical services in pediatrics and dentistry. The analysis identified the following three main challenges parents face when seeking medical care for their child with SM: “Journey to Receiving Treatment,” “Physicians’ Inability to Accurately Capture the Child’s Condition,” and “Healthcare Providers’ Responses.”
Conclusions
These findings highlight the numerous challenges faced by parents of children with SM when seeking medical services for their child. The challenges faced by parents when bringing their child with SM to medical facilities may be alleviated through the implementation of telemedicine, the development of mobile health applications, multidisciplinary collaboration, and the introduction of SM-specific training programs for healthcare professionals.
... Selective mutism (SM) is an anxiety disorder characterized by the ability to speak in situations such as at home but persistent difficulty in speech in specific social situations where speech is expected (e.g., kindergarten and school). 1 It is typically prevalent in about 0.18% to 1.90% of the population, and between the ages of two and five. 2 Numerous studies have shown that SM is associated with anxiety, particularly social anxiety. 2 Prior research has found that SM tends to persist over time, suggesting that adverse effects (e.g., maintaining high interpersonal anxiety, poor social skills, and higher risk of psychiatric disorders) may result from SM maintenance. [3][4][5] Therefore, early intervention is needed for SM. 6 Cognitive-behavioral therapy techniques such as contingency management, shaping, stimulus fading, and exposure are commonly used in SM interventions. ...
... Selective mutism (SM) is an anxiety disorder characterized by the ability to speak in situations such as at home but persistent difficulty in speech in specific social situations where speech is expected (e.g., kindergarten and school). 1 It is typically prevalent in about 0.18% to 1.90% of the population, and between the ages of two and five. 2 Numerous studies have shown that SM is associated with anxiety, particularly social anxiety. 2 Prior research has found that SM tends to persist over time, suggesting that adverse effects (e.g., maintaining high interpersonal anxiety, poor social skills, and higher risk of psychiatric disorders) may result from SM maintenance. [3][4][5] Therefore, early intervention is needed for SM. 6 Cognitive-behavioral therapy techniques such as contingency management, shaping, stimulus fading, and exposure are commonly used in SM interventions. ...
Although exposure-based practices are effective in treating selective mutism, difficulties arise when the child refuses to visit a clinical center. In this situation, it is important to intervene using remote technology and to support parents who have children with selective mutism. In this patient report, an exposure-based intervention using online technology was implemented for an 8-year-old girl with selective mutism. In addition, her mother was also experiencing increased parenting stress. Therefore, the mother received behavioral parent training specifically designed for parents of children with selective mutism. As a result, the child’s nervousness decreased during the intervention, and the frequency of their speech, facial expression, and body motion improved. Initially, the child refused to visit our clinical center. However, they eventually agreed and managed to communicate non-verbally with the primary author in our clinical center. Behavioral parent training for selective mutism improved her mother’s understanding of the condition, the way she interacts with her child, and reduced her parenting stress. Implementing Internet-based interventions is highly beneficial because it significantly reduces the fear of clinic or hospital visits among children with selective mutism. Furthermore, behavioral parent training tailored to selective mutism to improve parental stress and interaction can be a valuable support option for parents of children with selective mutism.
... To begin with, the SCAS includes a subscale measuring symptoms of obsessive-compulsive disorder, which is no longer classified as an anxiety disorder in the latest edition of DSM, whereas the SCARED incorporates school phobia, which is not considered as a separate anxiety category in this psychiatric classification system. Furthermore, both the SCAS and the SCARED do not incorporate selective mutism, which the DSM has added to the category of anxiety disorders, given compelling evidence showing that anxiety plays a key role in this condition [16]. A final limitation of these scales pertains to the deficient measurement of fears and phobias: the SCARED does not assess this type of anxiety at all, while the SCAS only measures a limited number of specific fears (by means of its physical injury fears subscale). ...
... It is worth noting that the selective mutism subscale, which was incorporated in the YAM-5-I following its inclusion as a new anxiety disorder in the DSM-5 [15,16], generally showed only modest to moderate relationships with other measures of anxiety or internalizing problems (e.g., [23,27,36]). However, it was also noted that this subscale was strongly and positively correlated with another index of selective mutism (Selective Mutism Questionnaire [45], see [28]). ...
The Youth Anxiety Measure for DSM-5 (YAM-5) is a self- and parent-report scale specifically developed to assess symptoms of major anxiety disorders (part 1 or YAM-5-I) and specific phobias/agoraphobia (part 2 or YAM-5-II) in children and adolescents in terms of the contemporary psychiatric classification system. Since its introduction, the measure has been increasingly used in research, making it feasible to provide a summary of its psychometric properties. The present article presents a systematic review of 20 studies that employed the YAM-5, involving 5325 young participants. Overall, the results supported the hypothesized factor structure of both parts of the measure, although there were also some studies that could not fully replicate the original five-factor model of YAM-5-I. The internal consistency of the YAM-5 was generally high for the total scores of both parts, while reliability coefficients for the subscales were more variable across studies. Research also obtained evidence for other psychometric properties, such as test–retest reliability, parent–child agreement, convergent/divergent validity, and discriminant validity. Results further revealed that girls tend to show significantly higher anxiety levels on the YAM-5 than boys. Overall, these findings indicate that the YAM-5 is a promising tool for assessing symptoms of anxiety disorders including specific phobias in young people. Some directions for future research with the YAM-5 and recommendations regarding the use of the measure are given.
... Viana et al. (2009) proposed that there may be a specific SM subgroup characterized by the presence of other communication disorders. Muris and Ollendick (2015) suggest a more general association with neurodevelopmental immaturity; Kearney and Rede (2021), similarly, describe SM as a neurodevelopmental disorder. However, no study has investigated the relation between the severity of children's SSDs and the occurrence of SM. ...
... Seven additional children with classic Dup7 who were tested during this period were not included in the final sample because the speech production measure could not be administered: five (ages 4-6 years) because they did not have enough language to meet the measure's administration criteria, one (age 4 years) because of a tongue laceration, and one (age 17 years) because of SM. 1 1 This adolescent became selectively mute at age 15 years (at about the time she entered puberty). Her stated reason for being selectively mute was that she did not like the way her voice sounded (see Muris & Ollendick, 2015, for additional reports of this reason for SM). At the time she participated in the research, the only people she talked to were two classmates whom she described as having disabilities. ...
Purpose
The aim of this study was to explore relations between speech sound disorder severity and selective mutism in a group of children with 7q11.23 duplication syndrome (Dup7), a genetic condition predisposing children to childhood apraxia of speech (CAS) and other speech sound disorders and to anxiety disorders, including selective mutism and social anxiety disorder.
Method
Forty-nine children aged 4–17 years with genetically confirmed Dup7 completed the Goldman–Fristoe Test of Articulation–Second Edition (GFTA-2), the Expressive Vocabulary Test–Second Edition (EVT-2), and the Differential Ability Scales–Second Edition (DAS-II). Parents completed the Anxiety Disorders Interview Schedule–Parent (ADIS-P).
Results
Mean standard scores (SSs) were 65.67 for the GFTA-2, 92.73 for the EVT-2, and 82.69 for the DAS-II General Conceptual Ability (GCA; similar to IQ). Standard deviations for all measures were larger than for the general population. GFTA-2 SS was significantly correlated with both EVT-2 SS and DAS-II GCA. Based on the ADIS-P, 22 participants (45%) were diagnosed with selective mutism and 29 (59%) were diagnosed with social anxiety disorder. No significant differences in performance on any of the measures were found either between the group with a selective mutism diagnosis and the group that did not have selective mutism or between the group with a selective mutism and/or social anxiety disorder diagnosis and the group that did not have either disorder.
Conclusions
For children with Dup7, neither the diagnosis of selective mutism nor the diagnosis of selective mutism and/or social anxiety disorder was related to severity of speech sound disorder, expressive vocabulary ability, or overall intellectual ability. Accordingly, treatment for speech sound disorder alone is unlikely to lead to remission of selective mutism or social anxiety disorder. Instead, selective mutism and/or social anxiety disorder should be treated directly. Further research is needed to determine if these findings generalize to other populations, such as children with idiopathic CAS.
... Η μεγάλη πλειοψηφία των παιδιών με επιλεκτική αλαλία είναι αγχώδη, ενώ πολλοί είναι οι ερευνητές που έχουν συνδέσει την επιλεκτική αλαλία με τις αγχώδεις διαταραχές (Anstendig, 1999;Carbone, Schmidt, Cunningham, McHolm, Edison, Pierre, & Boyle, 2010;Muris & Ollendick, 2015;Shumka, 2019), ιδιαίτερα την κοινωνική φοβία και τις νευροαναπτυξιακές διαταραχές (Kolvin & Fundudis, 1981;Steinhausen & Juzi, 1996;Kristensen, 2000;Cohan, Chavira, Shipon-Blum, Hitchcock, Roesch, & Stein, 2008;Oerbeck et al., 2015). ...
... Ιστορικά, η πλειοψηφία των επιτυχημένων διαδικασιών θεραπείας αφορούν συμπεριφοριστικές τεχνικές, στις οποίες περιλαμβάνονται μεταξύ άλλων η ενίσχυση και η διαμόρφωση ή η προτροπή (Sheridan, Kratochwill & Ramirez, 1995 Kovac, & Furr, 2019), αλλά όμως υπάρχουν λίγα προγράμματα που απευθύνονται συγκεκριμένα σε παιδιά με επιλεκτική αλαλία. Μία από αυτές είναι η ολοκληρωμένη θεραπεία συμπεριφοράς για την επιλεκτική αλαλία του Bergman (2013) η οποία είναι μια εβδομαδιαία θεραπεία 20 συνεδριών, που χρησιμοποιεί κοινές στρατηγικές συμπεριφοράς για την απόκτηση ομιλίας σε διάφορα περιβάλλοντα (Muris & Ollendick, 2015;Siroky, Carlson, & Kotrba, 2017). ...
Η παρούσα εργασία μελετά την παιδική διαταραχή της επιλεκτικής αλαλίας και προτείνει τρόπους αντιμετώπισής της εστιάζοντας κυρίως στο εκπαιδευτικό πλαίσιο. Σύμφωνα με τα κυριότερα συμπεράσματα, οι γνωστικές συμπεριφοριστικές θεωρίες αποτελούν τους πλέον αποτελεσματικούς τρόπους προκειμένου να αντιμετωπιστεί η επιλεκτική αλαλία, ενώ θεραπείες όπως είναι η φαρμακοθεραπεία και η αυτομοντελοποίηση δεν φαίνεται να χρησιμοποιούνται συχνά παρά το γεγονός ότι επιφέρουν καλά αποτελέσματα. Επιπλέον, ο συνδυασμός διαφόρων τεχνικών αποδεικνύεται ως η πιο ολοκληρωμένη πρακτική για την θεραπεία της συγκεκριμένης διαταραχής. Στο εκπαιδευτικό πλαίσιο, η γνωστική αναδόμηση και διάφορες διεπιστημονικές παρεμβάσεις και στρατηγικές μπορούν να χρησιμοποιηθούν ώστε να μειώσουν το άγχος που παρουσιάζουν τα παιδιά με επιλεκτική αλαλία, να ενισχύσουν τη λεκτική κα μη λεκτική τους
επικοινωνία καθώς και την κοινωνική τους αλληλεπίδραση.
... In psychiatric classification systems, SM is currently considered as an anxiety disorder [4,5]. The evidence to support this notion comes from three lines of research. ...
... The results underline the relation between SM and anxiety pathology: that is, symptoms of SM were clearly associated with social anxiety symptoms as well as with the temperament trait of behavioral inhibition, which has been shown to be an important developmental precursor of (social) anxiety disorder(s) [11,12]. Clearly, this justifies the current classification of SM as an anxiety disorder [4,5]. In the meantime, the results of the current investigation also suggest that autism spectrum problems play a role in SM and that there appears to be a subgroup of children who display selective non-speaking behavior within the context of ASD [27]. ...
The purpose of this study was to study psychopathological and temperamental correlates of selective mutism (SM) (symptoms) in a mixed sample of non-clinical (n = 127) and clinically referred (n = 42, of whom 25 displayed the selective non-speaking behavior that is prototypical for SM) 6- to 12-year-old children. Parents completed questionnaires to measure their child’s symptom levels of selective mutism, social anxiety, autism spectrum disorder, and the temperament trait of behavioral inhibition. The results first and foremost showed that SM symptoms were clearly linked to social anxiety and an anxiety-prone temperament (behavioral inhibition), but findings also suggested that autism spectrum problems are involved in the selective non-speaking behavior of children. While the latter result should be interpreted with caution given the methodological shortcomings of this study, findings align well with the notion that SM is a heterogeneous psychiatric condition and that clinical assessment and treatment need to take this diversity into account.
... In general, SM tends to occur in second to fifth year of life [24]. In addition, one study and a handful of case reports drew attention to the notion of adolescent-onset SM [4,25]. ...
... The most common accompanying anxiety disorder is social phobia, with a rate of 94% [29]. Overall, comorbidity rates range from 12% to 100% [24]. Collectively, these findings highlight the high comorbidity rates of SM. ...
Introduction: Clinical information regarding selective mutism (SM), a persistent and debilitating psychiatric disorder, in children is extremely limited. We aimed to examine sociodemographic characteristics and comorbid psychiatric conditions and identify clinical variables associated with sex and SM severity among children with SM.
Methods: We analyzed the medical records of 49 children who received treatment for SM in four different tertiary hospitals in Turkey between 2016 and 2021. Children’s charts were reviewed to examine clinical characteristics, comorbidities, and response to treatment.
Results: Thirty-one children were female, and 18 were male (female:male ratio is 1.7:1). Most children (73.5%) with SM displayed onset of SM in 3–6 years. However, most children (57.1%) were diagnosed between the ages of 7–11. The mean time from onset to diagnosis was 1.69 ± 1.37 years. Females displayed a later onset of SM (6.42 ± 2.40 vs. 4.89 ± 0.96; p= 0.013) and higher comorbidity rates (71% vs. 38.9%, p= 0.039) than males. The vast majority of children received two or more psychiatric diagnoses. Children in the severe group had a longer duration of illness, higher rates of psychiatric comorbidity, speech delay, and treatment resistance.
Conclusion: Our study suggests that SM may have different clinical features according to sex and symptom severity of SM. More information about children with SM is needed to understand the development and maintenance of SM.
... These challenges may include developmental coordination disorder, enuresis, encopresis, mild intellectual disability, and autism spectrum disorders (Kristensen, 2000). It has been suggested that in addition to the child's anxiety, neurodevelopmental factors may contribute to speaking avoidance (Muris and Ollendick, 2015). ...
The multi-faceted nature of Selective Mutism (SM), and its comorbidity with other disorders, necessitates a comprehensive assessment process. However, evaluating children with SM presents significant challenges, including difficulties in building rapport, establishing an accurate diagnosis, and conducting formal psychological and neuropsychological assessments. This paper explores the key obstacles in assessing children with SM and provides practical recommendations for overcoming these challenges. Effective strategies for reducing anxiety during assessments include extended rapport-building phases, playful and engaging interactions, and the strategic use of parental involvement. Additionally, given the variability in SM symptoms across different settings, a multi-informant and multi-method assessment approach—including clinical observation, structured interviews, and standardized parent- and teacher-report measures—is recommended. This paper also discusses adaptations for formal testing, particularly in cognitive, language, and neurodevelopmental assessments, where SM-related speech avoidance can interfere with standardized evaluations. Nonverbal assessment tools, modifications to testing environments, and alternative response formats are proposed as potential solutions. Furthermore, we highlight the importance of differentiating SM from overlapping conditions, such as autism spectrum disorder and language impairments, to ensure accurate diagnosis and intervention planning. By implementing tailored assessment strategies, clinicians and researchers can improve diagnostic accuracy and better understand the unique needs of children with SM. This, in turn, can inform individualized treatment plans, enhance educational placement decisions, and support the overall well-being of children with SM.
... MW uznawany jest więc za zaburzenie występujące w populacji dzieci dość rzadko. Badania epidemiologiczne wskazują jednak na średni wskaźnik rozpowszechnienia MW na około jeden procent (Muris, Ollendick 2015). Z tego względu zaburzenie to nie powinno być opisywane jako rzadkie. ...
... However, research points to various individual, familial, and contextual risk factors. At the child's level, etiological explanations include heightened anxiety, particularly social anxiety disorder [12], emotional dysregulation [33], language/communication deficits (Cohan et al., 2008), social skills deficits [10,35], and behavioral inhibition, especially in unfamiliar situations [17]. At the family level, SM was associated with parental psychiatric disorders Koskela et al. [25] and harsh parenting behaviors [52]. ...
Selective mutism (SM) is a poorly understood condition, and debate continues regarding its etiology and classification. Research suggests that a genetic vulnerability may play a role in the development of the disorder which may be compounded by anxious and over-protective parenting. While previous studies supported the role of parenting styles in the development of SM, most of them examined child and parent factors in isolation. The current study examined how the interactions between child internalizing and externalizing behaviors (anxiety and oppositionality, respectively) and parenting styles (authoritative, permissive, and authoritarian) are associated with SM diagnosis. The study included 285 children aged 3–7 years (57.2% females), and their parents (66 children with SM and 219 typically developed children). Parents completed questionnaires about child social anxiety, oppositional behavior, SM severity, and their parenting style. Results showed that parents of children with SM reported lower levels of authoritative practices than those of typically developed children. We also found that child social anxiety and oppositionality moderated the effects of authoritative and authoritarian parenting practices on SM diagnosis. Our results suggest that child anxiety and oppositionality may explain the different susceptibility of children to adaptive and maladaptive parenting styles.
... It has to be noted that the presently proposed consensus criteria for TR-AD are limited to the population of adult patients, while criteria for TR-AD in childhood and adolescence and in elderly patients remain to be established in future studies [108][109][110][111] . Along this line, the diagnostic entities "separation anxiety disorder" and "selective mutism", previously classified in the DSM-IV section "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" and now listed in the DSM-5 chapter on Anxiety Disorders [112][113][114] , warrant investigation with regard to treatment resistance in adulthood. ...
Anxiety disorders are very prevalent and often persistent mental disorders, with a considerable rate of treatment resistance which requires regulatory clinical trials of innovative therapeutic interventions. However, an explicit definition of treatment‐resistant anxiety disorders (TR‐AD) informing such trials is currently lacking. We used a Delphi method‐based consensus approach to provide internationally agreed, consistent and clinically useful operational criteria for TR‐AD in adults. Following a summary of the current state of knowledge based on international guidelines and an available systematic review, a survey of free‐text responses to a 29‐item questionnaire on relevant aspects of TR‐AD, and an online consensus meeting, a panel of 36 multidisciplinary international experts and stakeholders voted anonymously on written statements in three survey rounds. Consensus was defined as ≥75% of the panel agreeing with a statement. The panel agreed on a set of 14 recommendations for the definition of TR‐AD, providing detailed operational criteria for resistance to pharmacological and/or psychotherapeutic treatment, as well as a potential staging model. The panel also evaluated further aspects regarding epidemiological subgroups, comorbidities and biographical factors, the terminology of TR‐AD vs. “difficult‐to‐treat” anxiety disorders, preferences and attitudes of persons with these disorders, and future research directions. This Delphi method‐based consensus on operational criteria for TR‐AD is expected to serve as a systematic, consistent and practical clinical guideline to aid in designing future mechanistic studies and facilitate clinical trials for regulatory purposes. This effort could ultimately lead to the development of more effective evidence‐based stepped‐care treatment algorithms for patients with anxiety disorders.
... Another explanation attributes SM symptoms to social skills deficits (Cunningham et al., 2004(Cunningham et al., , 2006Muris & Ollendick, 2015). For example, Carbone et al. (2010) found that children with SM displayed significantly lower levels of social assertion and verbal social skills as compared to mixed anxiety and non-clinical control children. ...
Although the diagnosis of selective mutism (SM) is more prevalent among immigrant children, the link between the disorder and an immigration background has been elusive. Guided by ecocultural models of development, the current study aimed to construct a theory-based description of SM while considering individual, family, and contextual risk factors. Participants were 78 children with SM (38.4% with an immigration background), and 247 typically developed children (18.2% with an immigration background). Consistent with previous studies, our results suggest that anxiety was the most important predictor of SM symptoms, above and beyond immigration background. Immigration, especially if coupled with bilingual status and low family income, predicted increased levels of SM symptoms. Identifying multi-level predictors of SM may help researchers and clinicians to improve early identification and treatment of SM in culturally and linguistically diverse children.
... Another explanation attributes SM symptoms to social skills deficits (Cunningham et al., 2004(Cunningham et al., , 2006Muris & Ollendick, 2015). For example, Carbone et al. (2010) found that children with SM displayed significantly lower levels of social assertion and verbal social skills as compared to mixed anxiety and non-clinical control children. ...
Although the diagnosis of selective mutism (SM) is more prevalent among immigrant children, the link between the disorder and an immigration background has been elusive. Guided by ecocultural models of development, the current study aimed to construct a theory-based description of SM while considering individual, family, and contextual risk factors. Participants were 78 children with SM (38.4% with an immigration background), and 247 typically developed children (18.2% with an immigration background). Consistent with previous studies, our results suggest that anxiety was the most important predictor of SM symptoms, above and beyond immigration background. Immigration, especially if coupled with bilingual status and low family income, predicted increased levels of SM symptoms. Identifying multi-level predictors of SM may help researchers and clinicians to improve early identification and treatment of SM in culturally and linguistically diverse children.
... The development of the SCAS, SCARED, and MASC emerged in response to the clinical and research demands following the release of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) in 1994 [56]. Conversely, the YAM-5 represents a more recent scale aligned with the DSM-5, which introduced modifications to the classification of anxiety disorders by excluding certain disorders (e.g., obsessive-compulsive disorder) and incorporating others (e.g., selective mutism) [57,58]. Regarding the MASC-2, limitations have been previously documented by other scholars [59]. ...
The Spence Children’s Anxiety Scale (SCAS) is one of the most used instruments to assess anxiety symptoms in children and adolescents. Extensive research has been conducted to examine its psychometric properties and to develop other versions of the scale. The objective of this study was to examine the psychometric properties and factorial structure of the SCAS across different versions and populations. This systematic review followed PRISMA guidelines and was registered. APA PsycINFO, Web of Science (Core Collection) and MEDLINE (PubMed) were searched. Fifty-two studies were included in this systematic review. They examined the factor structure, convergent and divergent validity, and internal consistency of the scale. The most supported model was the original six-factor model, followed by the higher order six-factor model for the long version of the SCAS. Studies provided evidence of convergent validity and internal consistency. It is concluded that the SCAS is a valid and reliable instrument for assessing anxiety symptoms in children and adolescents, with a six-factor model structure well supported in most populations. Further research on the psychometric properties and factor structure of other versions of the scale and its application to clinical populations is warranted.
... These studies had a sample size ranging from 9 to 70 patients. There are also several empirical studies reporting similarities in the symptoms of SAD and SM (Carbone et al., 2010;Cohan et al., 2008;Driessen et al., 2020;Manassis et al., 2007;Muris & Ollendick, 2015; J. L. Vecchio & Kearney, 2005). Most children with SM have high levels of shyness, are easily distressed, and have a tendency to withdraw from unfamiliar situations, which are all symptoms of SAD. ...
Selective mutism (SM) is a rare pediatric anxiety disorder in which a child fails to speak in specific social situations. Due to its classification as a rare disorder that affects less than 1% of the world’s population, research on this disorder is limited, inhibiting available treatment options for SM patients. Thus, it is critical to research more on this relatively unexplored disorder. Social anxiety disorder (SAD) is a prevalent anxiety disorder characterized by the fear, self-consciousness, and embarrassment in social situations in which a person may be judged or evaluated negatively. SM is known to present with other anxiety disorders, primarily SAD. The main treatment for SM is cognitive-behavioral therapy (CBT), followed by pharmacological interventions such as selective serotonin reuptake inhibitors (SSRIs). With limited knowledge of this rare disorder, this paper attempts to suggest a potential novel treatment for SM, serotonin-norepinephrine reuptake inhibitors (SNRIs). SNRIs are a class of antidepressants used to increase both an individual’s serotonin and norepinephrine levels in the brain. Previous case studies of SM and research on these specific antidepressants used commonly to treat comorbid SAD elucidate the antidepressant’s potential on SM. With its strong usage in the treatment of SAD, SNRIs may also be effective as a treatment for SM, a disorder that has similar clinical presentations and therapeutic approaches to SAD. In conclusion, this review paper calls to attention the lack of research on SM and identifies a novel alternative approach for its effective treatment.
... Typical symptoms of SM are reduced gesture and facial expressions, cramped-looking postures, limited movements, gaze aversion and changes to the sound of their own voice as well as shut-down or freezing in specific settings [2]. The prevalence rate of SM is reported to range from 0.03% to 2% [3][4][5][6]. SM typically begins very early, first becoming apparent in unfamiliar situations such as the beginning of nursery or school. ...
Selective mutism (SM) mostly develops early in childhood and this has led to interest into whether there could be differences in relationships in families with SM compared to a control group without SM. Currently, there are merely few empirical studies examining family relationships in SM. A sample of 28 children and adolescents with SM was compared to 33 controls without SM. The groups were investigated using self-report questionnaires (Selective Mutism Questionnaire, Child-Parent Relationship Test—Child Version) for the assessment of SM and family relationships. Children with SM did not report a significantly different relationship to their mothers compared with the control group without SM. However, the scores in respect to the relationship to their fathers were significantly lower in cohesion, identification and autonomy compared with children without SM. Relationships in families with SM should be considered more in therapy.
... Although individuals can outgrow SM, symptoms of cooccurring social anxiety disorder often persist (Sutton, 2013); it has been proposed that SM may either be a subtype of social anxiety (Sharkey & McNicholas, 2008;Steinhausen et al., 2006), a severe form of it (Scott & Beidel, 2011), a symptom of social anxiety disorder (Black & Uhde, 1995;Krysanski, 2003) or a developmental variant or pre-cursor to social anxiety disorder (Standart & Courteur, 2003). Yet, there are significant differences between SM and social anxiety disorder, where SM typically manifests during early childhood (between 2 and 5 years old; Muris & Ollendick 2015), compared to social anxiety disorder's later average age of onset of 13 years old (Leichsenring & Leweke, 2017); this makes the longitudinal course of SM less clear. ...
The present study addressed the different contributors to social anxiety in children with Selective Mutism (SM), with and without co-occurring Autism Spectrum Disorder (ASD) (SM+ASD). Seventy-five parents completed an online composite questionnaire consisting of the symptoms of SM and ASD, anxiety and sensory measures. The results found the SM + ASD group showed significantly higher levels of social anxiety and sensory avoidance compared to the SM only group. However, a simple mediation model revealed sensory avoidance to be a mediator of this relationship between the diagnosis and social anxiety.. Therefore, higher levels of sensory avoidance may help to differentiate social anxiety between the groups and may also be a sign of ASD in children with SM who have and/or are yet to receive an ASD diagnosis.
... A major problem in recognizing SM, is that there is a lack of validated instruments that assess the different responses associated with SM, and are able to distinguish children with SM from those with other anxiety disorders. Without adequate instruments, risk increases that SM is overlooked or not recognized as such [9]. If as a result no timely intervention is started, this can lead to chronic and complex anxiety and mood issues. ...
Selective mutism (SM) is an anxiety disorder in children/adolescents, characterized by the absence of speaking in specific social situations, mostly at school. The selective mutism questionnaire (SMQ) is a parent report, internationally used to assess SM symptomatology and treatment outcomes. Since no assessment instrument for SM was available in the Netherlands, our aim was to investigate the psychometric properties of the Dutch translation of the SMQ, through reliability, confirmatory factor, and ROC analyses conducted on data obtained in 303 children (ages 3–17 years; clinical SM group n = 106, control group n = 197). The SMQ turned out to be highly reliable (α = 0.96 in the combined sample; 0.83 within the clinical group) and followed the expected factor structure. We conclude that the Dutch version of the SMQ is a reliable and valid tool both as a screening and clinical instrument to assess SM in Dutch speaking children.
Zusammenfassung
Der Selektive Mutismus (SM) ist eine Angsterkrankung, die etwa 1 % aller Kinder betrifft; mehrsprachige Kinder erkranken mit einer Prävalenz von 2–3 % noch häufiger. Etwa 30–50 % der Betroffenen zeigen Sprachentwicklungsauffälligkeiten. Kernsymptom ist ein situationsspezifisches Unvermögen zu sprechen, während die Kinder in anderen Situationen ihre Sprachkompetenz weitgehend ungehemmt zeigen. Mutistisches Verhalten wird oft von einer psychomotorischen Gehemmtheit, bis hin zu Freezing-Phänomenen, begleitet. Der SM beginnt in der Regel mit 2–4 Jahren, fällt aber oft erst nach Eintritt in Kindergarten oder Schule auf. Aufgrund der starken Tendenz zur Chronifizierung, der schweren psychosozialen und schulisch-beruflichen Funktionseinschränkungen und der mit steigendem Alter zunehmenden Behandlungsresistenz sind ein pädiatrisches Screening im Kindergartenalter und sofortige diagnostische und ggf. therapeutische Maßnahmen für die Prognose entscheidend.
Very preterm birth and treatment in neonatal intensive care cause stress early in life of the infant and may subsequently lead to psychological and behavioural traumas. Previous studies show positive outcomes of eye movement desensitisation and reprocessing (EMDR) therapy on trauma in children in general. This case report describes two girls that were born at very premature age (with birth weights of approximately 1000 g). They required intensive treatment in the neonatal intensive care. In early childhood, they presented with selective mutism (SM). We treated them with EMDR therapy because we hypothesised that trauma from the postnatal period had caused post-traumatic stress disorder. The EMDR therapy resulted in a long-lasting improvement in speech, social skills and communication. This is the first case report of development of SM in ex-premature infants that were treated with EMDR therapy in early childhood.
Selective mutism (SM) is a complex anxiety-related disorder, primarily prevalent in girls, and usually diagnosed in early childhood. The main diagnostic features include persistent failure to speak in some social situations, where there is an expectation for speaking, despite normal or near-normal speech in other social settings. AD, an abandoned girl, about 3-year-old, from a child care institute was referred for a medical examination to a tertiary care pediatric hospital. The major complaints were poor appetite, failure to speak to others, and excessive aloofness. She had no major behavioral difficulties, was cooperative, and complied with all verbal instructions. She would use gestures to communicate. The child was diagnosed with SM and a comprehensive individualized therapeutic plan was implemented. The management plan focused on enhancing attachment, cognitive stimulation, and language skills. As a first step, AD was enrolled in a day care center. An enabling and enriching environment was provided with plentiful opportunities for play and interaction with peers. Defocused communication that involved sitting alongside the child rather than face to face, creating joint attention using tasks that the child enjoyed, not asking direct questions, giving the child adequate time to reply, and continuing with the conversation even if she did not respond verbally was used as the primary treatment strategy. Collaborative teams including pediatricians and mental health professionals can play an integral role in early diagnosis and in overseeing the challenging path of overcoming SM in young children from adverse circumstances.
Selective mutism (SM) is a highly impairing anxiety disorder, characterized by a persistent inability to speak in unfamiliar settings and significant impairment in social and academic functioning. Although cognitive-behavioral therapy (CBT) is effective in treating childhood SM, traditional outpatient CBT for SM is inaccessible, relative to treatments for more common anxiety disorders. Intensive group behavioral treatment for SM (IGBT-SM) has garnered support for targeting the specific fears inherent to SM, mimicking the settings where youth with SM have most difficulty verbalizing, and increasing the availability of providers trained in specialty services for SM. This chapter provides a synthesis of current research on IGBT-SM and a description of the core components and skills used within the model. Special considerations are provided to effectively simulate the school environment within IGBTs, tailor skills to diverse presentations and verbal behaviors, and conduct treatment practices in non-therapeutic contexts. Case examples are provided throughout to illustrate the application and tailoring of skills. Finally, guidance is provided to support caregivers in implementing treatment skills with youth to support the generalization and sustainability of treatment gains.
In the 11th version of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), selective mutism (SM) is grouped under anxiety disorders based on empirical studies. This is based on recent findings on anxiety-related symptom clusters in SM since the classification in the ICD-10 and delineates the disorder from oppositional disorders. In this study, the diagnostic criteria and differential diagnostics as well as etiological and epidemiological data, and treatment options of SM are presented.
Selective mutism’s core symptom of a failure to speak in select situations that can persist for years causes marked impact on a child’s life and considerable concern for parents and schools. The disorder has had an interesting history, being viewed initially as an almost wilful act of defiance by the child to its current conceptualisation as a form of anxiety disorder with close ties to social anxiety disorder. In this chapter, the characteristics, features and classification of Selective Mutism as a form of anxiety are described, followed by a detailed exploration of factors that increase the risk for the disorder. The chapter then moves to issues of direct clinical relevance including coverage of relevant assessment measures and detailed discussion of strategies of relevance during clinical interview. Finally, empirically validated methods of its management are described, especially cognitive behavioural programs that focus around gradual, in vivo exposure. This includes a brief coverage of the evidence base along with a practitioner-informed description of key components of validated treatments and clinical indications of their application.KeywordsSelective mutismSocial anxietyBehavioural inhibitionCommunication continuumChildrenSchool
Background: The main characteristic of selective mutism (SM) is the failure to speak in specific social situations. Thus, assessing speech across social contexts is important for confirming a diagnosis of SM and for differentiating it from other disorders. The purpose of this review was to organize how the core symptom of SM, a lack of speech in specific social situations, has been assessed in previous studies.
Methods: A systematic search of articles was conducted in three databases, Web of Science, PsycINFO, and PubMed and reviews of surveys or experimental studies that reported empirical data on individuals with SM were performed. We excluded review, qualitative, epidemiological, and intervention studies. The study summarized the diagnostic criteria, methods of confirming SM diagnosis, distinction of SM from other disorders, and methods of speech assessment.
Results: A total of 447 articles were screened, where 60 articles were considered eligible. The results demonstrate that different interviews and questionnaires were used to establish the diagnosis of SM. However, the majority of interviews and questionnaires lacked validation. Only two (2/60) articles used validated methods of speech assessment to confirm SM diagnosis. Moreover, a consensus was lacking on the assessment method for differentiating SM from other disorders across studies. Specifically, 17 studies measured speech and are not intended for diagnosis. The majority of studies (16/17) used the questionnaire to assess the severity of the SM condition, and only one study conducted behavioral observation. Assessment methods based on the measurement of speech in real-life situations for individuals with SM were not established.
Conclusion: We have the limitation that we did not review intervention studies. However, this systematic review revealed the problem that speech assessment methods for surveys or experimental studies of SM were not established. Future studies should establish methods of speech assessment across social situations to assess SM symptoms.
Background: The main characteristic of selective mutism (SM) is the failure to speak in specific social situations. Thus, assessing speech across social contexts is important for confirming a diagnosis of SM and for differentiating it from other disorders. The purpose of this review was to organize how the core symptom of SM, a lack of speech in specific social situations, has been assessed in previous studies.
Methods: A systematic search of articles was conducted in three databases, Web of Science, PsycINFO, and PubMed and reviews of surveys or experimental studies that reported empirical data on individuals with SM were performed. We excluded review, qualitative, epidemiological, and intervention studies. The study summarized the diagnostic criteria, methods of confirming SM diagnosis, distinction of SM from other disorders, and methods of speech assessment.
Results: A total of 447 articles were screened, where 60 articles were considered eligible. The results demonstrate that different interviews and questionnaires were used to establish the diagnosis of SM. However, the majority of interviews and questionnaires lacked validation. Only two (2/60) articles used validated methods of speech assessment to confirm SM diagnosis. Moreover, a consensus was lacking on the assessment method for differentiating SM from other disorders across studies. Specifically, 17 studies measured speech and are not intended for diagnosis. The majority of studies (16/17) used the questionnaire to assess the severity of the SM condition, and only one study conducted behavioral observation. Assessment methods based on the measurement of speech in real-life situations for individuals with SM were not established.
Conclusion: We have the limitation that we did not review intervention studies. However, this systematic review revealed the problem that speech assessment methods for surveys or experimental studies of SM were not established. Future studies should establish methods of speech assessment across social situations to assess SM symptoms.
This article presents a case study on the treatment of Selective Mutism on a Spectrum Autistic boy. Autistic Spectrum Disorder is de?ned by impairments in communication and social interaction and by restricted and repetitive behaviors and interests that manifest in the childs daily life activities. Selective Mutism, on the other hand, is a social anxiety disorder that affects children mainly during schools entry point, is characterized by the persistent lack of speech and communication with some people, despite the fact that the child has preserved his verbal ?uency. The intervention was based on the theoretical presumptions of Cognitive-behavioral Therapy and has the particularity of having occurred during the Covid-19 pandemic and therefore, strategies adapted to an online format will be presented. The results showed that the adequacy of the techniques, the interdisciplinary work among the Psychiatrist, teachers, and the active participation of the family during treatment, were essential for the patients speech recovery. From communication with people in his family circle, the beginnings of speech in the school environment with friends and teachers, to the return of speech in other instances of the patients life interactions.
Selective mutism is a childhood psychiatric disorder that has been associated with adverse psychological, social and educational outcomes. Although evidence suggests that culturally and linguistically diverse children might be overrepresented among children with selective mutism, a direct examination of how migration or minority status are associated with the development and persistence of the disorder is still scarce. Guided by eco-cultural perspectives of development, the current review aims to provide an overview of selective mutism in culturally and linguistically diverse children. A systematic literature review of selective mutism studies that included a group of culturally and linguistically diverse children yielded eight studies that met our inclusion criteria. Although these studies support the view that bilingualism and minority status might be associated with selective mutism, the role of sociocultural factors in the development and persistence of the disorder remained mostly unexamined. The review concludes with a discussion of potential directions for future research, including examination of the cultural and psychological meanings of silence and talk, socialization goals, gender inequality, and parental acculturation strategies.
Background: The main characteristic of selective mutism (SM) is the failure to speak in specific social situations. Thus, assessing speech across social contexts is important for confirming a diagnosis of SM and for differentiating it from other disorders. The purpose of this review was to organize how the core symptom of SM, a lack of speech in specific social situations, has been assessed in previous studies.
Methods: A systematic search of articles was conducted in three databases, Web of Science, PsycINFO, and PubMed and reviews of surveys or experimental studies that reported empirical data on individuals with SM were performed. We excluded review, qualitative, epidemiological, and intervention studies. The study summarized the diagnostic criteria, methods of confirming SM diagnosis, distinction of SM from other disorders, and methods of speech assessment.
Results: A total of 447 articles were screened, where 60 articles were considered eligible. The results demonstrate that different interviews and questionnaires were used to establish the diagnosis of SM. However, the majority of interviews and questionnaires lacked validation. Only two (2/60) articles used validated methods of speech assessment to confirm SM diagnosis. Moreover, a consensus was lacking on the assessment method for differentiating SM from other disorders across studies. Specifically, 17 studies measured speech and are not intended for diagnosis. The majority of studies (16/17) used the questionnaire to assess the severity of the SM condition, and only one study conducted behavioral observation. Assessment methods based on the measurement of speech in real-life situations for individuals with SM were not established.
Conclusion: We have the limitation that we did not review intervention studies. However, this systematic review revealed the problem that speech assessment methods for surveys or experimental studies of SM were not established. Future studies should establish methods of speech assessment across social situations to assess SM symptoms.
Andy Millington looks at the underlying causes preventing some patients from speaking and addresses how best to manage them in eye care practice.
Exposure is the most important component of therapy for anxiety disorders and obsessive–compulsive disorder (OCD) in children and adolescents. Unfortunately, few clinicians offer this treatment, making it very difficult for youth and their families to seek effective care. In this installment of the Association for Behavioral and Cognitive Therapy’s Series on Implementation of Clinical Approaches, Whiteside, Ollendick, and Biggs deliver a succinct yet comprehensive guide to the use of exposure therapy with youth suffering from anxiety and OCD. Within the heart of this book, clinicians will discover a clear step-by-step model, illustrated with sample dialogue, for engaging their young patients in this most effective treatment. Detailed case examples bring to life the application of all forms of exposure (in vivo, imaginal, and interoceptive) to a wide range of anxiety and OCD presentations. Beyond teaching the mechanics for implementing exposure, the authors present a clinical model for understanding how exposure works, synthesizing the key issues from current competing theories. This model can enhance the ability of clinicians to apply exposure to new and more challenging presentations. In addition, the authors review common challenges to implementing exposure in real-world settings to assist clinicians in overcoming frequently encountered barriers. Clinicians can feel confident in the validity of the approach as the authors concisely review the foundation of history and research supporting exposure. Within this compact book, clinicians will find a comprehensive guide to build their expertise in the delivery of exposure therapy for children and adolescents suffering from anxiety disorders or OCD.
背景：場面緘黙の主要な特徴は特定の社会的状況における発話の欠如である。したがって，場面緘黙の診断確定，場面緘黙と他の障害との鑑別のため，異なる社会的状況での発話評価が重要である。しかしながら，場面緘黙児・者の発話評価手法は未だ確立されておらず，直接行動を観察する評価手法は少ない。さらに，異なる社会的状況における場面緘黙児・者の発話の評価方法について系統的なレビューを行った研究はこれまでにない。本システマティック・レビューの目的は，先行研究において，場面緘黙の主症状である特定の社会的状況における発話の欠如がどのように評価されてきたか，整理することだった。
方法：Web of Science，PsycINFO，PubMedの3つのデータベースを使用し，2020年1月28日に系統的検索を行った。場面緘黙児・者を対象とした実証データを報告した調査・実験研究をレビューの対象とした。展望論文，質的研究，疫学研究，介入研究は除外した。診断基準，場面緘黙診断確定手法，場面緘黙と他の障害との鑑別手法，発話評価手法について整理した。
結果：合計447編の研究についてスクリーニングを行い，採用基準に合致した研究は60編だった。場面緘黙診断を確定するため，様々な面接や質問紙が使用されていた。しかし，多くの面接や質問紙は妥当性が検証されていなかった。場面緘黙診断確定に関して妥当性検証済みの発話評価手法を用いた研究は2/60編のみだった。また，場面緘黙と他の障害を鑑別する評価手法は研究間で一致していなかった。17編の研究は，診断確定以外の目的で発話を測定していた。そのほとんどの研究（16/17編）で場面緘黙の重症度を評価するため，質問紙が使用されており，行動観察を行った研究は1編のみだった。実生活での発話測定に基づく場面緘黙児・者の評価手法は確立されていなかった。
結論：本研究は，介入研究をレビューしていないという限界がある。しかし，本研究によって，場面緘黙の調査・実験研究において発話評価手法が確立されていないという問題が明らかになった。今後の研究では，場面緘黙診断確定のため，また，場面緘黙と他の障害との鑑別のため，異なる社会的状況における発話評価手法を確立する必要がある。
Background
Randomized controlled psychosocial treatment studies on selective mutism (SM) are lacking. Method
Overall, 24 children with SM, aged 3–9 years, were randomized to 3 months treatment (n = 12) or wait list (n = 12). Primary outcome measure was the School Speech Questionnaire. ResultsA significant time by group interaction was found (p = .029) with significantly increased speech in the treatment group (p = .004) and no change in wait list controls (p = .936). A time by age interaction favoured younger children (p = .029). Clinical trail registration: Norwegian Research CouncilNCT01002196. Conclusions
The treatment significantly improved speech. Greater improvement in the younger age group highlights the importance of an early intervention.
Two efferent feedback pathways to the auditory periphery may play a role in monitoring self-vocalization: the middle-ear acoustic reflex (MEAR) and the medial olivocochlear bundle (MOCB) reflex. Since most studies regarding the role of auditory efferent activity during self-vocalization were conducted in animals, human data are scarce. The working premise of the current study was that selective mutism (SM), a rare psychiatric disorder characterized by consistent failure to speak in specific social situations despite the ability to speak normally in other situations, may serve as a human model for studying the potential involvement of auditory efferent activity during self-vocalization. For this purpose, auditory efferent function was assessed in a group of 31 children with SM and compared to that of a group of 31 normally developing control children (mean age 8.9 and 8.8 years, respectively). All children exhibited normal hearing thresholds and type A tympanograms. MEAR and MOCB functions were evaluated by means of acoustic reflex thresholds and decay functions and the suppression of transient-evoked otoacoustic emissions, respectively. Auditory afferent function was tested by means of auditory brainstem responses (ABR). Results indicated a significantly higher proportion of children with abnormal MEAR and MOCB function in the SM group (58.6 and 38%, respectively) compared to controls (9.7 and 8%, respectively). The prevalence of abnormal MEAR and/or MOCB function was significantly higher in the SM group (71%) compared to controls (16%). Intact afferent function manifested in normal absolute and interpeak latencies of ABR components in all children. The finding of aberrant efferent auditory function in a large proportion of children with SM provides further support for the notion that MEAR and MOCB may play a significant role in the process of self-vocalization. © 2013 S. Karger AG, Basel.
Examined the factor structure, internal reliabilities, and concurrent validity of a revised form of the Social Anxiety Scale for Children (SASC-R) with fourth through sixth graders (N = 587). Factor analysis on a subsample (n = 459) yielded three factors: Fear of Negative Evaluation From Peers, Social Avoidance and Distress Specific to New Situations, and Generalized Social Avoidance and Distress. Confirmatory factor analysis with another subsample (n = 128)revealed a good fit for the three-factor model of social anxiety. In addition, high-socially-anxious children perceived their social acceptance and global self-worth to be low. Neglected and rejected children reported more social anxiety than accepted classmates. The data support the reliability and validity of the SASC-R.
Selective mutism (SM) is a rare social anxiety disorder characterized by failure to speak in some situations despite normal verbal behavior in others. Previous work suggests a familial component for a predisposition to this disorder. The present article reviews the literature on twins with SM and examines the onset and progress of SM in a monozygotic female pair, age 5 years, 7 months. Information was gathered from parent and teacher interviews, birth records, direct observation, standard child assessment protocols and school performance reports. The variable symptom expression and severity in this concordant twin pair underline contributions from both genetic and environmental sources. Some unusual behavioral features observed in these twins, such as their popularity and non-verbal communication with classmates, underline the complexity of factors affecting the expression of SM. Pooling available data from affected monozygotic and dizygotic twins would advance understanding of the nature, course and management of this condition.
This study investigates the use of medications by child and adolescent psychiatrists for treating selective mutism. In 1993, a one-page survey was mailed to 962 child and adolescent psychiatrists selected at random from approximately 2500 active members of the American Academy of Child and Adolescent Psychiatry. Of the 962 questionnaires sent, 411 were returned (return rate 43%) and 308 were completed (sample participation rate 32%). A prevalence estimate of selective mutism within a clinical sample was calculated to be 1 case of selective mutism per 936 new patients (0.11%). Less than two-thirds (199/308) of the responding psychiatrists reported having treated a child with selective mutism in their practice. Of those who had treated a child with selective mutism, 36% (n = 71) reported having prescribed medication for this disorder. Antidepressants were the most frequently endorsed medication for being potentially beneficial in treating a hypothetical case example and, in addition, for being actually used by child psychiatrists in clinical practice for children diagnosed with selective mutism. Antianxiety agents were reported, at much lower rates, to be potentially useful in a hypothetical case and actually used in clinical practice for treating children with this disorder. These findings suggest that child psychiatrists may view selective mutism as being related to, having symptoms similar to, or often presenting comorbidly with depressive or anxiety disorders. However, a therapeutic program that includes pharmacotherapy was endorsed as the most effective treatment modality for selective mutism by only 14% of the reporting psychiatrists. Psychiatrists' impressions and observations cannot, even collectively, be used to make clinical inferences about the usefulness of treatments. This study did not examine treatment efficacy, since the outcomes of these open clinical trials were not judged by independent observers but were reported as observed and recollected by the clinicians involved. Moreover, these data on the treatment practices of sampled members of the American Academy of Child and Adolescent Psychiatry may not reflect the practices of other psychiatrists or pediatricians. The results indicate that child and adolescent psychiatrists are prescribing a variety of medications for selective mutism without the benefit of adequate efficacy studies. There is a significant need for further research and dissemination of information in this area.
Psychodynamic, family systems, behavioral, and psychopharmacological interventions of selective mutism are reviewed and discussed to examine effectiveness of treatment styles. Each modality has its own conceptualization of the disorder and specialized intervention techniques. While methodologies of the studies reviewed were often weak, there exist many treatment examples that illustrate effective interventions for selective mutism in childhood. The interventions that involved individualized or multimodal treatments produced the best overall results as evidenced through the symptom cessation. Many articles reported a close relationship between selective mutism and anxiety disorders. A clearer diagnostic understanding of selective mutism needs to be realized prior to generalizing a specific, effective treatment for this disorder. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study represents the first systematic analysis of the major treatment approaches used for selective mutism with the goal of drawing conclusions about selecting evidence-based procedures for practice. Based on nonparametric statistical tests of effect sizes, the major findings include the following: (a) treatment of selective mutism is more effective than no treatment, (b) behaviorally oriented treatment approaches are more effective than no treatment, and (c) no differential effectiveness was found between two common models of behavior therapy. In addition, researchers have given minimal attention to the impact of selective mutism on educational performance. In this study, which reviewed existing research, information regarding academic achievement was evaluated qualitatively. Recommendations are made for improving the methodological quality of future research on selective mutism within the context of research on evidence-based interventions. Implications for practice in school psychology are presented. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Examined the phenomenological characteristics of selective mutism (SM) in the following areas: (1) mute and variant talking patterns occurring prior to the identification of SM and/or that occur as conditions within SM, (2) events that precipitate SM, (3) biological vulnerabilities of SM in terms of anxiety and temperament, (4) characteristics associated with SM, (5) other problems experienced with SM, and (6) school and social competencies. Surveys were conducted with or for 153 people (aged 2–72 yrs) who had experience with SM. Results support the existence of variant talking behaviors (talking with less frequency, volume, and spontaneity than usual), in addition to mutism, prior to the identification of SM and as part of the SM syndrome. Setting (home, school, community) affected the rate of occurrence for mute and variant talking behaviors. Evidence supported a link between SM and social anxiety or phobia. Support was found for the idea that persons with SM have have characteristics similar to behaviorally inhibited or slow-to-warm children, suggesting a potential link between temperament and SM. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This article reviews the current state of evidence for the psychopharmacological treatment of children diagnosed with selective mutism within the context of its link to social anxiety disorder. An increased focus on potential medication treatment for this disorder has resulted from significant monetary and resource limitations in typical practice, parental choice in utilizing treatment from medical personnel, and children who fail to respond to psychosocial interventions. A total of 21 publications within the English literature were located. From these, data for only 57 children between the ages of 4 to 17 years have been reported, with the majority of studies utilizing single-case design or case study methodology. Yet, pharmacological data appear promising for treatment resistant cases of selective mutism. The need for additional research via efficacy/effectiveness methodologies remains. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Selective mutism (SM) is characterised by limited or a lack of speech in selected social settings. Recent reviews suggest that cognitive-behavioural therapy (CBT) is an effective and promising treatment approach for SM. However, there is still a lack of studies documenting the applicability of CBT for SM in diverse populations. The goal of the present study was to examine the use of a web-based CBT programme ('Meeky Mouse') among Singaporean children diagnosed with SM.
Five children with SM (one boy and four girls aged 6-11 years) participated in the 14-week 'Meeky Mouse' programme, in addition to being prescribed with an unchanged dosage of fluoxetine 10-20 mg daily. The progress made by the children throughout the course of the programme was documented by the therapist.
Post treatment, four out of the five children demonstrated improvements in the frequency of speech during therapy sessions at home, in school and at other social situations.
Findings from the present study provide support for the use of a web-based CBT programme in improving speech and decreasing the severity of SM among affected children.
In this paper, one of the most common disorders of childhood and adolescence, social anxiety disorder (SAD), is examined to illustrate the complex and delicate interplay between parent and child factors that can result in normal development gone awry. Our parent-child model of SAD posits a host of variables that converge to occasion the onset and maintenance of this disorder. Specifically, five risk factors--temperamental characteristics of the child, parental anxiety, attachment processes in the parent-child dyad, information processing biases, and parenting practices--will be highlighted. While it is acknowledged that other factors including genetic influences and peer relationships may also be important, they are simply not the focus of this paper. Within these constraints, the implications of our parent-child interaction model for prevention, treatment, research, and practice will be explored.
Reviews articles relating anxiety and verbal productivity. Studies are grouped into those in which anxiety is manipulated by varying environmental stress (situational anxiety), measured by choosing Ss differing in vulnerability to stress (dispositional anxiety), or by ongoing variations in speech disturbances or physiological indexes (concurrent anxiety). There is a strong tendency for verbal quantity to be positively related to dispositional and concurrent anxiety, but negatively related to situational anxiety. Silence tends to be related negatively to dispositional, but positively to situational and concurrent anxiety. These results, plus studies showing verbal quantity 1st rising and then falling as stress increases, appear to indicate a U-curve relationship between anxiety and verbal productivity. (61 ref.)
Speculation continues regarding the accurate classification of selective mutism and potential etiologic factors. Current research has shed some light on several factors that may predispose some children to this disorder, but conclusions are difficult to draw due to reliance on subjective measures, few comparison groups, and/or limited theoretical grounding. This article provides an update on recent efforts to elucidate the etiologic pathways of selective mutism and on the current debate regarding its strong overlap with anxiety disorders, most notably social phobia. An additional attempt is made to examine findings based on a developmental perspective that accounts for multiple pathways, context, and the developmental stage of the child. Emotion regulation theory is offered as a potential factor in why some children may be more vulnerable to the etiologic factors described. Suggestions for future research are offered based on this integration of information.
Written at a post-graduate level, this new volume provides a cumulative overview of the research available on the pathogenesis of fear and anxiety in youths. Its aim is to give the reader an idea of the factors that are thought to be involved in the development of abnormal fear and anxiety in children and adolescents, and to integrate this knowledge in a comprehensive model. This book also gives an update of the current scientific status on the psychological and pharmacological treatment and assessment of anxiety disorders in youths. *Reviews research literature on the cause of childhood anxiety, not only the existence and treatment *Discusses empirically supported intervention strategies *Includes questionnaires for measuring anxiety and related concepts that can be employed for research purposes *Anxiety disorders in children and adolescents is the author's primary area of research.
Written at a post-graduate level, this new volume provides a cumulative overview of the research available on the pathogenesis of fear and anxiety in youths. Its aim is to give the reader an idea of the factors that are thought to be involved in the development of abnormal fear and anxiety in children and adolescents, and to integrate this knowledge in a comprehensive model. This book also gives an update of the current scientific status on the psychological and pharmacological treatment and assessment of anxiety disorders in youths. *Reviews research literature on the cause of childhood anxiety, not only the existence and treatment *Discusses empirically supported intervention strategies *Includes questionnaires for measuring anxiety and related concepts that can be employed for research purposes *Anxiety disorders in children and adolescents is the author's primary area of research.
Selective mutism is a psychiatric disorder of childhood characterized by consistent inability to speak in specific situations despite the ability to speak normally in others. The objective of this study was to test whether reduced auditory efferent activity, which may have direct bearings on speaking behavior, is compromised in selectively mute children.Methods
Participants were 16 children with selective mutism and 16 normally developing control children matched for age and gender. All children were tested for pure-tone audiometry, speech reception thresholds, speech discrimination, middle-ear acoustic reflex thresholds and decay function, transient evoked otoacoustic emission, suppression of transient evoked otoacoustic emission, and auditory brainstem response.ResultsCompared with control children, selectively mute children displayed specific deficiencies in auditory efferent activity. These aberrations in efferent activity appear along with normal pure-tone and speech audiometry and normal brainstem transmission as indicated by auditory brainstem response latencies.Conclusions
The diminished auditory efferent activity detected in some children with SM may result in desensitization of their auditory pathways by self-vocalization and in reduced control of masking and distortion of incoming speech sounds. These children may gradually learn to restrict vocalization to the minimal amount possible in contexts that require complex auditory processing.
This paper reviews the behavioral treatment literature concerning elective mutism. Reluctant speech is differentiated from and compared to elective mutism. Twentynine studies were reviewed in terms of treatment strategy, experimental design and clinical outcome. It was concluded that behavioral interventions have advanced the area, but that more rigorous research using single-case methodology is now needed. In order to guide future research, a recommended teratment strategy was offered.
To evaluate the feasibility, acceptability, and preliminary efficacy of a novel behavioral intervention for reducing symptoms of selective mutism and increasing functional speech.
A total of 21 children ages 4 to 8 with primary selective mutism were randomized to 24 weeks of Integrated Behavior Therapy for Selective Mutism (IBTSM) or a 12-week Waitlist control. Clinical outcomes were assessed using blind independent evaluators, parent-, and teacher-report, and an objective behavioral measure. Treatment recipients completed a three-month follow-up to assess durability of treatment gains.
Data indicated increased functional speaking behavior post-treatment as rated by parents and teachers, with a high rate of treatment responders as rated by blind independent evaluators (75%). Conversely, children in the Waitlist comparison group did not experience significant improvements in speaking behaviors. Children who received IBTSM also demonstrated significant improvements in number of words spoken at school compared to baseline, however, significant group differences did not emerge. Treatment recipients also experienced significant reductions in social anxiety per parent, but not teacher, report. Clinical gains were maintained over 3 month follow-up.
IBTSM appears to be a promising new intervention that is efficacious in increasing functional speaking behaviors, feasible, and acceptable to parents and teachers.
The behavior of 21-month-old children was observed in the laboratory on 2 occasions in a series of situations designed to identify individual differences in behavioral inhibition to the unfamiliar. Additionally, heart rate and respiration in response to information varying in familiarity were quantified in a different laboratory. The tendency to be consistently inhibited or uninhibited in behavior was stable across the 2 sessions, and extremely inhibited children had significantly higher heart rates to all information and less variable heart rates to the less familiar information. A follow-up study 10 months later revealed moderate stability of the behavioral tendency toward inhibition versus lack of inhibition. Parental report data on the inhibition dimension were moderately correlated with the behavioral observations.
To examine the relationship between the syndromes of elective mutism and social phobia, a case of elective mutism associated with social phobia in a 12-year-old girl is presented, and the clinical literature regarding the syndrome of elective mutism is reviewed. Elective mutism or reluctance to speak in unfamiliar social situations may be a symptom of social phobia. Social anxiety is a nearly universal characteristic of children manifesting the syndrome of elective mutism. Elective mutism may respond to treatment with medications that also are effective in the treatment of social phobia. Elective mutism may be a manifestation of social phobia rather than a separate diagnostic syndrome. Pharmacologic treatment may be effective.
Background:
Elucidating differences in social-behavioral profiles of children with comorbid presentations, utilizing caregiver as well as teacher reports, will refine our understanding of how contextual symptoms vary across anxiety-related disorders.
Methods:
In our pediatric anxiety clinic, the most frequent diagnoses and comorbidities were mixed anxiety (MA; ≥ 1 anxiety disorder; N = 155), anxiety with comorbid attention-deficit hyperactivity disorder (MA/ADHD, N = 47) and selective mutism (SM, N = 48). Behavioral measures (CPRS, CTRS) were analyzed using multiple one-way multivariate analyses of covariance tests. Differences between the three diagnostic groups were examined using completed parent and teacher reports (N = 135, 46, and 48 for MA, MA/ADHD, and SM groups, respectively).
Results:
Comparisons across the MA, MA/ADHD, and SM groups indicate a significant multivariate main effect of group for caregiver and teacher responses (P < 0.01). Caregivers reported that children with SM are similar in profile to those with MA, and both groups were significantly different from the MA/ADHD group. Teachers reported that children with SM had more problems with social behaviors than with the MA or MA/ADHD groups. Further comparison indicates a significant main effect of group (P < 0.001), such that children with SM have the greatest differences in behavior observed by teachers versus caregivers.
Conclusions:
Clinical profiles between MA/ADHD, MA, and SM groups varied, illustrating the importance of multi-rater assessment scales to capture subtle distinctions and to inform treatment planning given that comorbidities occur frequently in children who present with anxiety.
The aim of this book is to achieve a high level of synthesis regarding learning theory and behavior. The author attempts to do so by examining both research and conjecture in a broadly historical context, in addition to presenting new experimental findings not available to earlier system makers and theorists. In this way, it is believed, empirical facts and divergent theories become maximally meaningful and most significantly related. The book begins with an introductory chapter that presents a historical review and perspective of the field of learning theory. Chapter 2 examines the law of effect, conditioning, and punishment. Chapter 3 discusses two versions of two-factor learning theory. In the fourth chapter, two conceptions of secondary reinforcement are presented. Chapters 5 and 6 continue the examination of secondary reinforcement with discussions of a unifying theory and reservations and complications. The topics of Chapter 7 are a revised two-factor theory and the concept of habit, followed by Chapter 8 which comparatively examines other theories and some further evidence. Hope, fear, and field theory are the focus of Chapter 9, and Chapter 10 focuses on reinforcement gradients and temporal integration. The book closes with two chapters on unlearning, conflict, frustration, courage, generalization, discrimination, and skill. The basic argument proposed by the author is epitomized in Chapter 7. Earlier chapters provide the logical and factual background from which this argument evolves; and the five subsequent chapters amplify and apply the argument in more specific ways. Thus, the reader who wishes a quick "look" at this volume as a whole may first read the chapter indicated; but the argument will unfold most naturally and persuasively if the chapters are read in the order in which they appear. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Presents a further report from the authors' New York Longitudinal Study of childhood personality and temperament development. Nine basic temperament variables are identified, short questionnaires on temperament for parents of infants and parents and teachers of children aged 3–7 yrs are provided, and 3 basic temperamental patterns are described. Results of the study which support the hypothesis that children with certain temperamental attributes are more at risk for behavioral and developmental disorders are also examined. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The aim of this study is to describe sociodemographic and clinical aspects of a large treated group of children referred with elective mutism. This case-control study includes 37 children, all of whom fulfilled ICD-10 criteria for elective mutism (EM) and a comparison group of 37 children, who were referred to the same hospital. The study is a retrospective sociodemographic and clinical analysis of records of patients with EM. In the group of EM children there was a slight preponderance of boys. The children came from two-parent families, most from the lower social classes. Almost 50% of the children had speech difficulties, and in addition to this enuresis, encopresis, and eating disturbances were more frequent than in the comparison group. With regard to other comorbid symptoms the EM children did not differ from the comparison group. A traumatic experience during the development of speech, severe enough to be noted in the case-record, was present in more than one-third of the files. In most of the parents of EM children similar symptoms, such as shyness and speech difficulties in social situations, were observed, and in one-third mental illness was present (depression being the most frequent). More often than not the condition had an insidious onset, being present several years before referral. In most cases the referral was made by a school psychologist, significantly more than in the group of comparison patients (P<0.001). More comparison patients than patients with EM came from a middle-class background (P<0.001), and fewer came from a broken home (P<0.05).
Behavioral inhibition (BI) has been associated with increased risk for developing social anxiety disorder (SAD); however, the degree of risk associated with BI has yet to be systematically examined and quantified. The goal of the present study was to quantify the association between childhood BI and risk for developing SAD.
A comprehensive literature search was conducted to identify studies that assessed both BI and SAD. Meta-analyses were performed to estimate the odds ratio (OR) of the association between BI and SAD in children.
Seven studies met inclusion criteria. BI was associated with a greater than sevenfold increase in risk for developing SAD (odds ratio = 7.59, p < .00002). This association remained significant even after considering study differences in temperament assessment, control group, parental risk, age at temperament assessment, and age at anxiety diagnosis.
Identifying early developmental risk factors is critical for preventing psychiatric illness. Given that 15% of all children show extreme BI, and that almost half of these inhibited children will eventually develop SAD, we propose that BI is one of the largest single risk factors for developing SAD.
Seven-year-olds to 15-year-olds in 2 school districts of Göteborg, Sweden, were screened for selective mutism by their teachers and follow-up was achieved for a full school year. Three girls and 2 boys met DSM-IV criteria for selective mutism and a further 25 had a combination of shyness and reticence that did not amount to clinical disorder. The rate of typical selective mutism was 18 in 10,000 children. Shyness/reticence occurred in 89 in 10,000 children. Selective mutism was more common than suggested by earlier studies. Teachers of school age children need to be better informed about its existence.
We examined receptive language and academic abilities in children with selective mutism (SM; n = 30; M age = 8.8 years), anxiety disorders (n = 46; M age = 9.3 years), and community controls (n = 27; M age = 7.8 years). Receptive language and academic abilities were assessed using standardized tests completed in the laboratory. We found a significant group by sex interaction for receptive vocabulary scores such that, within females, the SM and mixed anxiety groups had significantly lower receptive vocabulary scores than community controls. We also found that children with SM and children with anxiety disorders had significantly lower mathematics scores than community controls. Despite these differences in mathematics and receptive vocabulary performance, children with SM and children with anxiety disorders still performed at age-level norms, while more children in the community control group performed above age-level norms. Findings suggest that despite their speaking inhibition in the school setting, children with SM are still able to attain the receptive vocabulary and academic abilities that are expected at their age levels. Copyright © 2009 John Wiley & Sons, Ltd.
An identification and treatment model differentiating Transient from Persistent Selective Mutism is proposed. The model incorporates treatment recommendations for Persistent Selective Mutism and suggests that interventions are not usually warranted for Transient Selective Mutism. The case study of a 6-year-old female manifesting Persistent Selective Mutism is presented. A multimodal treatment approach combining behavioral techniques with play therapy and family involvement was applied to improve her verbal interactions. Pre- and posttreatment evaluations were conducted. During pretreatment evaluations the child was manifesting Persistent Selective Mutism, immaturity, and withdrawal behaviors. At posttreatment evaluations she was talking in a manner consistent with her peers without problematic behaviors displayed. Results of a 6-month follow-up completed after the child had entered first grade showed that she was continuing to speak in a manner consistent with her peers without behavioral concerns.
Social phobia (SOP) and selective mutism (SM) are related anxiety disorders characterized by distress and dysfunction in social situations. SOP typically onsets in adolescence and affects about 8% of the general population, whereas SM onsets before age 5 and is prevalent in up to 2% of youth. Prognosis includes a chronic course that confers risk for other disorders or ongoing social disability, but more favorable outcomes may be associated with young age and low symptom severity. SOP treatments are relatively more established, whereas dissemination of promising and innovative SM-treatment strategies is needed.
Background:
Selective mutism (SM) is now widely seen as a symptom of social anxiety. However, observations of children's interactions in the natural contexts of home and school/kindergarten suggest that this may be in need of review.
Method:
Data were available from two sources: first, interviews with six adults who had recovered from SM in childhood and adolescence; second, informal observations of five SM children in home and school/kindergarten, and semi-structured interviews with their parents and teachers. The research had three stages: (i) Data were examined for the presence of social anxiety and/or determined or stubborn behaviour, but neither provided a satisfactory explanation for the SM. (ii) The data suggested that SM could be reconceptualised as a specific phobia of their own speech. It is argued that if this is the case, SM should respond to intervention at school based broadly on a cognitive behaviour therapy methodology. (iii) A post hoc examination of observation and interview transcripts was used to test this hypothesis.
Results:
(i) Apart from two adults, no evidence was found of social anxiety. Determined and stubborn behaviour was observed but was inadequate as an explanation of SM. (ii) Two children recovered when exposed to classroom interactions that could be seen as consistent with the principles of graded in vivo flooding. Three children who were not exposed to similar interactions did not improve.
Conclusions:
SM may be understood and treated successfully at school/kindergarten as a specific phobia of expressive speech.
This study investigated the relationship between selective mutism (SM), social phobia (SP), oppositionality, and parenting styles. Twenty-one children with SP, 21 children with SM and SP, and 21 normal children ages 7–15, and the mother of each child, participated in an assessment of psychopathological factors potentially related to SM. Children with SM did not endorse higher levels of social anxiety than did children with SP, although clinicians gave higher severity ratings to those who had both disorders. In addition, although a dimensional measure of oppositionality (Eyberg Child Behavior Inventory) did not reveal group differences, there were significantly more diagnoses of oppositional defiant disorder among children with SM (29%) in comparison to children with SP alone (5%). With respect to parenting styles, there were no significant differences among parents of children with SM and the other groups, except that children with SP reported significantly less warmth/acceptance from parents than normal children. These data replicate previous findings that children with SM do not report greater social anxiety than other children with a SP diagnosis. Furthermore, they suggest that oppositional behaviors may be part of the clinical presentation of a subset of children with SM. Depression and Anxiety 23:117–123, 2006. © 2006 Wiley-Liss, Inc.
Fifteen children with selective mutism (SM), 15 children with anxiety disorders (AD) without selective mutism, and 15 children without anxiety disorders or selective mutism (CN) were compared to examine the relationship between selective mutism and anxiety. Data were collected from children (age 4–10 years), parents, teachers, and clinicians. Results indicated that children with SM closely resemble children with AD. All children with SM received a diagnosis of social anxiety disorder and 53% received a diagnosis for an additional anxiety disorder. In addition, the SM and AD groups differed substantially from controls with respect to parent- and teacher-rated internalizing behavior problems. No differences among the groups were found with respect to parent-and teacher-reported externalizing behavior problems. The results are consistent with prior research emphasizing the association between selective mutism and anxiety disorders, and suggest that selective mutism may be conceptualized, assessed, and treated as an anxiety-related problem.
This paper explores selective mutism as a complex anxiety disorder best treated using a multi-modal approach. A case of a young girl is presented to illustrate how selective mutism may be an attempt to regulate anxiety and other emotions. The author demonstrates the use of multiple treatment approaches (e.g., behavioral, cognitive-behavioral, modern psychoanalytic) used in conjunction as a means to overcome the selective mutism and to develop the ability to self-regulate a variety emotions and behaviors.
Although children with social phobia (SP) and selective mutism (SM) present similarly in a clinical setting, it remains unclear whether children with SM are unable to speak due to overwhelming anxiety, or whether withholding speech functions as an avoidance mechanism. A total of 35 children (ages 5-12 years) with either SM (n = 10), SP (n = 11), or no diagnosis (n = 14) participated in the current study. Measurements included clinician, child, and parent ratings as well as behavioral observations and psychophysiological measures. Independent evaluators and clinicians rated children with SM as more severely impaired, more anxious, and less socially effective, but the groups did not differ in self- or parent-reported anxiety. Psychophysiological measures indicated that children in the SM group experienced less arousal than other children during social interaction tasks. The authors postulate that lack of speech may serve as an avoidance mechanism and thus account for this lack of arousal.
Selective mutism (SM) is a rare childhood disorder characterized by a lack of speech in one or more settings in which speaking is socially expected. A comprehensive and uniform theory about the etiology, assessment, and treatment of SM does not exist. Historically, varying definitions and criteria have been applied to children with SM, therefore making comparisons between studies somewhat difficult. Accumulating findings on the phenomenology of SM point to a complex and multidetermined etiology. Developmental psychopathology represents a useful heuristic for conceptualization of SM and serves as an integrative framework for organizing the sometimes disparate findings that permeate the SM literature. The purpose of this review is to summarize the literature on SM, including phenomenology, assessment, and treatment, with the main goals of clarifying its clinical presentation, offering a theoretical understanding of SM from a developmental psychopathology perspective, and highlighting both research and practice gaps that may exist. Recommendations for future research are made with the goal of expanding the current knowledge base on the etiology of SM.
The prevalence of co-occurring anxiety and externalizing (i.e., attention deficithyperactivity, oppositional, and conduct disorders) conditions is examined in both epidemiological and clinic-referred studies among child and adolescent samples. In the context of comorbid anxious and externalizing conditions, issues of age, gender, and familial differences are explored. Literature that describes the associated characteristics of children diagnosed with comorbid anxiety and attention deficit disorders is reviewed, followed by a similar review of the literature with respect to comorbid anxiety and conduct disorders of childhood. Validation issues and suggestions for improvements to future research on comorbid childhood anxiety and externalizing disorders are discussed.
The current study compared ethnic minority and European American clinically-referred anxious youth (N=686; 2-19 years) on internalizing symptoms (i.e., primary anxiety and comorbid depression) and neighborhood context. Data were provided from multiple informants including youth, parents, and teachers. Internalizing symptoms were measured by the Multidimensional Anxiety Scale for Children, Child Depression Inventory, Child Behavior Checklist and Teacher Report Form. Diagnoses were based on the Anxiety Disorders Interview Schedule for Children. Neighborhood context was measured using Census tract data (i.e., owner-occupied housing, education level, poverty level, and median home value). Ethnic minority and European American youth showed differential patterns of diagnosis and severity of anxiety disorders. Further, ethnic minority youth lived in more disadvantaged neighborhoods. Ethnicity and neighborhood context appear to have an additive influence on internalizing symptoms in clinically-referred anxious youth. Implications for evidence-based treatments are discussed.
Introduction:
Anxiety disorders represent one of the most prevalent forms of psychopathology among children and adolescents. As these problems tend to persist and have a negative impact on young people's development, there is a need for evidence-based interventions. Cognitive-behavioral therapy (CBT) is at present the treatment of first choice, but pharmacotherapy and in particular antidepressant medication may be a viable alternative or adjunct to CBT.
Areas covered:
This paper provides a detailed overview of controlled treatment outcome studies on the efficacy of tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) in children and adolescents with anxiety disorders. Further, a discussion is provided on how clinically anxious youths should be preferably treated, with special focus on the position of pharmacotherapy in the treatment process.
Expert opinion:
The short-term efficacy of antidepressants in anxious youths is good, and this is particularly true for SSRIs. Therefore, this type of medication should be viewed as a viable treatment option, in particular for youths with obsessive-compulsive disorder (OCD) or other severe and pervasive anxiety disorders. More research is needed on the long-term effects, the consequences of prolonged use of this type of medication for children's developing brains and the efficacy of an intervention in which CBT and SSRIs are combined.