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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.
... 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.
... Situations typically associated with the inability to speak include, for example, unfamiliar places or the presence of strangers (Schwenck et al., 2021). The disorder typically occurs between 2 and 5 of age (Muris & Ollendick, 2015;Remschmidt et al., 2001;Steinhausen et al., 2006), severely interferes with everyday life functioning (Milic et al., 2020;Schwartz et al., 2006) and is associated with mental and communicative problems in adulthood (Remschmidt et al., 2001;Steinhausen et al., 2006Steinhausen et al., ). et al., 2006. ...
... et al., 2006. Despite the central importance of social anxiety for both SAD and SM (Gensthaler et al., 2016b;Muris & Ollendick, 2015;Schwenck et al., 2019;Vogel et al., 2019), it remains largely unclear why children with SM are unable to speak in certain social situations, whereas children with SAD do not. In this regard, evidence indicates that SM is associated with a more extreme fear in speech-demanding social situations than SAD and affected children are unable to speak because they are overwhelmed by their anxiety (Black & Uhde, 1995;Muris & Ollendick, 2015). ...
... Despite the central importance of social anxiety for both SAD and SM (Gensthaler et al., 2016b;Muris & Ollendick, 2015;Schwenck et al., 2019;Vogel et al., 2019), it remains largely unclear why children with SM are unable to speak in certain social situations, whereas children with SAD do not. In this regard, evidence indicates that SM is associated with a more extreme fear in speech-demanding social situations than SAD and affected children are unable to speak because they are overwhelmed by their anxiety (Black & Uhde, 1995;Muris & Ollendick, 2015). This is also supported by findings that show that children with SM are evaluated by teachers and clinicians to be more anxious than children with SAD in speech-demanding social situations, but not in nonverbal social situations (Poole et al., 2020;Yeganeh et al., 2003;Young et al., 2012). ...
Background
Children with selective mutism (SM) are consistently unable to speak in certain social situations. Due to an overlap between SM and social anxiety disorder (SAD) in children, similar mechanisms could apply to both disorders. Especially biased attentional processing of threat and fear-induced reduced visual exploration (referred to as attentive freezing) appear promising in SM.
Methods
A total of N = 84 children (8–12 years, SM: n = 28, SAD: n = 28, typical development (TD): n = 28) participated in an eye-tracking paradigm with videos of a social counterpart expressing a question, a social evaluation or a neutral statement. We investigated gaze behavior towards the social counterpart’s eye-region and the extent of visual exploration (length of scanpath), across conditions.
Results
There were no group differences regarding gaze behavior on the eye region. Neither gaze behavior with respect to the eye region nor visual exploration were dependent on the video condition. Compared to children with TD, children with SM generally showed less visual exploration, however children with SAD did not.
Conclusion
Reduced visual exploration might be due to the mechanism of attentive freezing, which could be part of an extensive fear response in SM that might also affect speech-production. Interventions that counteract the state of freezing could be promising for the therapy of SM.
... The disorder is associated with a chronic course of increased psychopathological symptoms persisting into adulthood and resulting in impairments in academic and socio-emotional development [2][3][4]. Previous research suggests a prevalence of approximately 1% [5], although the occurrence of SM is probably underestimated [6]. With the introduction of the DSM-5 [1], SM was classified among anxiety disorders for the first time. ...
... With the introduction of the DSM-5 [1], SM was classified among anxiety disorders for the first time. The reason for this was evidence that SM shares numerous similarities with other anxiety disorders, particularly social anxiety disorder (SAD) [5]. SAD is characterized by a marked fear of being evaluated by others in social situations as well as physiological symptoms [1]. ...
... In this respect, it is questionable whether the findings of Heilman et al. [26] indicate a chronically increased arousal in children with SM or are a consequence of the factors inducing symptoms in SM. Complementary to the assumption that SM is associated with extreme fear, it has been proposed that failure to speak is an avoidance mechanism [5,12,14,37]. Here, the assumption is that the intense fear experienced by children with SM during a verbal social situation is reduced by the failure to speak [14]. ...
Background
Selective mutism (SM) has been conceptualized as an extreme variant of social anxiety disorder (SAD), in which the failure to speak functions as an avoidance mechanism leading to a reduction of intense fear arousal. However, psychophysiological studies in children with SM are scarce and physiological mechanisms underlying the failure to speak are largely unknown. In contrast, children with SAD are characterized by a combination of a chronically elevated physiological arousal and a blunted physiological fear response to social stress. Due to the large overlap between SM and SAD, similar mechanisms might apply to both disorders, while differences might explain why children with SM fail to speak. The aim of our study is to investigate psychophysiological mechanisms of the failure to speak in children with SM.
Methods
We assessed in a total of N = 96 children [8–12 years, SM: n = 31, SAD: n = 32, typical development (TD): n = 33] resting baseline arousal in absence of social threat and the course of physiological fear response in two social stress paradigms, differing in terms of whether the children are expected to speak (verbal task) or not (nonverbal task).
Results
Children with SM were characterized by increased tonic arousal compared to the other two groups, and by a more inflexible stress response in the nonverbal but not in the verbal task compared to TD-children. Further analyses revealed that children with SM who did not speak during the verbal task already demonstrated reduced arousal in anticipation of the verbal task.
Conclusion
The increased tonic arousal generalized to non-social situations in SM could indicate a long-term alteration of the autonomic nervous system. Furthermore, the differential physiological stress response may indicate that silence acts as a maladaptive compensatory mechanism reducing stress in verbal social situations, which does not function in nonverbal situations. Our findings support the idea that the failure to speak might function as an avoidance mechanism, which is already active in anticipation of a verbal situation. Treatment of SM should take into account that children with SM may suffer from chronically elevated stress levels and that different mechanisms might operate in verbal and nonverbal social situations.
... The disorder usually begins in transitional situations from parental home to kindergarten and elementary school (Muris and Ollendick 2021). According to epidemiological studies, SM is a relatively rare disorder with a prevalence rate of around 1% (Muris and Ollendick 2015). ...
... Several studies have found evidence for an association between SM and clinically significant social anxiety as well as other anxiety disorders (Muris and Ollendick 2015;Vogel et al. 2019;Schwenck et al. 2019). Accordingly, in DSM-5 (American Psychiatric Association 2013) SM is classified as an anxiety disorder. ...
... Cohan et al. (2006) assume that a child experiencing high levels of anxiety is particularly sensitive to verbal interactions. Muris and Ollendick (2015) concluded in their review about the relationship between SM and anxiety that both disorders tend to overlap in terms of aetiology, symptomatology, and treatment approaches. ...
The study presented in the following verifies some assumptions of the novel ‘unsafe world’ model of selective mutism (SM). According to this model, SM is a stress reaction to situations erroneously experienced via cognition without awareness as ‘unsafe’. It assumes a high sensitivity to unsafety, whereby the nervous system triggers dissociation or freeze mode at relatively low thresholds. We examine whether there is a correlation between SM, sensory-processing sensitivity and dissociation. We compared a sample of 28 children and adolescents with SM (mean age 12.66 years; 18 females) to 33 controls without SM (mean age 12.45 years; 21 females). Both groups were compared using a medical history sheet, the ‘Selective Mutism Questionnaire’ (SMQ), a ‘Checklist for Speaking Behaviour’ (CheckS), the ‘Highly Sensitive Person Scale’ (HSPS), the ‘Child Dissociative Checklist’ (CDC), the ‘Adolescent Dissociative Experience Scale’ (A-DES) and the ‘Social Phobia and Anxiety Inventory for Children’ (SPAIK). Appropriate parametric and non-parametric tests were conducted to examine differences between groups. The results indicate that sensory-processing sensitivity was significantly higher in the group of children and adolescents with SM [ X ² (1) = 7.224, p = 0.0007; d = 1.092]. Furthermore, dissociative symptoms were more common in children and adolescents with SM than in controls [ F (1, 33) = 13.004, p = 0.001; d = 0.986]. The results indicate that sensory-processing sensitivity and dissociation are important factors of SM that may hold important implications for the treatment.
Trial Registration
This study is registered with the ClinicalTrials.gov number NCT04233905.
... Er geht überwiegend mit anderen Störungen einher. Am häufigsten sind andere Angststörungen (Muris & Ollendick, 2015), insbesondere soziale Angst bei bis zu 70 % und Trennungsangst bei bis zu 30 % der Betroffenen ebenso wie generalisierte Angststörung und spezifische Phobien, die sich bei etwa 10 % beobachten lassen (Kristensen, 2000). Weitere häufig genannte komorbide Störungen sind Depressionen, Enuresis und Enkopresis, Schlafstörungen, oppositionell-aggressive Verhaltensweisen, Essstörungen, Hyperaktivität, Tics und Zwänge (Steinhausen & Juzi, 1996) sowie Autistische-Spektrums-Störungen (Steffenburg, Steffenburg, Gilberg, & Billstedt, 2018). ...
... Zur Behandlung des selektiven Mutismus liegen einige Überblicksartikel vor (Anstendig, 1999;Cohan et al., 2006a;Isensee et al., 1997;Melfsen & Walitza, 2017a;Muris & Ollendick, 2015;Zakszeski & DuPaul, 2016). Obwohl der Störungsbeginn bei einem großen Anteil der Kinder mit selektivem Mutismus im Alter von vier bis fünf Jahren liegt (Dummit et al., 1997), wird ein durchschnittlicher Therapiebeginn erst mit acht Jahren angegeben (Remschmidt et al., 2001). ...
... Es fehlt an aussagekräftigen kontrollierten und randomisierten Behandlungsstudien, in denen die Therapieschritte ausreichend beschrieben sowie valide und reliable Ergebnismaße eingesetzt werden. Die untersuchte Altersgruppe ist sehr schmal und die Behandlungsdauer variiert stark (Cohan et al., 2006a;Muris & Ollendick, 2015). ...
... The causes of selective mutism are still not well known. In recent years many authors emphasize the multifactorial etiology of this disorder and the role of a vulnerability-stress model [10]. In the clinical approach, there must be mentioned the role of inheritance (inborn vulnerability), factors that trigger and sustain this disorder. ...
... This fact shows a great importance of the family background for the appearance and maintenance of this disorder [11]. The next factor that increases the person's vulnerability to suffer from selective mutism is temperament [10] and behavioral inhibition, described as anxiety reactivity to new stimuli. ...
... The most obvious and often proposed explanation of subtle or more visible deficits in the mutism etiology is avoidance [10]. A child starts to avoid speaking, because is not able to keep up with the environment's demands (for example parents, teachers). ...
Przedstawiony artykuł ma dwa główne cele. Po pierwsze, prezentację aktualnego sposobu rozumienia mutyzmu wybiórczego (selective mutism, SM), po drugie — opis przeprowadzonej terapii pacjentki w oparciu o model poznawczo-behawioralny. Głównym objawem SM jest wybiórczość mówienia, która dotyczy niektórych środowisk lub osób. W ostatnich latach zmieniał się sposób klasyfikowania i leczenia mutyzmu wybiórczego. Co więcej, badacze zajmujący się SM nadal nie opracowali spójnego modelu rozwoju i utrzymywania się tego zaburzenia. W najnowszej klasyfikacji DSM-5 mutyzm wybiórczy został przeniesiony z kategorii ,,zaburzeń okresu dzieciństwa i adolescencji” do podrozdziału ,,zaburzeń lękowych”. Wprowadzona zmiana miała głównie na celu zaakcentowanie wiodącej roli lęku w powstawaniu i utrzymywaniu się SM. Terapia poznawczo-behawioralna mutyzmu jest uznawana jako leczenie z wyboru i w dużym stopniu wiąże się z wykształceniem u dziecka umiejętności reagowania mniejszym lękiem w sytuacji komunikacji. Z uwagi na małą liczbę badań tego zaburzenia, modele terapii oparte na opisach przypadków oraz znaczną różnorodność obrazu klinicznego psychoterapeuta musi dopasowywać standardowy model terapii poznawczo-behawioralnej do konkretnego pacjenta. Jak wspomniano, większość prowadzonych badań opiera się głównie na opisach przypadków. Zauważa się zatem ogromną potrzebę prowadzenia badań na szerszą skalę, jak i sprawdzania skuteczności prowadzonej psychoterapii. Aktualnie dostęp do wykwalikowanych terapeutów jest bardzo ograniczony, a niska świadomość konieczności udzielenia pomocy (szczególnie dzieciom) wymaga zdecydowanej zmiany.
... 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.
... Various factors have been associated with the etiology of SM, including genetics, as well as temperamental, environmental and neurodevelopmental factors (Muris & Ollendick, 2015). The most prominent factor is anxiety. ...
... The majority of children (76%) were rated by the clinicians as treatment responders, and according to parental reports, there was a significant improvement in SM symptoms following treatment while no significant change was observed from baseline to treatment beginning. These findings support and match those of Bergman et al. (2013), who found that the IBTSM is efficacious in increasing functional speaking behavior in children with SM and add to growing evidence that behavioral, exposure-based treatments for children with SM are feasible and effective (Muris & Ollendick, 2015). ...
To test the hypothesis that the Integrated Behavior Therapy for Children with Selective Mutism (IBTSM), administered in a naturalistic setting, is (a) a feasible and acceptable treatment, (b) effective in reducing children’s selective mutism (SM) and social anxiety (SA) symptoms, and (c) effective in reducing parents’ accommodation behaviors to their children’s anxiety. This was an open, uncontrolled trial with assessments at baseline, first session, and post-treatment. The study treated 30 children aged 4–13, using the IBTSM protocol. The diagnosis of SM was established by psychologists using a structured interview. The parents reported levels of SM, SA, and parental accommodation on questionnaires, and the level of children’s global functioning was rated by clinicians. Feasibility and acceptability of the IBTSM were assessed using dropout rates, protocol adherence, adverse events, and therapist’s acceptability ratings. The IBTSM had acceptable dropout rates, with no adverse events and high acceptability rates. Following IBTSM, children’s SM and SA levels, and parents’ accommodation, significantly decreased. 75% of children were rated by clinicians as treatment responders. IBTSM is a feasible, acceptable, and efficacious treatment for children with SM, utilized in clinical settings. The results of this open trial must be replicated in randomized controlled studies.
... Anxiety disorders, as a whole, pose a significant mental health burden if left untreated. SM itself represents a less prevalent disorder requiring further investigation of treatment approaches (Muris & Ollendick, 2015). In recent years however, behavior-focused interventions have emerged as an effective option for treating SM, allowing clinicians to begin exploring optimal methods for care delivery. ...
... Treatment focuses on exposure to avoided situations -in this case, speaking in a range of settings (Christon et al., 2012;Fisak et al., 2006). This involves the use of graded exposure, in conjunction with other behavioral techniques such as contingency management, stimulus fading, and shaping, to develop new patterns based on positive reinforcement (Keeton & Budinger, 2012;Muris & Ollendick, 2015). Behavioral approaches not only address the presenting concerns of SM, but also circumvent problems that may arise through use of cognitive approaches, which require engagement in reciprocal conversation . ...
Recent selective mutism (SM) treatment approaches focusing on the delivery of interventions using intensive doses of cognitive behavioral therapy (CBT) and Parent-Child Interaction Therapy (PCIT-SM). In the current study, we sought to examine the effectiveness of an eight-session weekly outpatient group program for youth ages 3 to 14 diagnosed with SM. Group interventions included caregiver coaching and support for CBT skills, particularly graded speaking exposures for youth using the PCIT-SM framework. A total of 112 youth (Mage = 7.26; 57.1% white; 63.4% girls) were referred for treatment; 100 youth completed the weekly program with at least one caregiver. Initial evaluations assessed SM symptomology, communication behavior, anxiety, and impairment due to symptoms at pre-treatment and post-treatment. Parents and clinicians tracked communication behaviors during all treatment sessions. Results suggested a significant reduction in SM symptoms in various settings (e.g., school, social) and impairment associated with anxiety from pre- to post-treatment. Youth demonstrated a significant increase in speaking behaviors across treatment session, with a corresponding decrease in use of nonverbal communication behaviors. Caregivers did not report a significant change in family impairment, though this was not unexpected due to the demands placed on caregivers as part of treatment. Overall, the results of this study support the efficacy of a brief, weekly intervention for SM, even when symptoms are significantly impairing. Weekly outpatient treatment should be considered a viable option when intensive options are not feasible.
... Its prevalence is generally found to be about 1% of the general population (Bergman et al., 2002;Viana et al., 2009). The typical age of onset of SM ranges from two to five years of age, with a majority of referrals occurring during the first years of school given the increased pressure to speak (Muris & Ollendick, 2015;Viana et al., 2009). ...
... A growing body of evidence suggests that SM and various anxiety disorders, particularly social anxiety, are closely related (Driessen et al., 2020;Muris & Ollendick, 2015;Vogel et al., 2019). Hence, treating anxiety in order to improve speech appears to be an aetiologically sound option, which is now supported by the reclassification of SM as an anxiety disorder in the DSM-5 (American Psychiatric Association, 2013;Manassis, 2009). ...
Virtual reality exposure therapy (VRET) has been commonly utilised as an extension of cognitive behavioural therapy (CBT). However, most studies examined its effectiveness among adults, with no study focusing on children with selective mutism (SM). We aimed to examine its feasibility and acceptability among children with SM. Twenty children aged 6–12 with SM diagnosis were recruited and completed six therapist-guided VRET sessions. Parents and clinicians completed measures at pre-VRET, post-VRET, 1-month and 3-month follow-up visits. At post-VRET, parent and child participants completed the acceptability questionnaires. Findings suggested the feasibility of VRET as all participants completed the programme with no attrition. Parents and child participants also reported VRET to be an acceptable and effective treatment for SM. Significant improvement in overall functioning were found at post-treatment and follow-up measures, but there were no significant changes in parent-rated speech frequency and anxiety measures. These support the acceptability of VRET as an adjunct modality (and not substitute) of CBT in SM treatment. Future studies, with more robust experimental designs and larger sample sizes, can be conducted to confirm its efficacy. As technology becomes more sophisticated, tools such as virtual environments can be explored to enhance evidence-based care for children and their families.
... It can be seen that our sample includes a substantial number of individuals with clinically relevant levels of social anxiety (Table 1). Additionally, some of these individuals also exceed the cut-off for SM, which is in line with studies indicating that most children with SM also have a comorbid SAD [57], report elevated trait social anxiety [58] and do not differ on fear-related cognitions compared to children with SAD [54]. Thus, we were able to cover a broad spectrum of the dimension of social anxiety. ...
... high amount of explained variance of symptoms, as well as relatively high mean SPAI-C sum score (M = 20.00) of our sample, which on average even exceeds the clinical cut-off of the SPAI-C, suggest a sufficient variance regarding the SAD components of our sample. Also, the circumstance that some of the children additionally score higher on an SM screening is probably not problematic due to findings that children with SM do not differ from children with SAD with respect to fear-related cognitions [54] and due to high comorbidity rates between both disorders [58]. Nevertheless, future studies should compare network structures of SAD between a clinical and healthy group in children and adolescents to prove the assumption of dimensionality of social anxiety also for network analysis. ...
Clark and Wells’ prominent model of social anxiety disorder (SAD) assumes that cognitive variables such as negative expectations or dysfunctional cognitions play a central role in the symptomatology of SAD. In contrast to adults, it is less clear how well the cognitive model can be applied to children and adolescents. A network analysis with seven nodes was conducted to explore the importance of cognitive variables and their interaction with symptoms of SAD based on N = 205 children and adolescents (8–18 years, M = 11.54 years). Cognitive variables had a high but differential impact within the positively connected network of SAD. Dysfunctional cognitions were most strongly connected within the network. Dysfunctional cognitions, as predicted by Clark and Wells’ model, seem to act as a hub affecting several symptoms. The association between negative expectations and avoidance indicates that negative expectations may particularly contribute to the maintenance of SAD.
... Most importantly, it has been noted that SM and SAD are difficult to distinguish on behavioral, psychophysiological, self-, parent-, and teacherreport measures of social anxiety (Poole et al., 2020). Given all these research findings, the current classification of SM as an anxiety disorder (see American Psychiatric Association, 2013) seems justified (Sharp et al., 2007;Viana et al., 2009;Muris and Ollendick, 2015), with some scholars even pleading for the recognition of SM as a special variant of SAD (Bögels et al., 2010). ...
... The observation that SM is associated with multiple factors fits nicely within a developmental psychopathology framework (Cicchetti and Cohen, 2006). That is, the selective non-speaking behavior of children with SM does not seem to develop as the result of one deterministic variable, but likely originates from a complex of vulnerability factors that jointly increase the probability (risk) for this psychiatric condition to occur (Cohan et al., 2006;Viana et al., 2009;Muris and Ollendick, 2015). In keeping with the principle of equifinality (i.e., any one outcome might result from multiple and diverse pathways; see Cicchetti and Rogosch, 1996), the exact constellation of vulnerability factors can be and most likely is different across children. ...
Selective mutism (SM) is a psychiatric condition that is characterized by a failure to speak in specific social situations (e. g., at school) despite speaking normally in other situations (e.g., at home). There is abundant evidence that anxiety, and social anxiety in particular, is a prominent feature of SM, which is the main reason why this condition is currently classified as an anxiety disorder. Meanwhile, there is increasing support for the notion that autism-related problems are also involved in SM. The present study examined the relations between SM and social anxiety, autistic features, and behavioral inhibition to the unfamiliar (i.e., the tendency to react with restraint and withdrawal when confronted with unfamiliar stimuli and situations). Parents of 172 3- to 6-year-old preschool children completed an online survey for measuring the relevant constructs. Results showed that there were positive and statistically significant correlations between SM and social anxiety, autistic features, and behavioral inhibition. Regression analyses revealed that (1) both social anxiety and autistic features accounted for a significant and unique proportion of the variance in SM scores, and (2) that both of these variables no longer made a significant contribution once behavioral inhibition was added to the model. It can be concluded that while the involvement of social anxiety is unambiguous in SM, autism-related problems are also implicated. Furthermore, behavioral inhibition seems to play a key role in the non-speaking behavior of non-clinical young 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.
... 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.
... Usually, the diagnosis is discovered after entering school, nursery or kindergarten. According to epidemiological studies, the prevalence rate of SM is around 1% (Murris and Ollendick, 2015). Several studies have found a link between SM and clinically significant social anxiety as well as other anxiety disorders (Driessen et al., 2020). ...
A deficit in emotion regulation skills could be an important factor influencing the vulnerability and maintenance of symptoms in selective mutism (SM). Unfortunately, to date only a few studies have examined emotion regulation in SM. Therefore, the present study investigated whether SM is associated with dysfunctional emotion regulation strategies. We compared a sample of 28 children and adolescents with SM (M = 12.66 years, SD = 3.98; 18 females) to 33 controls without SM (M = 12.45 years, SD = 3.18; 21 females). Both groups were investigated for the assessment of SM, social anxiety and emotion regulation using self and parent report questionnaires. We assumed that the disorder is associated with less adaptive and more maladaptive strategies, especially maladaptive cognitive strategies. Instead of significant differences in these overall values, only significant differences in individual emotion regulation strategies were found. In terms of adaptive strategies, children and adolescents with SM reported less problem-oriented behaviour and less cognitive problem-solving. Instead, they reported the maladaptive strategy of abandonment more often than the control group. In contrast to other anxiety disorders, children and adolescents with SM did not report maladaptive cognitive strategies and more frequently seek support than the control group. Their emotion regulation strategies are qualitatively closely related to the symptoms of SM, which makes it difficult to determine their independent significance.
Trial registration: This study is registered with the ClinicalTrials.gov number NCT04233905.
... Selective mutism (SM) is a psychiatric condition characterized by persistent failure to speak in specific social situations (usually in school) despite speaking adequately in other situations (usually with close family members). The disorder was categorized as an anxiety disorder in the DSM-5 and ICD-11 [1,2] (see Table 1 for the current diagnostic criteria for selective mutism), based on multiple studies showing an overlap in behavioral characteristics and etiological factors in children with SM and high comorbidity with other anxiety disorders, specifically social anxiety [3,4]. ...
Selective mutism (SM) is an anxiety disorder (prevalence 1–2%), characterized by the consistent absence of speaking in specific situations (e.g., in school), while adequately speaking in other situations (e.g., at home). SM can have a debilitating impact on the psychosocial and academic functioning in childhood. The use of psychometrically sound and cross-culturally valid instruments is urgently needed.
The aim of this paper is to identify and review the available assessment instruments for screening or diagnosing the core SM symptomatology. We conducted a systematic search in 6 databases. We identified 1469 studies from the last decade and investigated the measures having been used in a diagnostic assessment of SM. Studies were included if original data on the assessment or treatment of SM were reported. It was found that 38% of published studies on SM reporting original data did not report the use of any standardized or objective measure to investigate the core symptomatology. The results showed that many different questionnaires, interviews and observational instruments were used, many of these only once. The Selective Mutism Questionnaire (SMQ), Anxiety Disorders Interview Schedule (ADIS) and School Speech Questionnaire (SSQ) were used most often. Psychometric data on these instruments are emerging. Beyond these commonly used instruments, more recent developed instruments, such as the Frankfurt Scale of SM (FSSM) and the Teacher Telephone Interview for SM (TTI-SM), are described, as well as several interesting observational measures. The strengths and weaknesses of the instruments are discussed and recommendations are made for their use in clinical practice and research.
... clinic vs school vs general population) and the ages of the individuals in the sample (APA, 2013). The prevalence in a school setting is higher because the classroom becomes a place where anxiety arises and is more frequent among girls than boys (Muris & Ollendick, 2015;Shriver et al., 2011). ...
Selective Mutism (SM) is characterized by failure to speak at some period of time in specific social situations (e.g., at school), but can talk in other familiar situations (home). This study aimed to determine the effectiveness of ‘Kita Semua Sahabat’ in improving communication skills in children with SM. The subject was a 5 year-old boy who had been diagnosed based on DSM-V. The research design was a single case experimental design. Interventions were performed using the technique of stimulus fading and contingency management which were packed through the training of ‘Kita Semua Sahabat’. The result showed that there was a significant increase, and communication with stimulus (prompts) had a greater increase than communication without stimulus (child’s initiation). The research showed that Training ‘Kita Semua Sahabat’ is effective to increase communication among children with SM, and more frequent verbal communication happens if more stimuli were given to the child.
... In fact, such children are anxious to overcome their social isolation, but they hesitate initiating social connections for fear that they will be scorned by others. Hence, they refrain from countering their anxiety and as a result they experience farther frustration and despair due the absence of experience in acquiring social skills (Muris & Ollendick, 2015). Finally, avoidant individuals according to many studies usually shy away from asking for help (Schneier et al., 2011;Kashdan et al., 2014) and seek social relations only when they are certain that the other person likes them. ...
This study examines a mother's parenting style and in particular her neglect of her child as risk factors for the development of avoidant personality disorders among Israeli school children aged 11-12. The findings of this study are based on qualitative, comparative research where two groups, each comprised of five Israeli mothers of children in the same age range and from the same school, were thoroughly interviewed about their parenting style. One group comprised mothers of regular children and the other of children who suffer from avoidant personality disorder. The findings of this research lead to the conclusion that parental neglect constitutes a significant factor contributing to the development of the avoidant personality disorder.
... Age of onset is likely in the preschool years though most youth with selective mutism are identified in the early elementary school years (Kristensen, 2000;Cunningham et al., 2004). Selective mutism may be more frequent among males than females in clinical samples but the gender ratio may be more comparable in community samples (Karakaya et al., 2008;Muris and Ollendick, 2015). Selective mutism is a persistent disorder with a variable outcome (Hua and Major, 2016). ...
Selective mutism is a persistent and debilitating psychiatric disorder in which a child fails to speak in situations where speaking is expected. Although listed as an anxiety disorder, the multifaceted and heterogeneous nature of selective mutism indicates that a more accurate conceptualization may be as a neurodevelopmental disorder. This article serves as a primer of historical and clinical presentations, empirical clinical profiles, clinical distinctions, assessment, and treatment related to the complexity of selective mutism. The article includes a brief discussion of selective mutism within a developmental psychopathology perspective with an eye toward reformed efforts for prevention, assessment, and treatment regarding this population.
... Jacob, for instance, did not speak unprompted in the social skills class for the first half of the year when the class was inside, likely due to selective mutism. Selective mutism is reported as being connected to stressful life experiences, including those occurring at school (Muris and Ollendick, 2015), though some autistic individuals with selective mutism are reported as not speaking due to a lack of interest in the social context rather than shyness or anxiety (Steffenburg et al., 2018). It is possible that this was a factor for Jacob as well. ...
School is often stressful for autistic students. Similarly, special educators are susceptible to burnout because of the unique demands of their jobs. There is ample evidence that spending time outside, particularly in nature, has many positive effects on mental, emotional, and physical wellbeing. In this case study of two special educators and five autistic students in a social skills group at an elementary school in the southeastern United States, we sought to identify the effects of moving the class outside several times per week. Findings indicated that while there were challenges, the autistic children experienced numerous affordances that supported development toward achieving Individualized Education Plan goals. Moreover, there were also notable positive effects for the special educators. We found that even with little prior experience, learning outside is possible and beneficial to everyone involved.
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.
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。
This chapter explores how loneliness, alienation and solitude set their stamp on ‘quiet professionalism’ in a climate of neoliberalism. This theme is considered in the context of a higher education system that is increasingly associated with efficiency, effectiveness and ‘time-management’ rather than passion or vocation. Departing from the example of Greta Garbo, who famously declared that she wanted to be let alone, the authors explore how the notion of correspondence – with its echoes of response, responsibility and responsiveness – sheds new light on the state of being ‘alone together’ as conducive to the freedom to think. They explore attacks on subjectivity through a novel reading of the psychoanalytical notion of impingement. This is considered against the background of a form of alone/togetherness that arises in and through a quest for ethical forms of collaboration.
The current study is a two-year case study focusing on an upper-elementary girl who had been diagnosed with selective mutism in 1st grade. While multiple theoretical frameworks have been used to explain selective mutism, the current study borrowed the frameworks of critical sociocultural theory, a social semiotic theory of multimodality, and self-efficacy theory. The data consisted of daily field notes written by the researcher, video and audio recordings, artifacts of schoolwork and student written communication. The researcher served as Tina’s learning specialist in Year 1 and her homeroom teacher in Year 2 during the data collection period. Those data sources were used to explain the evolution of new insights, identities, and pedagogical practices designed to support Tina in the school setting. The findings showed that being attentive and observant, establishing a safe learning environment, and cultivating a strong teacher-student relationship were critical to student success. In addition, the role of writing as a communication tool and use of digital tools supported Tina’s growth. In conclusion, implications for teacher development will be discussed.
Because evidence has suggested that individuals who have experienced selective mutism (SM) may become maladapted even after their mutism has improved, this can be an issue for individuals who are in remission. The purposes of the present study were to elucidate specific difficulties of individuals who had experienced selective mutism and to examine the process by which they reached their present state. Individuals who had experienced selective mutism (N=19) were interviewed, after which the interviews were analyzed using a Modified Grounded Theory Approach (M-GTA; a qualitative research method widely used in Japan), and a process model was generated. The model included 5 categories: temperament, negative experiences with selective mutism, maladaptation after remission, improvement in maladaptation, and adaptation, and 21 concepts. It was found that temperament and negative experiences with selective mutism influenced maladaptation after remission, and that maladaptation could lead to adaptation through improvement in maladaptation. The following were found to be useful for improvement: reducing the need to speak, reducing anxiety and tension, and improving speaking skills. The findings of the present study may help individuals who have experienced selective mutism and who have become maladapted to improve their state.
Background
Selective mutism is a rare childhood anxiety disorder characterized by a consistent failure to speak in certain social situations where speech is expected, despite fluent speech in other situations. The purpose of this meta-analysis was to investigate the efficacy of psychological interventions for selective mutism in randomized controlled trials (RCTs).
Methods
Five RCTs with a total of 233 participants were analyzed using a random-effects model. A quality assessment of the included studies revealed that psychometrically-sound measures and treatment manuals were used across all studies.
Results
The results of the analyses showed psychological interventions to be more effective than no treatment, with the overall weighted effect size of g = 0.87, indicating a large mean treatment effect. This effect did not significantly differ whether only selective mutism specific or non-selective mutism specific measures were included in the analysis.
Conclusions
These findings provide support for the efficacy of psychological treatment for selective mutism. Future research could examine the effects of the successful treatments identified in this meta-analysis when compared with a psychological placebo or another bona fide treatment.
Selective mutism (SM) is typically identified in early childhood and is characterised by a lack of speech in specific social situations, usually at school. This study interviewed 11 teachers and used qualitative methods to develop an explanatory framework to represent the lived experience of teaching pupils with SM. Interviews were analysed using grounded theory methods. The final theoretical framework captured nine categories. This included five key processes: categorisation of teacher beliefs; the development and change in beliefs through a process of scientific enquiry; teacher efforts to support pupils; measuring and monitoring pupil progress; management of teacher emotional responses, and four contextual factors; pupil characteristics, peer relationships, teacher self- identity and staff relationships. The findings highlighted a link between teacher categorisation of SM and pupil support. Implications of the framework for guiding research and educator practice to support pupils with SM are discussed.
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.
[Clin Psychol Sci Prac 17: 307–318, 2010]
Although oppositional defiant disorder (ODD) and anxiety disorders (ADs) often co-occur, the literature is mixed regarding the effects of such co-occurrence. For example, there is evidence that AD symptoms may mitigate ODD symptoms (buffer hypothesis) or exacerbate ODD symptoms (multiple problem hypothesis). A dual-pathway model incorporates previous research and addresses both hypotheses. We describe several possible etiological or risk processes that may underlie each of these ODD–AD pathways, including child temperament, aggression, limbic system processes, executive functioning abilities, and social information–processing biases, and suggest an integrated model. We conclude with implications for the model and directions for future research involving co-occurring ODD and ADs.
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.