ANXIETY DISORDERS Chapter F.5 SELECTIVE MUTISM Beate Oerbeck, Katharina Manassis, Kristin Romvig Overgaard & Hanne KristensesAND ADOLESCENTS Companion PowerPoint Presentation Adapted by Julie Chilton

The IACAPAP Textbook of Child and Adolescent Mental Health is available at the IACAPAP website Please note that this book and its companion powerpoint are: Free and no registration is required to read or download it This is an open-access publication under the Creative Commons Attribution Noncommercial License. According to this, use, distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited and the use is non-commercial. Selective Mutism

Outline Introduction

Clinical Presentation Prevalence & Course Etiology Diagnosis Comorbidity Differential Diagnosis Assessment Treatment Culturally Specific Issues Key Points Selective Mutism Introduction: Definition

A disorder characterized by a consistent failure to speak in specific settings (school, social situations) despite speaking normally in others (at home) Significant social and academic impairment if left untreated Rare but serious Selective Mutism Introduction

Selective Mutism Clinical Presentation

Context and person specific Better with friendly, funny, talkative people Easier to talk to other children Some can whisper to a friend Differ widely in non-verbal communication School refusal rare Comorbid: anxiety & language disorders More common in immigrant, bilingual children Onset between 2 and 5 years Fear of mistakes and dislike attention Selective Mutism Clinical Presentation

When they occasionally do talk they get everybodys attention, which they find anxiety-provoking, perpetuating mutism in a vicious cycle Selective Mutism Clinical Presentation CIGSsyK0 ch?v=SNPyXOPJonQ Selective Mutism Ann: A case example

5 year old girl Mutism since kindergarten at age 3 Normal development Shy temperament like her parents Lively, happy, talkative at home No speech with paternal grandparents Parents speak for her outside the home Only nonverbal communication at school after a few months Included in play Other children speak for her at school

Selective Mutism Etiology No single cause Act of willfullness lack of ability Interplay of causes Genetic Temperament Neurodevelopmental Environmental Selective Mutism Diagnostic Criteria: DSM-5 and ICD-11

Consistent failure to speak in specific settings despite talking normally in others At least for one month Not due to a lack of knowledge of or comfort with the required language Not better explained by a communication disorder Not occur during autism, schizophrenia or another psychotic disorder Interferes with daily functioning at school and in social situations Selective Mutism

Diagnostic Challenges Overlap with other disorders Consistent lack of speech is unclear Some speaking ok if still impaired Bilingual children often overlooked Lasts longer than 6 months Is muteness due to lack of understanding new language? Are there comorbid speech and language

disorders? Mutism prolonged or disproportionate to degree of new language knowledge and exposure Selective Mutism Comorbidity 90 % comorbid social anxiety disorder Separation anxiety but not school refusal Neurodevelopmental disorders Speech and language problems Elimination disorders Motor delay Autism disorder <10% of cases ADHD rare No longer viewed primarily as oppositional; just oppositional when pressured to speak Selective Mutism Assessment Information from both parents and teachers diagnostic interviews K-SADS-PL ADIS-IV-C/P PAPA questionnaires behavioral observations

Patient interview yes and no nods written questionnaires talking maps & feelings thermometers Selective Mutism Practical Issues in Assessment

Allow parents to join if child wishes Before beginning, tell child they do not have to talk to you Explain non verbal options: pointing, nodding or writing Sit beside not opposite No time limits on receptive vocabulary tests-Peabody Picture Vocabulary Test For articulation evaluation, parents record speech at home for clinician

Pleasurable play activity for joint attention Thinking aloud> questioning directly Neutral conversation topics Allow periods of silence to give time to answer Continue dialogue even if no response Calmly acknowledge eventual verbal response Selective Mutism Rating Scales Revised Childrens Anxiety & Depression Scale (RCADS) The Selective Mutism Questionnaire (for

parents) School Speech Questionnaire (for teachers) Social Communication Anxiety Inventory (S-CAI) Selective Mutism Treatment: Factors to consider Vulnerability factors: genetics, temperament, social anxiety, behavioral inhibition, neurodevelopmental disorders Triggering factors:

transitions, starting kindergarten or school, migration, use of a new language Sustaining factors: either too much acceptance of non-speech or too much pressure put on the child to speak Selective Mutism Treatment: Components Cognitive Behavioral Therapy Decrease speech anxiety Graduated exposure tasks Rewards for speaking behavior

Psychosocial Treatments Psycho-educational literature for parents Coordination with teachers Pharmacotherapy Selective Mutism Psycho-educational Literature Selective Mutism Treatment

eZiWDo h?v=QgFKuBCKhUw Selective Mutism Psychotherapy: Integrated Behavioral Therapy by Lindsey Bergman Conducted at clinic by experienced clinicians with parental participation 20 sessions Graded exposure tasks to feared stimuli/situation Therapists in close communication with teachers

about exposure tasks Pilot randomized controlled trial of 21 children Significant increase of speech after treatment 67% no longer qualified for selective mutism Clinical gains maintained at 3 months Social anxiety symptoms improved per parent not teacher report Selective Mutism Psychotherapy: Social Communication Anxiety Treatment (S-CAT) by Elisa Shipon-Blum Nine 3-weekly sessions Also at the clinic with parental participation using

graduated exposure tasks and consultation with teachers Increasingly demanding verbalization stages using SM-Social Communication Comfort Scale Pilot study of 40 children Significant increase of speech by parent rating Low SM symptom severity and high family therapy compliance associated with better outcome Selective Mutism

Psychotherapy: Home & School Based Intervention for SM by Hanne Kristensen Starts at home and extends to school Useful in rural areas or where limited access to experts Teacher etc can carry out intervention under supervision from clinician Pilot study of 7 children: 6 spoke freely after 14 weeks Continued 1.5 years later

RCT of 24 children Significant increase of speech after 3 months Multiple other studies positive Selective Mutism Medication Treatment : Factors to consider

Not much evidence, so off-label 2 trials: fluoxetine and sertraline Potential side effects Use in concert with therapy Child must have failed therapy alone Symptoms severe and handicapping May be more effective in older children Selective Mutism How should medication be prescribed? Younger children: 5mg fluoxetine or 12.5mg

sertraline Monitor for weight change, behavioral activation, increased suicidal behavior Improvement more noticeable at school Improvement after 2-4 weeks at optimal dose Taper off medication once good social and academic functioning If symptoms return, resume lowest effective dose Long term effects unknown Selective Mutism Culturally Specific Issues

International variation Importance of childrens ability to present orally at school Amount of acceptable pressure on children to increase speaking How acceptable it is for health personnel to help children at home or school How readily people are willing to use medication Selective Mutism Key Points

Relatively rare Significant social/academic impairment Cardinal symptom=consistent failure to speak in specific setting despite normal speaking in other setting Runs in families

Associated with behavioral inhibition Prevalent comorbidities: anxiety and neurodevelopmental disorders Input from parents and teachers First steps: psychoeducation and behavioral management Gradual exposure and reward contingency=treatment of choice Selective Mutism Key Points (contd) Consider medication: If no or partial response to psychosocial treatment If psychosocial treatment not available

Only in conjunction with psychosocial treatment No medication approved in children and adolescents Studies suggest cautious optimism for SSRIs If untreated, high risk for: Other psychiatric disorders Anxiety disorders Continued social/academic impairment Selective Mutism Thank You!

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