Abstract
Selective mutism (SM) has been defined as an anxiety disorder in the diagnostic and statistical manual of mental disorders (DSM-5). Cognitive behavioral therapy (CBT) is the recommended approach for SM, but prospective long-term outcome studies are lacking. Reports from the children themselves, and the use of more global quality of life measures, are also missing in the literature. We have developed a school-based CBT intervention previously found to increase speech in a pilot efficacy study and a randomized controlled treatment study. Continued progress was found in our 1-year follow-up studies, where older age and more severe SM had a significant negative effect upon outcome. In the present study, we provide 5-year outcome data for 30 of these 32 children with SM who completed the same CBT for mean 21 weeks (sd 5, range 8–24) at mean age 6 years (10 boys). Mean age at the 5-year follow-up was 11 years (range 8–14). Outcome measures were diagnostic status, the teacher- and parent-rated selective mutism questionnaires, and child rated quality of life and speaking behavior. At the 5-year follow-up, 21 children were in full remission, five were in partial remission and four fulfilled diagnostic criteria for SM. Seven children (23%) fulfilled criteria for social phobia, and separation anxiety disorder, specific phobia and/or enuresis nocturna were found in a total of five children (17%). Older age and severity at baseline and familial SM were significant negative predictors of outcome. Treatment gains were maintained on the teacher- and parent questionnaires. The children rated their overall quality of life as good. Although most of them talked outside of home, 50% still experienced it as somewhat challenging. These results point to the long-term effectiveness of CBT for SM, but also highlight the need to develop more effective interventions for the subset of children with persistent symptoms.Clinical trials registration NCT01002196
Highlights
Selective mutism (SM) is characterized by a consistent lack of speech in specific social situations in which there is an expectation for speaking despite speaking in other situations [1, 2]
To obtain some form of child report we asked the children to rate their difficulties with speaking at school/outside home on a Likert scale, corresponding to the 1–5 range on the in Children and Adolescents (ILC), especially adapted by the authors for the present study (1 = very easy, through 3 = mixed), to 5 = very difficult)
Based on the diagnostic categories of SM, we found a more prominent improvement in the younger children, as 14 of the 16 children (88%) aged 3–5 years at inclusion were in full remission at the 5-year follow-up, compared with seven of the 14 children (50%), aged 6–9 years at inclusion (χ2 square 4.99, df = 1, p = 0.03)
Summary
Selective mutism (SM) is characterized by a consistent lack of speech in specific social situations in which there is an expectation for speaking (e.g., school) despite speaking in other situations (e.g., at home) [1, 2]. SM is reported to run in families, and a family history study of 38 children with SM reported a clear excess of the personality trait of taciturnity in 1st-, 2nd-, and 3rd-degree relatives, underlining the importance of the familial background for outcome studies [13]. Support for a familial relationship between social phobia and SM was found in parents to children with SM [14]. Due to the gradual shift in the understanding of SM from an act of will to an anxiety-based avoidance of speaking in specific situations, SM was classified as an anxiety disorder in the fifth edition of Diagnostic and statistical manual of mental disorders (DSM-5) [2]
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