Treatment Of Selective Mutism Research Articles

Treatment of Selective Mutism: Focus on Selective Serotonin Reuptake Inhibitors

Abstract Selective mutism is a pediatric psychiatric disorder that occurs when a child consistently fails to speak in specific situations in which speaking is expected, such as at school and social gatherings, but speaks appropriately in other settings. Selective mutism often is diagnosed when a child starts school and does not talk to teachers or peers, but talks to family members at home; the condition is frequently accompanied by anxiety and shyness. Although the underlying etiology of the condition remains unclear, psychotherapy is the preferred initial treatment, with the support of parents and teachers. If the child does not respond to psychotherapy, addition of pharmacologic treatment should be considered, depending on the severity of symptoms and presence of other illnesses. Although data are limited to case reports and trials with small patient populations and short follow-up periods, some patients with selective mutism respond to therapy with selective serotonin reuptake inhibitors (SSRIs). Fluoxetine is the most studied SSRI as treatment for the condition, although further investigation is required to determine the optimal dosage and duration of therapy.

Practitioner Review: Psychosocial interventions for children with selective mutism: a critical evaluation of the literature from 1990–2005

There have been several reports of successful psychosocial interventions for children with selective mutism (SM), a disorder in which a child consistently fails to speak in one or more social settings (e.g., school) despite speaking normally in other settings (e.g., home). The present literature review was undertaken in order to provide an up-to-date summary and critique of the SM treatment literature published in the past fifteen years. PubMed, PsycINFO, and Web of Science databases were searched to identify SM treatment studies published in peer-reviewed journals between 1990 and 2005. A total of 23 studies were included in the present review. Of these, ten used a behavioral/cognitive behavioral approach, one used a behavioral language training approach, one used a family systems approach, five used a psychodynamic approach, and six used multimodal approaches to SM treatment. Although much of this literature is limited by methodological weaknesses, the existing research provides support for the use of behavioral and cognitive-behavioral interventions. Multimodal treatments also appear promising, but the essential components of these interventions have yet to be established. An outline of a cognitive-behavioral treatment package for a typical SM child is provided and the review concludes with suggestions for future research.

Treatment Modifications Based on Childhood Anxiety Diagnosis: Demonstrating the Flexibility in Manualized Treatment

The current article presents suggestions for modifications to common manualized treatments to tailor the interventions to specific anxiety diagnoses and common comorbid diagnoses. The authors utilize one cognitive-behavioral treatment manual (Coping Cat; Kendall, 2000) to demonstrate appropriate clinical accommodations. As the majority of cognitive-behavioral treatment manuals contain both skill (e.g., relaxation training, cognitive restructuring, problem solving) and exposure components, suggestions for accommodations are grouped into relevant skill or exposure sections. Recommended modifications include a focus on imaginai exposure for generalized anxiety disorder, involvement of parents in the treatment of separation anxiety disorder, completion of a variety of in vivo exposures for social phobia, and involvement of school personnel in the treatment of selective mutism. Brief recommendations are also included for common comorbid symptoms of depression and attention-deficit/hyperactivity disorder. Keywords: child anxiety; Coping Cat; cognitive-behavioral therapy; manualized treatment The last decade has seen significant improvement in the treatment of anxiety disorders in children and adolescents, in part due to the efficacy and widespread availability of empirically supported manualized treatments (e.g., Coping Koala, Barrett, Dadds, & Rapee, 1991; FRIENDS, Barrett, Lowry-Webster, & Turner, 2000; Coping Cat, Kendall, 2000). Cognitive-behavioral manual-based treatments for childhood anxiety, whether group or individual modalities, typically include similar components. One commonly used manual-based program is the Coping Cat (or C.A.T. Project for adolescents), a package that includes a therapist manual and child and adolescent versions of ancillary workbooks (Kendall, 2000). The treatment program is composed of two main phases, the first focusing on skill development (e.g., introduction of relaxation techniques, cognitive restructuring, problem solving) and the second targeting graded exposure to fearful situations. Although helpful, the majority of existing treatment manuals were designed to be flexibly applied to a range of anxiety disorders. Typically, the clinician is challenged with the task of individualizing the treatment by making modifications based on a child's age, developmental level, and diagnostic status. To aid clinicians in the adaptation of the common treatment manuals for child anxiety, we suggest potential accommodations appropriate for several anxiety and anxiety-related diagnoses (i.e., generalized anxiety disorder [GAD], separation anxiety disorder [SAD], social phobia, selective mutism) as well as frequently comorbid diagnoses (depression, attention-deficit/hyperactivity disorder [ADHD]). TREATMENT MODIFICATIONS FOR GENERALIZED ANXIETY DISORDER The predominant features of GAD are uncontrollable worry about a number of events or activities and accompanying physical symptoms of anxiety (e.g., muscle tension, sleep difficulties, restlessness, difficulty concentrating). Children with GAD commonly report worries about school, family, friends, performance, and health. Often described as "worriers" by family members, GAD children frequently require extensive reassurance regarding their anxious concerns. In order to meet diagnostic criteria, the worry or accompanying physical symptoms must occur more days than not for a minimum of 6 months and cause significant distress or impairment in important areas of functioning (e.g., school, home, peer relationships; American Psychiatric Association, 1994). Given that the core symptoms of GAD in children and adolescents include uncontrollable worry and physical signs of anxiety, treatment manual modifications should target these features. Adapted Skill Components Children with GAD may report experiencing a number of different physical symptoms when worrying, such as muscle tension, difficulty falling asleep, headaches, and stomachaches. …

Treatment Modifications Based on Childhood Anxiety Diagnosis: Demonstrating the Flexibility in Manualized Treatment

The current article presents suggestions for modifications to common manualized treatments to tailor the interventions to specific anxiety diagnoses and common comorbid diagnoses. The authors utilize one cognitive-behavioral treatment manual (Coping Cat; Kendall, 2000) to demonstrate appropriate clinical accommodations. As the majority of cognitive-behavioral treatment manuals contain both skill (e.g., relaxation training, cognitive restructuring, problem solving) and exposure components, suggestions for accommodations are grouped into relevant skill or exposure sections. Recommended modifications include a focus on imaginal exposure for generalized anxiety disorder, involvement of parents in the treatment of separation anxiety disorder, completion of a variety of in vivo exposures for social phobia, and involvement of school personnel in the treatment of selective mutism. Brief recommendations are also included for common comorbid symptoms of depression and attention-deficit/hyperactivity disorder.

Functional analysis and treatment of selective mutism in children.

Abstract Selective mutism refers to a persistent failure to speak in public situations, especially school, where speaking is expected. Researchers have linked selective mutism to social anxiety in many cases. Functional analysis of selective mutism generally involves interviews, questionnaires, behavioral observations, and daily logs. Assessors should look closely for conditions under which selective mutism commonly occurs, especially directives from others, lack of attention from others, high child anxiety, and lack of interpersonal skills. Treatments for selective mutism often involve exposure-based practices and parent- and teacher-based contingency management. Keywords: Mutism; social anxiety; functional assessment; interviews; scales; questionnaires; behavioral observations; treatment; contingency management. Introduction Selective mutism refers to a persistent failure to speak in public situations where speaking is expected, despite speaking in other situations (American Psychiatric Association, 2000). Children with selective mutism commonly fail to speak in situations outside their home and especially in places such as school, restaurants, stores, and recreational settings. From a diagnostic perspective, selective mutism must last at least one month. This excludes children who are naturally reticent about speaking during the first month of school. Selective mutism is not diagnosed in cases where a child simply lacks knowledge or comfort with the language that is spoken in the public situation. A child whose parents speak only Spanish, for example, would likely not be diagnosed with selective mutism during his or her first year of school unless the child was already quite familiar with English. Furthermore, selective mutism is not due specifically to difficulties in communication such as stuttering or specifically to a developmental disorder, though these problems may co-occur. Many children with selective mutism do try to communicate in public situations via nonverbal means such as nodding, pointing, mouthing, or writing letters in the air (APA, 2000). Failure to speak in public situations, especially school, can hinder a child's academic progress because teachers are less likely to call upon these children for answers and because many of these children cannot undergo intelligence and other testing (Bergman, Piacentini, & McCracken, 2002). In addition, some of these children are teased or disliked by their peers, which further affects their social-communication development. Speech and language development may be delayed as well (Krysanski, 2003; Kumpulainen, Rasanen, Raaska, & Somppi, 1998). The prevalence of selective mutism is not well known because of the furtive nature of the disorder and lack of literature regarding this population. Prevalence estimates range from 0.2-2.0%, but the actual rate may be higher because many parents attribute the problem to simple shyness that the child will eventually outgrow (Bergman et al., 2002; Kopp & Gillberg, 1997; Kumpulainen et al., 1998). In addition, because many of these children speak freely at home, parents often delay seeking treatment. An overt speech or language problem does not seem evident to them. Initial studies on selective mutism indicated the prevalence of selective mutism to be higher for girls than boys, but recent evidence suggests a more equal gender distribution (Andersson & Thomsen, 1998; Hayden, 1980; Remschmidt, Poller, Herpertz-Dahlmann, Hennighausen, & Gutenbrunner, 2001; Wilkens, 1985). Age of onset for the disorder is typically 3-6 years but the problem is usually not recognized until school entry or later (i.e., age 6-8 years) (Black & Uhde, 1992; Ford et al., 1998). Selective mutism appears to have a variable but sometimes chronic course that can persist for years (Krysanski, 2003). In one study of second-graders with selective mutism, most (53%) had been mute since kindergarten and a substantial portion (18%) had been mute since preschool (Kumpulainen et al. …

Clinical perspectives on the treatment of selective mutism.

Abstract Selective mutism is a childhood disorder characterized by a failure to speak in some but not all of the contexts where speaking is normally expected. It is commonly associated with co-occurring anxiety, both on the part of the child and on the part of one or more family members. The prevailing opinion on treatment recommends medication, cognitive-behavioral therapy (CBT) and family counseling. However, treatment efficacy research is extremely limited. Further, since selective mutism is often first identified during the preschool years, CBT must be modified to match a child's developmental level. This paper summarizes the nature and prevalence of selective mutism, techniques used to treat this disorder, and issues in need of research. The discussion of behavioral treatment techniques is based on the literature and on the author's clinical experience. Keywords: Selective Mutism; Operant Conditioning, Cognitive Behavior Therapy, Communication Hierarchy, Talking Scale, Talking Map, Parent Counseling, Collaboration. Introduction Selective mutism is an intriguing childhood disorder that presents considerable treatment challenges. The core symptom is that a child persistently and systematically refrains from speaking in some settings where speaking is expected (e.g., school, community) but speaks fluently in other settings (e.g., home.) Often there are additional complicating factors, such as co-occurring anxiety symptoms or oppositional behaviors, as well as a familial history of anxiety. While a number of articles have been written about selective mutism, there is no universally accepted treatment regimen. Following a short summary describing the nature and incidence of selective mutism, this paper will address approaches to treatment based on the literature and on the author's clinical experience with this population. Also presented are recommendations for research. Definition, Incidence, and Co-Occurring Conditions According to the DSM-IV-TR (American Psychiatric Association, 2000) the onset of selective mutism usually occurs before the age of five years. However, sometimes it is not recognized as a specific problem until a child enters school, when the systematic and selective failure to talk becomes more noticeable. A clinical diagnosis of selective mutism is made on the basis of five criteria: A. The child refrains from speaking in specific social situations (e.g., school) while speaking in others (e.g., home) B. Failure to speak interferes with educational achievement or with social communication C. Symptoms persist for at least one month (not including the first month of school) D. The failure to speak can not be attributed to a lack of knowledge or comfort with the spoken language (as might be true for bilingual children who have immigrated from another culture). E. The symptoms are not better accounted for by a communication disorder, a pervasive developmental disorder, or a psychotic disorder. Prevalence estimates of selective mutism range from .03 to 2 percent; and it is more common among girls, with ratios ranging from 1.5 to 2.6 girls to 1 boy with the diagnosis (Garcia, Freeman, Francis, Miller, & Leonard, 2004). Current research indicates that children with selective mutism show more anxiety symptoms than do other children (Bergman, Piacenti, & McCracken, 2002; Cunningham, McHolm, Boyle, & Patel, 2004) and that anxiety symptoms co-occur with selective mutism at a rate of 74 to 100 percent (Garcia et al.; Kristensen, 2000; Vecchio & Kearney, 2005). Oppositional disorder may also co-occur, but there is some dispute in the literature about its co-occurrence rate. Garcia et al., and Vecchio and Kearney reported that the rate of occurrence is quite low. However, Cunningham et al. reported oppositional disorder to co-occur twice as often among children with selective mutism as among children in a control group. …

Fluoxetine treatment of selective mutism in pervasive developmental disorder

We report the successful treatment of selective mutism in a child with pervasive developmental disorder (PDD). There are several studies and case reports in which Fluoxetine has been reported effective in diminishing adult social anxiety and increasing speech in public settings. The literature is much smaller for children. The efficacy of fluoxetine supports the argument that selective mutism is a developmental equivalent of social anxiety disorder. To our knowledge this is the first description of successful treatment when the selective mutism is complicated by PDD.

Phenomenology and Treatment of Selective Mutism

Selective mutism is a multidimensional childhood disorder in which, according to the most recent studies, biologically mediated temperament and anxiety components seem to play a major role. Several psychotherapy methods have been reported in case studies to be useful, but the disorder is commonly seen to be resistant to change, particularly in cases of long duration. Currently, behaviour modification and other cognitive methods, together with cooperation with the family and the school personnel, are recommended in the treatment of selective mutism. Selective serotonin reuptake inhibitors and selective monoamine oxidase inhibitors have also been reported to be helpful when treating children with selective mutism. At the moment, pharmacotherapy cannot be recommended as the treatment of first choice but if other methods of treatment are not helpful, medication can be included in the treatment scheme. Comprehensive evaluation and treatment of possible primary and comorbid problems that require treatment are also essential.

Two Sets of Twins with Selective Mutism: Neuropsychological Findings

Neuropsychological data are reviewed from two sets of dizygotic twins presenting with selective mutism characterized by situation specific anxiety, extreme passive behavior, lack of responsivity, lack of peer interaction, and a chronic course of selective mutism. Both sets of twins had a history of prematurity and delayed speech development. One set of twins presented with normal intelligence and normal receptive language skills but with expressive language and oral motor sequencing difficulties. The second set of twins presented with Verbal IQ deficits and significant receptive and expressive language deficits. A summary of current conceptualizations regarding etiology and treatment of selective mutism is provided.

Treatment of selective mutism: A best-evidence synthesis.

A major goal of treatment of children with selective mutism has been to help them speak in situations to people with whom they did not previously speak. A systematic analysis examining the effectiveness of treatment models, assessed by treatment outcomes (e.g., speaking) and methodological quality of the studies, has not been conducted on the existing selective mutism literature. Further, most treatment outcome studies have utilized case studies or single-case designs, which, until recently, were more difficult to examine systematically (e.g., meta-analysis). Thus, 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 (i.e., applied behavior analysis and combined behavioral approaches). 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 methodologi-

Assessment and Treatment of Selective Mutism

Abstract We present the results of a stimulus fading procedure used to treat a six-year-old girl who met DSM-DJ-R criteria for elective mutism (now Selective Mutism in DSM-IV). An assessment protocol is presented that features procedures that can be used to render a diagnosis and assist in treatment planning. A treatment program was implemented through a consultation process that required close monitoring and revision over several months. Results of the case study suggested that the stimulus fading of new persons into the school setting was effective in producing speech. Future re-search directions in assessment and treatment of selective mutism are discussed.

Practical Guidelines for the Assessment and Treatment of Selective Mutism

To provide practical guidelines for the assessment and treatment of children with selective mutism, in light of the recent hypothesis that selective mutism might be best conceptualized as a childhood anxiety disorder. An extensive literature review was completed on the phenomenology, evaluation, and treatment of children with selective mutism. Additional recommendations were based on clinical experience from the authors' selective mutism clinic. No systematic studies of the phenomenology of children with selective mutism were found. Reports described diverse and primarily noncontrolled treatment approaches with minimal follow-up information. Assessment and treatment options for selective mutism are presented, based on new hypotheses that focus on the anxiety component of this disorder. Ongoing research suggests a role for behavior modification and pharmacotherapy similar to the approaches used for adults with social phobia. Selectively mute children deserve a comprehensive evaluation to identify primary and comorbid problems that might require treatment. A school-based multidisciplinary individualized treatment plan is recommended, involving the combined effort of teachers, clinicians, and parents with home- and clinic-based interventions (individual and family psychotherapy, pharmacotherapy) as required.

Successful treatment of selective mutism: collaborative work in a secondary school setting

This article describes the successful treatment of a single case of selective mutism. The client is a teenage girl with moderate learning difficulties. Issues surrounding the role of the speech and language therapist in a case such as this are discussed. The nature of collaborative work within the school is described, together with practical ideas used for both supporting staff and parents and actual treatment of the client.

Selective Mutism

Selective mutism is characterized by a persistent lack of speech in some social situations but not in others. One of the most common settings where selective mutism occurs is the school. This article reviews some of the published literature regarding the causes, assessment, and treatment of selective mutism in school-age children. The most successful treatments have included various forms or combinations of behavior modification. However, a strict behavioral approach may not be the best method to use, offering only the illusion of success while underlying problems may still remain.

Prevalence and Treatment of Selective Mutism in Clinical Practice: A Survey of Child and Adolescent Psychiatrists

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 s...